Cervical subluxation in rheumatoid arthritis
- Peter H Schur, MD
Peter H Schur, MD
- Editor-in-Chief — Rheumatology
- Section Editor — Basic Science
- Professor of Medicine
- Harvard Medical School
- Bradford L Currier, MD
Bradford L Currier, MD
- Professor of Orthopedics
- Mayo Clinic
- Section Editor
- Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
- Section Editor — Rheumatoid Arthritis
- Emeritus Professor of Rheumatology, Imperial College London
- Visiting Professor, Oxford University
The discovertebral joints in the cervical spine may be affected in patients with rheumatoid arthritis (RA) with resulting osteochondral destruction [1,2]. A review of the clinical manifestations and treatment of atlantoaxial (C1 to C2) and subaxial subluxation in RA is presented here. The clinical features and general medical management of RA, as well as the differential diagnosis and general evaluation of the patient with neck pain and of cervical spine disorders, are discussed separately. (See "Clinical manifestations of rheumatoid arthritis" and "General principles of management of rheumatoid arthritis in adults" and "Evaluation of the patient with neck pain and cervical spine disorders".)
Cervical joint destruction in patients with rheumatoid arthritis (RA) may lead to vertebral malalignment (eg, subluxation), causing pain, neurological deficit, and deformity. Risk factors for development of cervical subluxation include older age at onset of RA, more active synovitis, higher levels of C-reactive protein, rapidly progressive erosive peripheral joint disease, and early peripheral joint subluxations [3,4]. Both atlantoaxial and subaxial (below C2) joints may be involved.
Atlantoaxial disease — Among the joints of the cervical spine, the atlantoaxial joint is prone to subluxation in multiple directions, potentially leading to cervical myelopathy . The atlas (C1) can move anteriorly, posteriorly, vertically, laterally, or rotationally relative to the axis (odontoid and body of C2):
●Abnormal anterior movement on the axis is the most common type of subluxation. It often results from laxity of the transverse ligament induced by proliferative C1 to C2 synovial tissue, but may also occur as a result of erosion or fracture of the odontoid process .
●Posterior movement on the axis can occur only if the odontoid peg has been fractured from the axis or has been destroyed.
- Bland J. Rheumatoid arthritis of the cervical spine. J Rheumatol 1974; 1:319.
- Ball J. Enthesopathy of rheumatoid and ankylosing spondylitis. Ann Rheum Dis 1971; 30:213.
- Neva MH, Isomäki P, Hannonen P, et al. Early and extensive erosiveness in peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis. Arthritis Rheum 2003; 48:1808.
- Paimela L, Laasonen L, Kankaanpää E, Leirisalo-Repo M. Progression of cervical spine changes in patients with early rheumatoid arthritis. J Rheumatol 1997; 24:1280.
- Santavirta S, Kankaanpää U, Sandelin J, et al. Evaluation of patients with rheumatoid cervical spine. Scand J Rheumatol 1987; 16:9.
- Kauppi M, Sakaguchi M, Konttinen YT, et al. Pathogenetic mechanism and prevalence of the stable atlantoaxial subluxation in rheumatoid arthritis. J Rheumatol 1996; 23:831.
- Chang DJ, Paget SA. Neurologic complications of rheumatoid arthritis. Rheum Dis Clin North Am 1993; 19:955.
- Davidson RC, Horn JR, Herndon JH, Grin OD. Brain-stem compression in rheumatoid arthritis. JAMA 1977; 238:2633.
- Martel W. Pathogenesis of cervical discovertebral destruction in rheumatoid arthritis. Arthritis Rheum 1977; 20:1217.
- Bywaters EG. Rheumatoid and other diseases of the cervical interspinous bursae, and changes in the spinous processes. Ann Rheum Dis 1982; 41:360.
- Winfield J, Young A, Williams P, Corbett M. Prospective study of the radiological changes in hands, feet, and cervical spine in adult rheumatoid disease. Ann Rheum Dis 1983; 42:613.
- Collins DN, Barnes CL, FitzRandolph RL. Cervical spine instability in rheumatoid patients having total hip or knee arthroplasty. Clin Orthop Relat Res 1991; :127.
- Ward MM. Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983-2001. Arthritis Rheum 2004; 50:1122.
- Neva MH, Kaarela K, Kauppi M. Prevalence of radiological changes in the cervical spine--a cross sectional study after 20 years from presentation of rheumatoid arthritis. J Rheumatol 2000; 27:90.
- Henderson DR. Vertical atlanto-axial subluxation in rheumatoid arthritis. Rheumatol Rehabil 1975; 14:31.
