Anterior Atlantoaxial Subluxation Research Articles

Prevalence of anterior atlantoaxial subluxation and association with established rheumatoid arthritis.

Spinal involvement in rheumatoid arthritis (RA) is limited to the upper cervical spine, leading to cervical spine instability. This study aimed to evaluate the prevalence of anterior atlantoaxial subluxation (aAAS) and its associated risk factors in patients with RA. This single-centre cross-sectional study 240 patients consecutively were recruited. Radiographs of the cervical spine were obtained in the flexion and neutral neck positions and read by two blinded observers. The diagnosis of aAAS was based on the distance between the anterior aspect of the dens and the posterior aspect of the anterior arch of the atlas, which was >3mm during flexion. Statistical analysis was performed to determine the predictive factors of aAAS. Two hundred and forty patients with a mean±SD age of 56.4±11.4years were recruited, and 191 (78%) were female. The mean±SD duration of the disease was 10.2±8.5years. Of all 25 cases (10.4%) diagnosed with aAAS, the mean anterior atlantodental interval in patients with AAS was 4.19±1.20mm. One in three patients with aAAS had no neck pain. Patients with aAAS had longer disease duration, lower age at diagnosis, lower body mass index, higher anti-cyclic citrullinated peptide autoantibodies (anti-CCP), more frequent erosion, joint restriction, and joint prostheses. In the multivariate regression model, joint limitation, history of joint prostheses, low BMI, and higher anti-CCP levels were independent predictors of the aAAS. Thirty-three percent of patients with cervical involvement do not experience neck pain. Cervical involvement should be considered even without neck pain, particularly in established diseases.

Radiographs and MRI of the Cervical Spine in Juvenile Idiopathic Arthritis: A Cross-Sectional Retrospective Study.

Background: Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease among children. In some patients, cervical spine arthritis remains a serious and chronic manifestation of JIA. The aim of this study was to assess the frequency of cervical spine lesions on radiographs and MRI in JIA patients with clinical signs of cervical spine involvement and to verify if with the addition of MRI, the use of radiographs could be abandoned. Methods: This retrospective study evaluated consecutive 34 children (25 girls; aged 6–18 years, median 15.5 years) with JIA and with clinical involvement of cervical spine. In each patient, both radiographs and MRI of the cervical spine were performed. Imaging findings were correlated with clinical and laboratory data. Results: The cervical spine was affected in 35% of patients. The most frequent lesions were subaxial subluxations (SAS; 24%), apophyseal joint ankylosis (9%), and C1/C2 joint lesions (9%). Anterior atlanto-axial subluxation (AAS) was diagnosed only by radiography, and most of the SAS were seen on radiography, whereas only a few on MRI. Reversely, C1/C2 soft tissue involvement were seen on MRI only. Cervical spine involvement was associated with raised ESR (p = 0.012) and CRP (p = 0.014). Conclusions: The cervical spine lesions are still frequent complication of JIA affecting up to 35% of JIA patients. Most of them develop serious complications, such as AAS and ankylosis. Despite advantages of MRI in terms of the imaging of the atlanto-axial region radiography shows superiority in diagnosis of AAS and SAS.

Radiological Evaluation of Cervical Spine Involvement in Rheumatoid Arthritis: A Cross-Sectional Retrospective Study.

Background: Cervical spine lesions are a common manifestation of rheumatoid arthritis (RA). The purpose of this study was to conduct a retrospective analysis of radiological lesions in cervical spine in patients with RA and to correlate findings with clinical and laboratory parameters. Methods: Overall, 240 consecutive patients with RA were referred for imaging by clinicians based on symptoms suggesting cervical spine involvement and/or long disease duration. In each patient, lateral radiographs and MRI of the cervical spine were performed. The imaging data were correlated with clinical records and laboratory data. Results: The cervical spine was affected in 179 patients (75%). The most common lesions were anterior atlanto-axial subluxation (AAS; 58%), subaxial subluxation (58%), and demineralization (48%). Cervical spine involvement was linked to longer disease duration (p = 0.007), the presence of rheumatoid factor (RF; p = 0.010), elevated C-reactive protein (CRP) levels (p = 0.016), and accelerated erythrocyte sedimentation rate (ESR; p = 0.025). Longer disease duration was associated with anterior AAS (p = 0.005), subaxial subluxation (p = 0.005), and basilar settling (p = 0.003). Conclusions: As many as 75% of RA patients develop lesions that can be observed on radiographs and through MRI. The most frequent radiological findings include anterior AAS and subaxial subluxation. Long disease duration, RF seropositivity, and elevated inflammatory markers were risk factors for cervical spine involvement.

