Spine In Rheumatoid Arthritis Research Articles

Update on imaging of the cervical spine in rheumatoid arthritis.

Rheumatoid arthritis is a multisystem, autoimmune, inflammatory disorder with numerous musculoskeletal manifestations. Involvement of the cervical spine is common and may result in severe complications due to synovitis, erosions, pannus formation, spinal instability and ankylosis. The purpose of this article is to review the current role of imaging in the rheumatoid spine, with emphasis on radiographs and MRI.

Поражение позвоночника при ревматоидном артрите

Ревматоидный артрит (РА) относится к наиболее частым воспалительным заболеваниям суставов, приводящим к стойкой инвалидизации и ранней смерти больных, а одним из частых проявлений РА является поражение позвоночника, которое значительно ухудшает качество жизни таких пациентов. Цель исследования: оценить поражение позвоночника у больных с разными вариантами течения РА и факторы, его определяющие. Материал и методы. Под наблюдением находился 131 больной РА в возрасте от 18 до 79 лет (в среднем 45 лет), среди которых было 18 % мужчин и 82 % женщин. Длительность заболевания составила 10 лет, I рентгенологическая стадия артрита установлена в 8 % случаев заболевания, II — в 38 %, III — в 35 %, IV — в 19 %, серопозитивность по ревматоидному фактору отмечена у 77 % от числа обследованных пациентов, а по наличию антител к цитруллиновому циклическому пептиду — у 3/4. Внесуставная (системная) форма болезни имела место в 43 % наблюдений, системный остеопороз — в 67 %. Результаты. Поражение позвоночника в виде остеохондроза и спондилоартроза наблюдается у 1/2 от числа больных РА, причем клинически манифестно протекает в 35 % случаев, что прямо связано с возрастом пациентов, вовлечением в процесс лучезапястных, локтевых, тазобедренных и крестцовоподвздошных суставов, наличием системного остеопороза и тендовагинитов, сенсорных и моторных расстройств, обусловленных периферической нейропатией. Соотношение частоты механического, дисфиксационного, дисгемического и воспалительного характера боли в позвоночнике при РА составляет 1 : 2 : 6 : 14. На рентгенограммах обнаруживаются оссификация наружных слоев межпозвоночных дисков и формирование синдесмофитов, а также спондилодисцит. Вовлечение дугоотростчатых суставов характеризуется нечеткостью суставных поверхностей и сужением щелей. Вертебральная патология влияет на признаки патологии сердца (изменения электрической проводимости, размеры камер, диастолическую функцию левого желудочка), вегетативные изменения и тяжесть нейропатии, а прогностическими показателями являются уровни в крови ревматоидного фактора и С-реактивного протеина. Выводы. Спондилопатия является частым проявлением РА, взаимосвязана со многими клинико-лабораторными признаками заболевания. В будущем таким больным будет полезно активное раннее выявление патологии позвоночника для своевременных реабилитационных мероприятий.

IgA rheumatoid factor is associated with bone mineral density preservation in rheumatoid arthritis

Autoantibodies such as IgM rheumatoid factor (RF) and anti-citrullinated proteins/peptides antibodies (ACPA) have previously been incriminated in systemic bone loss in rheumatoid arthritis (RA). There are, however, no data describing association of IgA RF and IgG RF with systemic bone loss. This study was aimed to investigate the association of RF isotypes with systemic bone loss among patients with RA. RF isotypes and ACPA were measured by enzyme-linked immunosorbent assay among 153 patients with RA. Bone mineral density (BMD) was assessed using dual-energy X-ray absorptiometry. Ninety-four (61.4%) patients had positive IgA RF, 89 (58.2%) had positive IgG RF, 109 (71.2%) had positive IgM RF, whereas 122 (80.3%) RA patients tested positive for ACPA. Compared to the IgA RF-negative patients, IgA RF-positive patients exhibited higher disease activity and had higher RF titers. Seven (4.6%) patients had low BMD at femoral neck, 12 (7.8%) at total femur, and 47 (30.7%) at lumbar spine. IgA RF was found to be associated with protection against low BMD at spine (OR = 0.47, 95% CI = 0.23-0.95, p = 0.034). This association was further confirmed in the multivariate regression analysis taking into account several potential confounding factors(OR = 0.21, 95% CI = 0.06-0.65, p = 0.039). No association between low BMD and the presence of IgG RF or IgM RF or ACPA was found. IgA RF for the first time ever was shown to be associated with BMD preservation at spine in RA. Key points • IgA RF was associated with protection against low spinal BMD. • No association between low BMD and the presence of IgG RF or IgM RF was found.

