Treatment of upper cervical spine involvement in rheumatoid arthritis patients

Background Disorders of the cervical spine are often observed in patients with rheumatoid arthritis (RA). However, the best head position for RA patients with atlantoaxial subluxation in the perioperative period is unknown. This study investigated head position during general anesthesia for the patients with RA and proven atlantoaxial subluxation. Methods During anesthesia of patients with RA and proven atlantoaxial subluxation, the authors used fluoroscopy to obtain a lateral view of the upper cervical spine in four different positions: the mask position, the intubation position, the flat pillow position, and the protrusion position. Copies of the still fluoroscopic images were used to determine the anterior atlantodental interval, the posterior atlantodental interval, and the angle of atlas and axis (C1-C2 angle). Results The anterior atlantodental interval was significantly smaller in the protrusion position (2.3 mm) than in the flat pillow position (5.1 mm) (P < 0.05). The posterior atlantodental interval was significantly greater in the protrusion position (18.9 mm) than in the flat pillow position (16.2 mm) (P < 0.05). The C1-C2 angle was, on average, 9.3 degrees greater in the protrusion position than in the flat pillow position (P < 0.05). Conclusion This study showed that the protrusion position using a flat pillow and a donut-shaped pillow during general anesthesia reduced the anterior atlantodental interval and increased the posterior atlantodental interval in RA patients with atlantoaxial subluxation. This suggests that the protrusion position, which involves support of the upper cervical spine and extension at the craniocervical junction, might be advantageous for these patients.

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Evaluation of flexion/extension of the upper cervical spine in patients with rheumatoid arthritis: an MRI study with a dedicated positioning device compared to conventional radiographs

Acta Radiologica ◽

10.1080/02841850510012012 ◽

2005 ◽

Vol 46 (1) ◽

pp. 55-66 ◽

Cited By ~ 26

Author(s):

J. O. Karhu ◽

R. K. Parkkola ◽

S. K. Koskinen

Keyword(s):

Rheumatoid Arthritis ◽

Cervical Spine ◽

Healthy Subjects ◽

Upper Cervical Spine ◽

Imaging Method ◽

Neutral Position ◽

Segmental Motion ◽

Flexion Extension ◽

Upper Cervical ◽

Positioning Device

Purpose: Using flexion/extension magnetic resonance imaging (MRI) with a dedicated positioning device, our purpose was to analyze pathologic cranio‐vertebral joint anatomy and motion in patients with rheumatoid arthritis in comparison to normal patients, and to compare flexion/extension MRI with conventional radiographs (CRs) in patients with rheumatoid arthritis. Material and Methods: The 31 patients with rheumatoid arthritis and 20 healthy subjects included in the study were imaged in an open MRI scanner during flexion/extension. A dedicated positioning device was used. Additionally, we compared flexion/extension MRI with CRs in patients with rheumatoid arthritis. In MRI, the orientation and segmental motion of C0, C1, and C2 were assessed and structure of the dens and amount of pannus tissue were observed. Configuration of the cerebrospinal fluid space and the cord was evaluated in each position. In both MRI and CRs, anterior atlanto‐axial subluxation and vertical dislocation were assessed and sagittal diameter of the dural sac was measured. Results: In the neutral position, C1 of the patients was oriented in a more flexed position in relation to both C0 and C2 compared to that in healthy subjects. The patients had more extension in the upper cervical spine than did healthy subjects. In flexion, atlanto‐axial subluxation was greater in CRs than in MRI. In MRI, the amount of vertical dislocation did not depend on position. In the patients, there was considerably more cord impingement in flexion than in other positions. Conclusion: Evaluation of the rheumatoid cervical spine is optimized using MR images in the neutral, flexed, and extended positions. Measurements and relationships between structures should be compared in all positions. CRs with flexion‐extension views are recommended as the first imaging method.

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THU0213 The importance of screening and spinal instrumentation in patients with instability of upper cervical spine due to rheumatoid arthritis

10.1136/annrheumdis-2001.1115 ◽

2001 ◽

Author(s):

Z Klezl ◽

M Vesela ◽

J Fousek ◽

K Pavelka

Keyword(s):

Rheumatoid Arthritis ◽

Cervical Spine ◽

Spinal Instrumentation ◽

Upper Cervical Spine ◽

Upper Cervical

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The characteristics of bony ankylosis of the facet joint of the upper cervical spine in rheumatoid arthritis patients

European Spine Journal ◽

10.1007/s00586-009-1023-8 ◽

2009 ◽

Vol 18 (8) ◽

pp. 1130-1134 ◽

Cited By ~ 7

Author(s):

Haku Iizuka ◽

Masahiro Nishinome ◽

Yasunori Sorimachi ◽

Tsuyoshi Ara ◽

Takashi Nakajima ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Cervical Spine ◽

Facet Joint ◽

Upper Cervical Spine ◽

Upper Cervical ◽

Bony Ankylosis

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Rheumatoid Arthritis Affecting the Upper Cervical Spine: Biomechanical Assessment of the Stabilizing Ligaments

BioMed Research International ◽

10.1155/2017/6131703 ◽

2017 ◽

Vol 2017 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Carolin Meyer ◽

Jan Bredow ◽

Elisa Heising ◽

Peer Eysel ◽

Lars Peter Müller ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Cervical Spine ◽

Neurological Disorders ◽

Cord Compression ◽

Upper Cervical Spine ◽

Neutral Position ◽

Transverse Ligament ◽

Alar Ligaments ◽

Upper Cervical

Diameters of anterior and posterior atlantodental intervals (AADI and PADI) are diagnostically conclusive regarding ongoing neurological disorders in rheumatoid arthritis. MRI and X-ray are mostly used for patients’ follow-up. This investigation aimed at analyzing these intervals during motion of cervical spine, when transverse and alar ligaments are damaged. AADI and PADI of 10 native, human cervical spines were measured using lateral fluoroscopy, while the spines were assessed in neutral position first, in maximal inclination second, and in maximal extension at last. First, specimens were evaluated under intact conditions, followed by analysis after transverse and alar ligaments were destroyed. Damage of the transverse ligament leads to an increase of the AADI’s diameter about 0.65 mm in flexion and damage of alar ligaments results in significant enhancement of 3.59 mm at mean. In extension, the AADI rises 0.60 mm after the transverse ligament was cut and 0.90 mm when the alar ligaments are damaged. After all ligaments are destroyed, AADI assessed in extension closely resembles AADI at neutral position. Ligamentous damage showed an average significant decrease of the PADI of 1.37 mm in the first step and of 3.57 mm in the second step in flexion, while it is reduced about 1.61 mm and 0.41 mm in the extended and similarly in the neutrally positioned spine. Alar and transverse ligaments are both of obvious importance in order to prevent AAS and movement-related spinal cord compression. Functional imaging is necessary at follow-up in order to identify patients having an advanced risk of neurological disorders.

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