- Zikou AK, Alamanos Y, Argyropoulou MI, et al. Radiological cervical spine involvement in patients with rheumatoid arthritis: a cross sectional study. J Rheumatol 2005; 32:801.
- Fujiwara K, Fujimoto M, Owaki H, et al. Cervical lesions related to the systemic progression in rheumatoid arthritis. Spine (Phila Pa 1976) 1998; 23:2052.
- Stevens JC, Cartlidge NE, Saunders M, et al. Atlanto-axial subluxation and cervical myelopathy in rheumatoid arthritis. Q J Med 1971; 40:391.
- Nakano KK, Schoene WC, Baker RA, Dawson DM. The cervical myelopathy associated with rheumatoid arthritis: analysis of patients, with 2 postmortem cases. Ann Neurol 1978; 3:144.
- Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993; 75:1282.
- Mayer JW, Messner RP, Kaplan RJ. Brain stem compression in rheumatoid arthritis. JAMA 1976; 236:2094.
- MARTEL W. The occipito-atlanto-axial joints in rheumatoid arthritis and ankylosing spondylitis. Am J Roentgenol Radium Ther Nucl Med 1961; 86:223.
- Weissman BN, Aliabadi P, Weinfeld MS, et al. Prognostic features of atlantoaxial subluxation in rheumatoid arthritis patients. Radiology 1982; 144:745.
- Lipson SJ. Rheumatoid arthritis in the cervical spine. Clin Orthop Relat Res 1989; :121.
- Bell GR, Stearns KL. Flexion-extension MRI of the upper rheumatoid cervical spine. Orthopedics 1991; 14:969.
- Neva MH, Häkkinen A, Mäkinen H, et al. High prevalence of asymptomatic cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery. Ann Rheum Dis 2006; 65:884.
- Raskin RJ, Schnapf DJ, Wolf CR, et al. Computerized tomography in evaluation of atlantoaxial subluxation in rheumatoid arthritis. J Rheumatol 1983; 10:33.
- Braunstein EM, Weissman BN, Seltzer SE, et al. Computed tomography and conventional radiographs of the craniocervical region in rheumatoid arthritis. A comparison. Arthritis Rheum 1984; 27:26.
- Breedveld FC, Algra PR, Vielvoye CJ, Cats A. Magnetic resonance imaging in the evaluation of patients with rheumatoid arthritis and subluxations of the cervical spine. Arthritis Rheum 1987; 30:624.
- DAVIS FW Jr, MARKLEY HE. Rheumatoid arthritis with death from medullary compression. Ann Intern Med 1951; 35:451.
- Stiskal MA, Neuhold A, Szolar DH, et al. Rheumatoid arthritis of the craniocervical region by MR imaging: detection and characterization. AJR Am J Roentgenol 1995; 165:585.
- Glew D, Watt I, Dieppe PA, Goddard PR. MRI of the cervical spine: rheumatoid arthritis compared with cervical spondylosis. Clin Radiol 1991; 44:71.
- Narváez JA, Narváez J, Serrallonga M, et al. Cervical spine involvement in rheumatoid arthritis: correlation between neurological manifestations and magnetic resonance imaging findings. Rheumatology (Oxford) 2008; 47:1814.
- Narváez JA, Narváez J, de Albert M, et al. Bone marrow edema in the cervical spine of symptomatic rheumatoid arthritis patients. Semin Arthritis Rheum 2009; 38:281.
- Dickman CA, Mamourian A, Sonntag VK, Drayer BP. Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability. J Neurosurg 1991; 75:221.
- Martel W. Fatal atlanto-axial luxation in rheumatoid arthritis. Arthritis Rheum 1963; 6:224.
- Laiho K, Soini I, Kautiainen H, Kauppi M. Can we rely on magnetic resonance imaging when evaluating unstable atlantoaxial subluxation? Ann Rheum Dis 2003; 62:254.
- Pellicci PM, Ranawat CS, Tsairis P, Bryan WJ. A prospective study of the progression of rheumatoid arthritis of the cervical spine. J Bone Joint Surg Am 1981; 63:342.
- Smith PH, Benn RT, Sharp J. Natural history of rheumatoid cervical luxations. Ann Rheum Dis 1972; 31:431.
- Isdale IC, Conlon PW. Atlanto-axial subluxation. A six-year follow-up report. Ann Rheum Dis 1971; 30:387.
- Mathews JA. Atlanto-axial subluxation in rheumatoid arthritis. A 5-year follow-up study. Ann Rheum Dis 1974; 33:526.
- Winfield J, Cooke D, Brook AS, Corbett M. A prospective study of the radiological changes in the cervical spine in early rheumatoid disease. Ann Rheum Dis 1981; 40:109.
