Neurosurgery notes/Spine/Special diseases of the spine/Rheumatoid arthritis (RA)

Rheumatoid arthritis (RA)

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Special diseases of the spine
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Anterior atlantoaxial subluxation in RA

General

  • Rheumatoid arthritis is a systemic autoimmune disease
  • Advances in disease modifying antirheumatic drugs and biological agents have reduced the number of patients presenting with RA- related cervical spinal disease
  • The use of modern therapeutic agents when started early can prevent the destructive joint pathology from occurring but are unable to prevent progression of cervical spine lesions if already present.

Numbers

  • > 85% of patients with moderate or severe rheumatoid arthritis (RA) have radiographic evidence of C-spine involvement.
  • Mortality rate 17%
  • 1% of adults in Europe and the United States

Pathophysiology

  • Novel antigenic expression by synovial cells leading to persistent cellular activation and immune complex production (rheumatoid factor- IgM) → Cytokine- mediated (IL- 1, IL- 6, TNF- α) chronic inflammation → granulation tissue deposition within the synovium (rheumatoid pannus) → The pannuis produces proteolytic enzymes capable of destroying adjacent cartilage, ligaments, tendons, and bone → in cervical spine destructive synovitis leads to ligamentous laxity and bony erosions → instability and subluxation of the vertebrae
  • Compression of neural structures can result from
    • Instability
    • Direct compression from pannus formation.
  • The upper cervical articulations at occiput/ C1 and C1/ C2 are primarily affected because the normal ligamentous structures surrounding the occipito-atlantoaxial region that confer a significant proportion of strength and stability are degraded as part of the disease process.

Associated conditions

  • Cervical spine: Upper cervical spine: (44–88% of RA cases (often found together)
    • C1/2 instability (65%)
    • Basilar invagination (20%)
    • Subaxial subluxation (15%)
      • Subaxial subluxation results from facet and uncovertebral joint instability.
      • Translational movement of the vertebrae in the sagittal and coronal planes with or without rotation can occur.
      • Abnormal alignment may include
        • Spondylolisthesis
        • Kyphosis
        • Scoliosis
        • ‘Staircase’ deformity

Treatment

  • Surgical decompression and arthrodesis
  • Indication
    • Instability
    • Canal compromise with Cord compression and neurological dysfunction.