Reproducibility and diagnostic value of a new method using ratios to diagnose anterior atlanto-axial subluxation on plain radiographs.

Measures on conventional radiography are used to detect, especially in rheumatoid arthritis, upper cervical spine instabilities (CSIs) with the anterior and posterior atlanto-dental intervals (AADI and PADI) measurements. Our objective was to evaluate the diagnostic performance and reliability of AADIs and PADIs extrapolated based on ratios in assessing anterior atlanto-axial subluxation (aAAS) when plain radiographs do not allow the measures. Radiographies of 119 patients were randomly selected. Two blinded observers performed two measurements of the odontoid sagittal diameter (O), axis body base sagittal diameter (C2), AADI, PADI, Clark station and Ranawat index, and the AADI/O, AADI/C2, PADI/O and PADI/C2 ratios were calculated. The diagnostic value of AADI and PADI extrapolated from the AADI/O, AADI/C2, PADI/O and PADI/C2 ratios was evaluated using ROC curves, with AADI>2.9mm used as the gold standard. Among the 119 patients, 12 patients had aAAS (AADI>2.9mm), 6 of them had severe aAAS (AADI>8.9mm and/or a PADI<14mm), and 6 patients had vertical AAS (Clarks station=2 or 3 and/or Ranawat index<13mm). The AADI extrapolated from the AADI/O and AADI/C2 ratios has excellent intra- and inter-observer reproducibility. The diagnostic value of the extrapolated AADI was high for aAAS (sensitivity 92%; specificity of 100%) and severe aAAS (sensitivity75%; specificity 100%). The diagnostic value of the extrapolated PADI was good but lower than the diagnostic value of the extrapolated AADI. Extrapolated AADI can be used instead AADI to detect aAAS and severe aAAS.

Cervical spine instability and canal stenosis caused by rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that impacts on weakening ligaments, synovial arthritis and cartilage damage. The effect that can occur is instability and neural compression in the upper and sub-axial cervical. The prevalence of atlantoaxial instability (AAI) is around 40-80% among rheumatoid patients, but it is interesting to examine the clinical symptoms that are not so visible despite radiological instability confirmed on the cervical spine. However, once the clinical symptoms of myelopathy occur, the mortality rate will increase sharply.&#x0D; We report a case of a 66-years old female who was admitted to our hospital with gait disturbance and weakness of her lower extremities. Radiographic evaluation of the cervical spine showed erosive destruction of the odontoid process of C2, anterior atlantoaxial subluxation, and thickened yellow ligaments from C3 to C7. Surgery was performed by removal of the posterior arch of C1 and laminectomy C3 to C7, posterior occipito-cervical screw fixation from C3 to C7, combined with atlantoaxial transpedicular screw fixation. A sterno sub-occipitomandibular immobilization (SOMI) orthosis was applied for postoperative immobilization for 12 weeks. Improvement of motoric status noted after surgery.

Cervical Myelopathy in Patients Suffering from Rheumatoid Arthritis-A Case Series of 9 Patients and A Review of the Literature.

Cervical myelopathy occurs in approximately 2.5% of patients suffering from rheumatoid arthritis (RA) and is associated with notable morbidity and mortality. However, the surgical management of patients affected by cervical involvement in the setting of RA remains challenging and not well studied. To address this, we conducted a retrospective analysis of our clinical database between May 2007 and April 2017, and report on nine patients suffering from cervical myelopathy due to RA. We included patients treated surgically for cervical myelopathy on the basis of diagnosed RA. Clinical findings, treatment and outcome were assessed and reported. In addition, we conducted a narrative review of the literature. Four patients were male. Mean age was 64.8 ± 20.5 years. Underlying cervical pathology was anterior atlantoaxial instability (AAI) associated with retrodental pannus in four cases, anterior atlantoaxial subluxation (AAS) in two cases and basilar invagination in three cases. All patients received surgical treatment via posterior fixation, and in addition two of these cases were combined with a transnasal approach. Preoperative modified Japanese orthopaedic association scale (mJOA) improved from 12 ± 2.4 to 14.6 ± 1.89 at a mean follow-up at 18.8 ± 23.3 months (range 3–60 months) in five patients. In four patients, no follow up was available, and the mJOA of these patients at time of discharge was stable compared to the preoperative score. One patient died two days after surgery, where a pulmonary embolism was assumed to be the cause of mortality, and one patient sustained a temporary worsening of his neurological deficit postoperatively. Surgery is generally an effective treatment method in patients with inflammatory arthropathies of the cervical spine. Given the nature of the RA and potential instability, fixation in addition to cord decompression is generally required.