Radiological Findings of the Cervical Spine in Rheumatoid Arthritis: What a Rheumatologist Should Know.

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting mainly the peripheral skeleton in a symmetrical manner rather than the axial skeleton, but when it occurs it can affect the cervical spine (CS). Although CS involvement is a frequent radiographic finding in RA, the clinical features are scarce, but potentially life-threatening with severe neurological deficits or even death due to brain stem compression. The commonest site of inflammation of the CS is the articulation between C1 and C2 vertebrae, the atlanto-axial region. The radiological finding observed in this region is the atlanto-axial subluxation (AAS). For the evaluation of CS in RA the classical diagnostic technique used mostly is conventional radiography (CR). Since CR does not provide good information regarding synovial inflammation, other imaging modalities are used such as magnetic resonance imaging and computed tomography. However, CR is the most valuable tool for screening CS in RA patients. Thus, we reviewed the literature until December 2019 for studies regarding CS radiological manifestations using CR in RA patients. We found that the frequency of radiological findings varies substantially, ranging between 0.7-95% in different studies. The commonest radiological feature was the AAS followed by subaxial subluxation. Because CS involvement can often be clinically asymptomatic, its assessment should not be forgotten by physicians and should be assessed using CR which is an easy to perform technique and gives important information as a screening tool.

Surgical Management of the Lumbar Spine in Rheumatoid Arthritis.

Study Design:Narrative review.Objective:To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited.Methods:Using PubMed, studies published prior to November 2018 with the keywords “RA, etiology”; “RA, spine management”; “RA, surgical management”; “RA, treatment”; “RA, DMARDs”; “RA, lumbar spine”; “RA, spine surgical outcomes”; “RA, imaging” were evaluated.Results:The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine.Conclusions:Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.

Bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis: Its characteristics and relationship to the clinical findings

Objectives: The purpose of this study was to clarify the characteristics of bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis (RA) patients who required cervical spine surgery, and its relationship to the clinical findings.Methods: Eighty consecutive RA patients with cervical spine disorder who received initial surgery were reviewed. The occurrence of bony ankylosis of the facet joint of the cervical spine was investigated using computed tomography (CT) before surgery. We also evaluated the severity of neurological symptoms and the plain wrist radiographs taken before surgery; furthermore, we evaluated each patient’s medical history for total knee arthroplasty (TKA) or hip arthroplasty (THA).Results: The preoperative CT imaging demonstrated bony ankylosis of the facet joint of the cervical spine in 45 facet levels of 19 cases (BA + group). In all patients, responsible instability or stenosis was demonstrated just caudal or on the cranial side of those bony ankylosis. Before surgery, the BA + group included significantly more patients showing severe cervical myelopathy (p < 0.05), and significantly more cases showing progressed ankylosis in the wrist joint bilaterally (p < 0.01). There were also significantly more patients who received two or more TKA or THA before the cervical spine surgery in the BA + group (p < 0.01).Conclusions: Bony ankylosis of the facet joint of the cervical spine may be a risk factor of instability or stenosis at the adjacent disc level and severe cervical myelopathy. Furthermore, its ankylosis was demonstrated in RA patients with severe destroyed joints.

Spinal Affections in Rheumatological Diseases

AbstractA brief resume of management of rheumatoid arthritis in India is highlighted causes of deformity its radiological features and the goals of its management are discussed. Management included medical drug treatment, physical therapy and surgical treatment including synovectomy, osteotomies and joint replacement. Brief description of involvement of cervical spine in rheumatoid arthritis is also made.The evolution of treatment of scoliosis starting from conservative to all stages of surgical treatment is also described. Surgical correction involved posterior instrumentation and fusion anterior release with or without instrumentation and fusion. Treatment of congenital and paralytic scoliosis is also discussed. Newer surgical modalities in treatment of paediatric scoliosis was also highlighted.