- Mikulowski P, Wollheim FA, Rotmil P, Olsen I. Sudden death in rheumatoid arthritis with atlanto-axial dislocation. Acta Med Scand 1975; 198:445.
- Meijers KA, Cats A, Kremer HP, et al. Cervical myelopathy in rheumatoid arthritis. Clin Exp Rheumatol 1984; 2:239.
- Wolfs JF, Kloppenburg M, Fehlings MG, et al. Neurologic outcome of surgical and conservative treatment of rheumatoid cervical spine subluxation: a systematic review. Arthritis Rheum 2009; 61:1743.
- Matsunaga S, Sakou T, Onishi T, et al. Prognosis of patients with upper cervical lesions caused by rheumatoid arthritis: comparison of occipitocervical fusion between c1 laminectomy and nonsurgical management. Spine (Phila Pa 1976) 2003; 28:1581.
- Hamilton JD, Johnston RA, Madhok R, Capell HA. Factors predictive of subsequent deterioration in rheumatoid cervical myelopathy. Rheumatology (Oxford) 2001; 40:811.
- Casey AT, Crockard HA, Bland JM, et al. Surgery on the rheumatoid cervical spine for the non-ambulant myelopathic patient-too much, too late? Lancet 1996; 347:1004.
- Neva MH, Kauppi MJ, Kautiainen H, et al. Combination drug therapy retards the development of rheumatoid atlantoaxial subluxations. Arthritis Rheum 2000; 43:2397.
- Kauppi MJ, Neva MH, Laiho K, et al. Rheumatoid atlantoaxial subluxation can be prevented by intensive use of traditional disease modifying antirheumatic drugs. J Rheumatol 2009; 36:273.
- Kauppi M, Anttila P. A stiff collar for the treatment of rheumatoid atlantoaxial subluxation. Br J Rheumatol 1996; 35:771.
- Althoff B, Goldie IF. Cervical collars in rheumatoid atlanto-axial subluxation: a radiographic comparison. Ann Rheum Dis 1980; 39:485.
- Hakkinen A, Makinen H, Ylinen J, et al. Stability of the upper neck during isometric neck exercises in rheumatoid arthritis patients with atlantoaxial disorders. Scand J Rheumatol 2008; 37:343.
- Schmitt-Sody M, Kirchhoff C, Buhmann S, et al. Timing of cervical spine stabilisation and outcome in patients with rheumatoid arthritis. Int Orthop 2008; 32:511.
- Paus AC, Steen H, Røislien J, et al. High mortality rate in rheumatoid arthritis with subluxation of the cervical spine: a cohort study of operated and nonoperated patients. Spine (Phila Pa 1976) 2008; 33:2278.
- Agarwal AK, Peppelman WC, Kraus DR, et al. Recurrence of cervical spine instability in rheumatoid arthritis following previous fusion: can disease progression be prevented by early surgery? J Rheumatol 1992; 19:1364.
- Yonenobu K, Hosono N, Iwasaki M, et al. Neurologic complications of surgery for cervical compression myelopathy. Spine (Phila Pa 1976) 1991; 16:1277.
- Hamilton JD, Gordon MM, McInnes IB, et al. Improved medical and surgical management of cervical spine disease in patients with rheumatoid arthritis over 10 years. Ann Rheum Dis 2000; 59:434.
- Wolfs JF, Peul WC, Boers M, et al. Rationale and design of The Delphi Trial--I(RCT)2: international randomized clinical trial of rheumatoid craniocervical treatment, an intervention-prognostic trial comparing 'early' surgery with conservative treatment [ISRCTN65076841]. BMC Musculoskelet Disord 2006; 7:14.
- Nannapaneni R, Behari S, Todd NV. Surgical outcome in rheumatoid Ranawat Class IIIb myelopathy. Neurosurgery 2005; 56:706.
- Henderson FC, Geddes JF, Crockard HA. Neuropathology of the brainstem and spinal cord in end stage rheumatoid arthritis: implications for treatment. Ann Rheum Dis 1993; 52:629.
- Rath SA, Moszko S, Schäffner PM, et al. Accuracy of pedicle screw insertion in the cervical spine for internal fixation using frameless stereotactic guidance. J Neurosurg Spine 2008; 8:237.
- Mizutani J, Matsubara T, Fukuoka M, et al. Application of full-scale three-dimensional models in patients with rheumatoid cervical spine. Eur Spine J 2008; 17:644.
- Zygmunt SC, Christensson D, Säveland H, et al. Occipito-cervical fixation in rheumatoid arthritis--an analysis of surgical risk factors in 163 patients. Acta Neurochir (Wien) 1995; 135:25.