Assessment of cervical spine involvement in rheumatoid arthritis patients in the era of biologics: a real-life, cross-sectional MRI study

Cervical spine involvement may lead to severe complications in rheumatoid arthritis (RA). In the era of modern therapies, atlantoaxial subluxation (AAS) may be rare; however, it may still be detected in asymptomatic patients. The onset of myelopathy can occur at any time. Altogether 49 female RA patients were included. Among them, 15 were methotrexate treated, biologic free, while 34 patients received biologics. The patients had no cervical pain or any neurological symptoms. We assessed the first (C1) and second (C2) cervical vertebrae by 3 T magnetic resonance imaging (MRI). In addition to AAS, we also determined odontoid erosion or periodontal soft tissue thickening. We associated our MRI findings with clinical, laboratory parameters, and hand radiography. We detected anterior AAS and soft tissue thickening in one-quarter, while odontoid erosions in eight (16%) of RA patients. There were no significant differences among the therapeutic subgroups. No posterior or vertical AAS was seen. Anterior AAS was associated with higher degree of inflammation, soft tissue thickening was seen at younger age, while odontoid erosions were associated with van der Heijde–Sharp scores of the hand. None of the patients had any lesions requiring surgery. The presence of cervical involvement in RA patients with 10–11 years of disease duration is still an important and frequent phenomenon. Higher disease activity and erosive disease are associated with atlantoaxial involvement. 3 T MRI is a sensitive method to assess AAS, as well as soft tissue lesions and odontoid erosions.

Apparent diffusion coefficient as an indicator of spinal cord compression due to anterior atlanto-axial subluxation in rheumatoid arthritis patients

PurposeThe aim of this retrospective study was to evaluate the apparent diffusion coefficient (ADC) as a potential parameter of spinal cord damage in cervical spine instability at the atlanto-axial level in rheumatoid arthritis (RA) patients.MethodsOne hundred and six RA patients were included in the study. MRI examinations were performed with 1.5T scanner. The ADC was measured at six locations in the cervical spinal cord at the height of the first six cervical vertebrae (from C-1 to C-6). The ADC values were assessed in 2 groups: with and without anterior atlanto-axial subluxation (AAS) diagnosed on plain radiographs. Correlations between ADC values and radiographic measurements and RA activity indicators were evaluated.ResultsThe ADC values at C1 level (ADC1) was higher in the group with anterior AAS than in the group without AAS (p < 0.001). Statistically significant moderate positive correlation between ADC1 and anterior atlanto-axial diameter interval AADI (rho = 0.58; p < 0.008) was found as well as statistically significant weak negative correlation between ADC1 and posterior atlanto-axial diameter interval PADI (rho = − 0.34; p < 0.008).ConclusionsThe conducted study demonstrates the applicability of the ADC maps in the identification of spinal cord compression due to anterior AAS in RA patients. The results encourage the practical use of the ADC as an additional parameter in the qualification for surgical treatment.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Impact of the occiput and external acoustic meatus to axis angle on dysphagia in patients suffering from anterior atlantoaxial subluxation after occipitocervical fusion