MRI evaluation of lumbar endplate and facet erosion in rheumatoid arthritis.

A cross-sectional study. This study was aimed to quantify the extent of lumbar endplate and facet joint erosion in patients with rheumatoid arthritis (RA) using magnetic resonance imaging, to calculate the prevalence of erosion, and sought correlated factors. Few studies have examined the lumbar spine in RA, especially the relationship between endplate and facet joint erosions and lumbar lesions induced by RA. A total of 201 patients with RA were enrolled. Lumbar endplate and facet joint erosion were defined as irregularities and low-intensity change on magnetic resonance imaging, and graded utilizing the Rheumatoid Arthritis Magnetic Resonance Imaging Score. Lumbar lesions were defined as scoliosis, spondylolisthesis, and vertebral fracture on plain x-ray. Multivariable logistic regression analysis was used to seek correlations between the erosion and spinal level, RA-related factors and x-ray findings. Lumbar endplate and facet erosion were detected in 70.6% and 76.6% of individuals, respectively, and at 33.8% and 38.7% of lumbar intervertebral levels, respectively. The severity of erosion in individual patients correlated with lumbar lesions. Endplate and facet erosion at each level correlated with high disease activity, and were most common at mid-lumbar and lower-lumbar levels. Strong correlations were observed between endplate erosion and adjacent vertebral body fracture or disk degeneration, and between facet erosion and spondylolisthesis. Lumbar endplate and facet erosion are common in RA, and are observed more frequently at mid-low levels and when RA is poorly controlled. This pattern of erosion may play a crucial role in the generation of lumbar lesions in RA.

Accelerated Development of Cervical Spine Instabilities in Rheumatoid Arthritis: A Prospective Minimum 5-Year Cohort Study

ObjectiveTo clarify the incidence and predictive risk factors of cervical spine instabilities which may induce compression myelopathy in patients with rheumatoid arthritis (RA).MethodsThree types of cervical spine instability were radiographically categorized into “moderate” and “severe” based on atlantoaxial subluxation (AAS: atlantodental interval >3 mm versus ≥10 mm), vertical subluxation (VS: Ranawat value <13 mm versus ≤10 mm), and subaxial subluxation (SAS: irreducible translation ≥2 mm versus ≥4 mm or at multiple). 228 “definite” or “classical” RA patients (140 without instability and 88 with “moderate” instability) were prospectively followed for >5 years. The endpoint incidence of “severe” instabilities and predictors for “severe” instability were determined.ResultsPatients with baseline “moderate” instability, including all sub-groups (AAS+ [VS− SAS−], VS+ [SAS− AAS±], and SAS+ [AAS± VS±]), developed “severe” instabilities more frequently (33.3% with AAS+, 75.0% with VS+, and 42.9% with SAS+) than those initially without instability (12.9%; p<0.003, p<0.003, and p = 0.061, respectively). The incidence of cervical canal stenosis and/or basilar invagination was also higher in patients with initial instability (17.5% with AAS+, 37.5% with VS+, and 14.3% with SAS+) than in those without instability (7.1%; p = 0.028, p<0.003, and p = 0.427, respectively). Multivariable logistic regression analysis identified corticosteroid administration, Steinbrocker stage III or IV at baseline, mutilating changes at baseline, and the development of mutilans during the follow-up period correlated with the progression to “severe” instability (p<0.05).ConclusionsThis prospective cohort study demonstrates accelerated development of cervical spine involvement in RA patients with pre-existing instability—especially VS. Advanced peripheral erosiveness and concomitant corticosteroid treatment are indicators for poor prognosis of the cervical spine in RA.