BACKGROUND CONTEXTDysphagia is a complication that sometimes occurs after occipitocervical fusion (OCF). An appropriate O-C2 angle (O-C2a) is recognized as a critical factor for preventing dysphagia. The occiput and external acoustic meatus to axis angle (O-EAa) has some advantages over the O-C2a and is now recognized to outperform O-C2a in predicting dysphagia. However, there are no data on this topic from patients with anterior atlantoaxial subluxation (AAS). PURPOSETo evaluate the relationship between the O-EAa and dysphagia in patients suffering from AAS after OCF surgery. STUDY DESIGNA retrospective clinical study. PATIENT SAMPLEData from 22 consecutive AAS patients who had undergone OCF were reviewed retrospectively. OUTCOME MEASURESThe outcome measures included the O-EAa, O-C2a, the narrowest oropharyngeal airway space (nPAS), and the morbidity of dysphagia after OCF. METHODSBetween September 2011 and September 2017, data from 22 consecutive AAS patients who had undergone OCF were reviewed retrospectively. The patients were divided into two groups according to whether they had suffered postoperative dysphagia by face-to-face questioning or telephone interview. Lateral radiographs were analyzed to determine the pre- and postoperative O-EAa, O-C2a, angle formed by the inferior endplate of C2 and the EA-line (C2Ta), and smallest anteroposterior diameter of the oropharynx between the levels of the uvula and the tip of the epiglottis (nPAS). RESULTSThe incidence of dysphagia after OCF was 18.18% (4/22). The pre- and postoperative mean nPAS values were significantly different between the groups (p<.05). The postoperative mean O-EAa of the group with dysphagia was significantly smaller than that of the group without dysphagia (p<.05). The mean change in nPAS was significantly larger in the group with dysphagia than that in the group without dysphagia (p<.05). The changes in the O-EAa, O-C2a, and nPAS were linearly correlated within patients. The marginal R2 values for the patients were 0.452 and 0.202 for the O-EAa and O-C2a, respectively. CONCLUSIONSThe O-EAa impacts dysphagia in patients with AAS after OCF. Measuring this angle intraoperatively may be a simple and effective procedure. The O-EAa may be used as a practical index to avoid postoperative dysphagia in patients with AAS after OCF.

Atlantoaksiyel Eklem Başlangıçlı Psöriatik Artrit

Psoriasis is an inflammatory skin condition that presents with red scaly rash often in extensor surfaces but may also affect the scalp and flexural areas as well as palms and soles. Psoriatic arthritis spresents clinically as distal joint disease, polyarthritis, arthritis mutilans, oligoarthritis or axial disease. Atlantoaxial involvement is seen very rare in psoriatic arthritis. A typical case of psoriatic arthritis with atlantoaxial involvement and anterior atlantoaxial subluxation is discussed in the article. Anterior atlantoaxial subluxation were demonstrated by cervical x-rays, but we had a doubt about odontoid lytic erosions. Magnetic resonance imaging of the cervical spine revealed marked small fluid collection in the atlantoaxial joint and erosions in the odontoid process with contrasted T1 enhanced series. This report highlights that atlantoaxial involvement may be an early feature of psoriatic arthritis. Furthermore this can be the earliest joint impaction.

Atlantoaxial Subluxation in Rheumatoid Arthritis

The first description of the cervical spine involvement in patients with rheumatoid arthritis (RA) dates to 1890 and was made by Sir Archibald Edward Garrod1. RA is the most common inflammatory disease involving the cervical spine2, and anterior atlantoaxial subluxation, resulting from laxity of the primary and secondary ligamentous restraints, is the most common cervical deformity associated with RA3. In February 2013, a 40-year-old white …

Reduction of Atlantoaxial Subluxation Causes Airway Stenosis

A cross-sectional study. The purpose of this study was to investigate the effect of reduction of anterior atlantoaxial subluxation (AAS) on the oropharyngeal airway space. Our previous studies have shown that reduction of the occipito-C2 angle (O-C2A) makes the mandible shift posteriorly, resulting in oropharyngeal airway stenosis, which occasionally causes postoperative dysphagia after occipitocervical fusion. Based on this background, we hypothesized that reduction of AAS would also cause oropharyngeal airway stenosis independent of the O-C2A, because it also shifts the mandible posteriorly. To our knowledge, there are no data demonstrating an association between reduction of AAS and the oropharyngeal airway space. The authors prospectively evaluated 64 patients with rheumatoid arthritis. We analyzed lateral cervical plain radiographs of 5 different positions (neutral, flexion, extension, retraction, and protrusion), and measured the O-C2A, C2-C6 angle, anterior atlantodental interval, anteroposterior distance of the narrowest oropharyngeal airway space (nPAS), and so on. The subjects were classified into 2 groups: group R comprised patients with a "reducible AAS" in dynamic cervical movement, and group N comprised "patients without AAS" patients. In the multiple regression analysis, the change in the O-C2A was the only significant independent variable related to the percentage change in the nPAS from the neutral position in group N. On the contrary, the change in the anterior atlantodental interval and change in the O-C2A were significantly related to the percentage change in the nPAS in group R. No cases in group N and 7 cases (28%) in group R showed a paradoxical decrease in the nPAS in extension, in which the O-C2A is largest and reduction of AAS is obtained. Reduction of AAS has a negative effect on the oropharyngeal airway space. Therefore, reduction of AAS during occipitocervical fusion may cause postoperative dysphagia despite maintenance of the O-C2A.

Long-term follow-up of the cervical spine with conventional radiographs in patients with rheumatoid arthritis

Objectives: To investigate the prevalence of cervical spine damage due to rheumatoid arthritis (RA) in the long term and to investigate which disease-specific factors are related to this damage.Method: Patients with early RA from the Nijmegen inception cohort with 6 to 12 years of follow-up were included. Conventional radiographs of the cervical spine were obtained at baseline, 3, 6, 9, and 12 years and scored for erosions of C1 and C2, anterior atlantoaxial subluxation (AAS) and atlantoaxial impaction (AAI). Disease-specific factors, such as disease activity, functionality, and peripheral joint damage, at baseline, 3, 6, and 9 years, were compared between patients with and without cervical spine damage at 9 years.Results: A total of 196 patients were included, of whom 134 had radiographs at 9 years. Cervical spine damage was present in 16% (22/134) of the patients at 9 years. During the total 12 years of follow-up, AAS and erosions of C2 were observed most frequently. Erosions of C1 and AAI were very rare. Patients with cervical spine damage at 9 years had a higher number of erosions of the peripheral joints and failed more disease-modifying anti-rheumatic drugs (DMARDs) at 3, 6, and 9 years. Patients without peripheral erosive disease at 3 years were unlikely to develop cervical spine damage within 9 years of disease duration.Conclusions: The prevalence of cervical spine damage due to RA was 16% at 9 years. Patients without peripheral erosive disease at 3 years were unlikely to develop cervical spine damage at 9 years.

Congenital anterior midline cleft of the atlas and posterior atlanto-occipital fusion associated with symptomatic anterior atlantoaxial subluxation.

Congenital partial anterior arch defect of the atlas is extremely rare. It could be found as an incidental radiological finding or patients can present with neurological deficit after head or neck trauma. To describe an extremely rare presentation of anterior midline cleft at the atlas and congenital posterior atlanto-occipital fusion with symptomatic anterior atlantoaxial subluxation. This report includes a feasible hypothesis for the development of this anomaly on the basis of previous hypotheses and surgical findings. A 46-year-old female presented with a 6-day history of right limbs numb and left upper and lower extremities paraparesis (Frankel D). Radiographs of the cervical spine showed anterior atlantoaxial subluxation with congenital posterior atlanto-occipital fusion. Computed tomography subsequently revealed partial midline absence of the anterior arch of the atlas and the odontoid tip ahead of the anterior arch of the atlas. Magnetic resonance imaging showed that the cervical dura was compressed by the remnant of anterior arch of the atlas. The patient underwent Gardner-Wells tong traction and surgery of occipitocervical fusion with autogenous iliac bone graft because she had definite neurological symptom and congenital posterior atlanto-occipital fusion. Atlantoaxial reduction was confirmed with fluoroscopic X-ray evaluation by bed, her neurological deficit was resolved from Frankel D to E, and numb of right limbs completely disappeared 6 days postoperation. No instability has been observed during 2-year follow-up. We describe the association between compressive myelopathy and congenital defect of the anterior arch of the atlas with symptomatic anterior atlantoaxial subluxation. Both computed tomography and magnetic resonance image were required to demonstrate the bony configuration and cord compression. And Gardner-Wells tong traction and surgery of occipitocervical fusion with autogenous iliac bone graft were effective as a treatment for this compressive myelopathy caused by the remnant of anterior arch of the atlas.