In vivo 3D kinematics of the upper cervical spine during head rotation in rheumatoid arthritis

The upper cervical spine is commonly involved in persons with rheumatoid arthritis (RA). Although 2D measurements have long been used in the evaluation of cervical lesions caused by RA, 2D measurements are limited in their effectiveness for detecting subtle and complex morphological and kinematic changes. The purpose of this study was to elucidate the 3D kinematics of the upper cervical spine in RA and the relationship between 3D morphological changes and decreased segmental rotational motion. Twenty-five consecutive patients (2 men and 23 women, mean age 63.5 years, range 42-77 years) with RA (the RA group) and 10 patients (5 men and 5 women, mean age 69.9 years, range 57-82 years) with cervical spondylosis and no involvement of the upper cervical spine (the control group) underwent 3D CT of the cervical spine in 3 positions (neutral, 45° head rotation to the left, and 45° head rotation to the right). The segmental rotation angle from the occiput (Oc) to C-2 was calculated for each participant using a voxel-based registration method, and the 3D destruction of articular facets was quantified using the authors' own parameter, the articular facet index. The segmental rotation angle was significantly smaller at C1-2 and larger at Oc-C1 in the RA group compared with the control group. The degree of the destruction of the articular facet at C-1 and C-2 correlated with the segmental rotation angle. In vivo 3D kinematics of the upper cervical spine during head rotation in patients with RA were accurately measured, allowing quantification of the degree of joint destruction for the first time. Joint destruction may play an important role in decreasing segmental motion of the upper cervical spine in RA.

Radiographic changes of the cervical spine in rheumatoid arthritis

IntroductionThe involvement of the cervical spine is a common feature of rheumatoid arthritis (RA). ObjectiveTo study the prevalence of radiographic changes of the cervical spine in patients with RA and their association with clinical and serological profiles of the disease. MethodsWe analysed lateral (neutral position, hyperextension, hyperflexion) and transoral views of cervical spine radiographs from 80 individuals with RA to investigate the presence of atlanto-axial subluxation (AAS), basilar invagination (BI), and subaxial instability (SAI). Demographic, clinical (nodules, interstitial pneumonitis, secondary Sjögren's syndrome, medications etc.), and serologic (rheumatoid factor - RF, cyclic citrullinated peptide antibody – anti-CCP, and antinuclear factor - ANF) data were obtained from the clinical records. ResultsCervical spine misalignments were identified in 26/80 (32.5%) participants; AAS occurred in 12/80 (15%) participants, BI in 6/80 (7.5%), and SAI in 13/80 (32.5%). Odontoid erosions were identified in 16/80 (20.0%) participants. Cervical spine misalignment exhibited associations with age at onset and disease duration (P=0.03 and 0.02, respectively). No associations were identified between the cervical spine changes and the participants’ ethnicity or gender, presence of nodules, interstitial pneumonitis, secondary Sjögren's syndrome, RF, ANF, or anti-CCP. The participants with cervical spine misalignment exhibited higher frequencies of odontoid erosion (P=0.03). ConclusionCervical spine misalignment was a common radiographic finding and occurred more frequently in participants with earlier onset and longer length of RA.

Incidence and Aggravation of Cervical Spine Instabilities in Rheumatoid Arthritis