Radiological cervical spine involvement in young adults with polyarticular juvenile idiopathic arthritis

Radiological cervical spine involvement in JIA has already been assessed with a large range of prevalence (5-80%), but most studies were performed a long time ago, in symptomatic JIA and without differentiating subsets of JIA. We set out to describe structural cervical spine involvement in young adults with polyarticular JIA (pJIA) regardless of the cervical symptoms and to compare lesions with those observed in adult RA. All consecutive pJIAs followed in a transition programme were included. Standard radiographs of the cervical spine, hands, feet and hip were analysed by two independent radiologists blinded to the diagnosis. An RA control group (<55 years), matched for sex and disease duration, was recruited. Fifty-seven pJIA and 58 RA patients were included. Radiographs showed cervical lesions in 65% of pJIA and 67% of RA patients. In total, 51% of pJIA with radiographic abnormalities had no clinical symptoms. In pJIA, the most frequent structural lesions were anterior atlantoaxial subluxation (33%), erosion of the odontoid process (19%), C1-C2 arthritis (17%) and apophyseal joint arthritis (16%). Cervical lesions in pJIA were similar to those in RA except for ankylosis and hypotrophia (P < 0.05). The presence of cervical lesions correlated with a more severe disease. Structural cervical spine involvement is common in pJIA persisting into adulthood, frequently asymptomatic and associated with a more severe disease. We suggest that radiographic assessment of the cervical spine should be done systematically at onset of the disease and regularly during its course regardless of clinical symptoms.

Changes in the cervical spine of children with juvenile idiopathic arthritis evaluated with lateral cephalometric radiographs:A case control study

To evaluate whether plain lateral cephalometric radiographs in the neutral position could be used as a diagnostic tool to investigate changes in the cervical spine related to juvenile idiopathic arthritis (JIA). Lateral cephalometric radiographs of 82 subjects, 21 males and 61 females (8-25 years old), affected with JIA were revised and compared with 82 healthy control subjects matched in age and gender. Changes inspected in the cervical spine were erosions of the dens and fusion of the apophyseal joints. Anterior atlantoaxial subluxation of the first vertebra in relation to the second was examined by measuring the anterior atlanto-dens interval (aADI). Atlantoaxial impaction (AAI) was studied by using the Sakaguchi-Kauppi method. In the JIA sample, erosion was seen in 14.7%, (12 patients), of the patients and apophyseal joint ankylosis (fusion) in 18.3%, (15 patients). Three children and one adult had aADI more than 4.5 or 3 mm, respectively, which is considered to be abnormally increased, and AAI was noted in 13.0% of the subjects. In total, 35%, (29 children), of the children with JIA showed one or several radiographically visible changes as described earlier. Two of the control subjects showed ankylosis of the apophyseal joints, and one had aADI of 4 mm. Compared with the controls, significantly more changes were found in the JIA group. It can be concluded that arthritic changes in the cervical spine can be detected at a young age on plain lateral cephalometric radiographs and should be evaluated when available.

Assessment of cervical pain and function in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by inflammation of the synovial membrane, which can lead to deformities and functional disability. Unlike the dorsal and lumbar spine, the cervical spine is often affected by RA. The objective of this paper is to assess cervical pain and function in patients with RA and correlate these variables with overall function, quality of life, and radiographic findings on the cervical spine. One hundred individuals aged 18 to 65 years were divided into study group (50 patients with rheumatoid arthritis) and control group (50 healthy individuals, paired for gender and age). Patients with prior surgery, prior trauma or other symptomatic cervical spine condition were excluded. The visual analogue pain scale (VAS), Neck Pain and Disability Scale (NPDS), SF-36, HAQ and X-rays were used for evaluation purposes. Mean disease duration was 11.1 years. The cervical VAS was 2.4 cm and 1.3 cm for the study and control groups, respectively (p = 0.074). Statistical differences were found in NPDS scores, mean = 26.7 and 6.9, and HAQ scores, mean = 1.1 and 0.1, for the study and control groups, respectively (p < 0.001). SF-36 scores were statistically worse in the study group, except for the vitality, social aspects and mental health subscales. There was a positive correlation between the NPDS and VAS (r = 0.54) and between the NPDS and HAQ (r = 0.67). There was a negative correlation between the NPDS and SF-36 functional capacity domain (r = -0.53) and physical limitation domain (r = -0.58). The radiographic findings revealed more prevalent anterior atlanto-axial subluxation (p = 0.030), listhesis in neutral posture (p = 0.037), listhesis in extension (p = 0.007), degenerative alteration of C4-C5 segment (p = 0.023), size of C2 spinal canal (p = 0.002) and C3 spinal canal (p = 0.029) in the study group. Patients with RA have poorer cervical function than healthy individuals, although there is no difference in cervical pain.

Transnasal endoscopic odontoidectomy after occipito-cervical fusion during the same operative setting—technical note

Recently, a purely transnasal endoscopic approach (TNEA) for decompression of the anterior cranio-cervical junction has been described. At present, there is only a limited number of patients having been operated on in a few specialized centers. The possibilities, safety, and limits of this approach are still under investigation. The relationship between TNEA and occipito-cervical fusion, especially, which may typically be considered in this kind of pathologies, should be further elucidated. So far, the feasibility of TNEA after previous occipito-cervical fusion has only been reported for a single case. In that case, there was a posterior atlanto-axial subluxation and basilar invagination. In the present paper, another example of a surgical procedure of TNEA after previous posterior fusion during the same operative setting is given. It differs from the other case concerning the pathophysiology. In fact, here, there was anterior atlanto-axial subluxation and no basilar invagination. The possibilities and limits of this novel approach are thoroughly discussed. Special interest is given to the problem of CCJ instability and previous occipito-cervical fusion. Technical hints and pitfalls are described in detail.

Risk factors for development and progression of atlantoaxial subluxation in Korean patients with rheumatoid arthritis

We sought to evaluate the frequency of cervical spine (C-spine) involvement, and associated risk factors for this disorder and its progression in Korean patients with rheumatoid arthritis (RA). From 1995 to 2008, we recruited patients with RA attending the rheumatology clinic of a single tertiary care hospital, and evaluated 1,120 of the patients who had neck pain for C-spine involvement. A diagnosis of C-spine involvement was made in 28.6% of patients evaluated, and within this group, anterior atlantoaxial subluxation (AAS) and subaxial subluxation were found in 89.7 and 15%, respectively. Of the 1,120 patients, 570 patients were followed for more than 3years. Comparing the clinical characteristics of 193 patients with C-spine involvement and 377 patients without C-spine involvement, we found the associations with female gender, RA diagnosis at or before age 45, erosive changes in hand or foot radiographs, C-reactive protein levels and erythrocyte sedimentation rates at the time of first visit, and combination disease-modifying anti-rheumatic drug (DMARD) therapy. We found using logistic regression analysis that significant predictors of C-spine involvement included erosion in hand or foot radiographs (OR=2.22, p=0.001) and RA diagnosis at or before age 45 (OR=2.26, p<0.001). Among 137 patients followed for more than 3years, for whom at least two consecutive X-rays were available, we observed radiographic progression in 60.4%. Patients with and without radiologic evidence for cervical progression did not differ significantly in clinical characteristics. In conclusion, Korean patients with RA frequently show radiographic evidence for progressive involvement of the cervical spine. Significant risk factors for C-spine involvement may be associated with erosive peripheral joint disease and RA diagnosis at an early age.

MRI of the transverse and alar ligaments in rheumatoid arthritis: feasibility and relations to atlantoaxial subluxation and disease activity

Dysfunctional transverse and alar craniovertebral ligaments can cause instability and osseous destruction in rheumatoid arthritis (RA). This study examined (1) the feasibility of high-resolution magnetic resonance imaging (MRI) of these ligaments in RA and (2) the relation between ligament high-signal changes and atlantoaxial subluxation and RA duration/severity. Consecutive RA patients (n=46) underwent clinical examination, functional radiography, and high-resolution MRI. Two blinded radiologists rated MRI image quality, graded ligament high-signal changes 0-3 on proton-weighted sequences using an existing grading system, and assessed cervical spine rheumatic changes on short tau inversion recovery images. Agreement was analyzed using kappa and relations using multiple logistic regression. MRI images had good quality in 42 (91.3%) of 46 patients and were interpretable in 44 (32 women and 12 men, median age/disease duration 60.4/9.1 years). MRI grades 2-3 changes of the transverse and alar ligaments showed moderate and good interobserver agreement (kappa 0.59 and 0.78), respectively, and prevalence 31.8% and 34.1%. Such ligament changes were more frequent with increasing anterior atlantoaxial subluxation (p=0.012 transverse, p=0.028 alar), higher erythrocyte sedimentation rate (p=0.003 transverse), positive rheumatoid factor (p=0.002 alar), and neck pain (p=0.004 alar). This first study of high-resolution MRI of these ligaments in RA showed high feasibility and relations with atlantoaxial subluxation, RA disease activity, and neck pain. The clinical usefulness of such MRI needs further evaluation.