A prospective minimum 5-year follow-up study of the cervical spine in patients with rheumatoid arthritis (RA) initially without cervical involvement. To clarify the incidence and aggravation of cervical spine instabilities and their predictive risk factors in patients with RA. Many reports have shown the progression of cervical spine involvement in RA. However, few articles have described comprehensive evaluation of its prognostic factors. A total of 140 patients with "definite" or "classical" RA initially without cervical involvement were prospectively followed for more than 5 years. Radiographical cervical findings were classified into 3 instabilities: atlantoaxial subluxation (AAS: atlantodental interval >3 mm), vertical subluxation (VS: Ranawat value <13 mm), and subaxial subluxation (SAS: irreducible translation ≥ 2 mm). "Severe" extents were defined as AAS with atlantodental interval 10 mm or more, VS with Ranawat value 10 mm or less, and SAS with translation 4 mm or more or at multiple levels. Incidence of these developments and predictors for "severe" instabilities were investigated. During 6.0 ± 0.5 years, 43.6% of 140 patients developed cervical instabilities: AAS in 32.1%, VS in 11.4%, and SAS in 16.4% with some combinations. "Severe" instabilities were exhibited in 12.9% of patients: AAS in 3.6%, VS in 6.4%, and SAS in 5.0%. Furthermore, 4.3% presented canal stenosis, with 13 mm or less space available for the spinal cord (SAC) due to "severe" AAS or "severe" VS in 2.9% and 12 mm or less SAC due to "severe" SAS in 2.1%. Multivariable logistic regression analysis identified corticosteroid administration, mutilating changes at baseline, and the development of nonmutilating into mutilating changes during the follow-up period correlated with "severe" instabilities (P < 0.05). A minimum 5-year follow-up reveals the occurrence of cervical instabilities in 43.6%, "severe" aggravation in 12.9%, and decreased SAC in 4.3% of patients with RA. Characteristics of severe disease activity-established mutilating changes, progressive development into mutilating changes, and potentially concomitant corticosteroid treatment-are indicators for poor prognosis of the cervical spine in RA.

Surgical Treatment for Subaxial Lesion of the Cervical Spine in Rheumatoid Arthritis

Surgical Treatment for Subaxial Lesion of the Cervical Spine in Rheumatoid Arthritis

Clinical Study of Cervical Spine in Rheumatoid Arthritis

Clinical Study of Cervical Spine in Rheumatoid Arthritis

Influence of Surgical Extent of Cervical Spine on Post-operative Subaxial Cervical Spine in Rheumatoid Arthritis

Influence of Surgical Extent of Cervical Spine on Post-operative Subaxial Cervical Spine in Rheumatoid Arthritis

Changes of the Cervical Spine in Rheumatoid Arthritis

Changes of the Cervical Spine in Rheumatoid Arthritis

Radiological changes of the upper cervical spine in rheumatoid arthritis.

Radiological changes of the upper cervical spine in rheumatoid arthritis.

A Radiographic Study of the Cervical Spine in Rheumatoid Arthritis

A Radiographic Study of the Cervical Spine in Rheumatoid Arthritis

Hypercalcemia in rheumatoid arthritis: relationship with disease activity and bone metabolism

To investigate the relationship between ionized calcium and disease activity, parameters of bone metabolism and bone mineral density (BMD) at the lumbar spine (BMD-LS) and the femoral neck (BMD-FN) measured by dual X-ray absorptiometry in rheumatoid arthritis (RA). In 146 patients with RA, the following parameters were investigated: serum levels of ionized calcium, total calcium, vitamin D metabolites 25-hydroxyvitamin D3 (25D3) and 1,25-dihydroxyvitamin D3 (1,25D3), intact parathyroid hormone (iPTH), interleukin-6, osteocalcin, erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP); renal excretion of pyridinolin (PYD)- and desoxypyridinolin (DPD)-crosslinks. A total of 30.1% of the patients were hypercalcemic (ionized calcium >1.30 mmol/l). In comparison with normocalcemic patients, those with hypercalcemia had significantly higher ESR (P<0.01) and CRP values (P<0.05) and significantly lower serum levels of both iPTH (P<0.01) and 1,25D3 (P<0.05) and a significantly lower BMD-LS (P<0.05). The results indicate that a substantial part of RA patients is hypercalcemic. Hypercalcemia is associated with high disease activity and may contribute to suppression of PTH secretion and vitamin D hormone synthesis. High levels of ionized calcium may be a reflection of disease-activity-related systemic bone loss, and could be a predictor of BMD at the lumbar spine in RA.

Tetraplegia in rheumatoid arthritis with complete recovery after surgery.

Abstract A patient with tetraplegia caused by subluxation of the lower cervical spine in rheumatoid arthritis is presented. The clinical history, early complication, and delayed diagnosis are described. Compression of the dura mater by rheumatoid granulation tissue and vertebral subluxation are suggested to be responsible for the cord damage. Failure of conservative treatment after a week is a strong indication for surgery. Posterior decompression of the cervical spine and splitting of the dura mater are recommended.