1. Rheumatoid Arthritis of the Cervical Spine Zikou Anastasia Radiology Department University Hospital of Ioannina

2. Rheumatoid arthritis (RA) is a chronic multisystemic disease of unknown cause. Characteristic feature: inflammatory synovitis - peripheral joints / symmetrical distribution - cartilage destruction / bone erosion - joint deformity After the metacarpophalangeal joints, the most common region to be involved in RA is the cervical spine. History: 1890, *Garrod reported that 36% of his pts with RA had c-spine involvement. Introduction * Garrod, A.Griffins Medical Series.1890. Available at: http://books.google. Accessed July 11, 2011.

3. Radiographic signs: 43-86% Introduction *Pellicci et al ( 5 yrs study / 106 RA pts) radiological evidence of c-spine involvement: 43% of pts / baseline 86% of pts / follow-up **Mikulowski et al: fatal cord compresion 10% in pts with RA Wasserman B,et al. Bull NYU Hosp for Jt Dis. 2011;69(2):136-48. * Pellicci P et al.J Bone Joint Surg Am. 1981;63:342-50. ** Mikulowski P et al. Acta Med Scand. 1975;198(6):445-51.

4. Introduction Risk factors for c-spine involvement: – Males – RF - Rheumatoid nodules – Peripheral activity - Vasculitis – Corticosteroid use Clinical signs: – Neck pain 40 to 88% – Neurologic compromise 7 to 34% * Wasserman B,et al. Bull NYU Hosp for Jt Dis. 2011;69(2):136-48

5. Atlanto-axial subluxation ( 65% of all cervical subluxations ) - majority anterior - 20% lateral - 7% posterior - rotatory rare Superior migration of the odontoid - second most common deformity - 20% of pts - odontoid erosions Subaxial c-spine involvement - Subaxial subluxation :15% of pts - Apophyseal joint ankylosis RA & C-Spine Imaging * Wasserman B,et al. Bull NYU Hosp for Jt Dis. 2011;69(2):136-48

6. RA & C-Spine Imaging

7. Radiography RA & C-Spine Imaging Anterior atlantoaxial subluxation Vertical subluxation - Subaxial subluxation Subaxial spinal involvement Magnetic Resonance Imaging Pannus Spinal cord

8. Radiography Anterior atlantoaxial subluxation (AAS) AAS : 50% of pts symptomatic The role of plain radiography is to establish whether there are risk factors for cord compression. RA & C-Spine Imaging

9. AAS - Anterior atlantodental interval (AADI) AADI > 3-6 mm: early instability transverse lig. AADI > 6 mm transverse & alar lig. AADI > 9 mm surgical stabilization. AADI : yellow line

10. AAS AADI : yellow line Flexion Neutral

11. AAS - Posterior atlantodental interval (PADI) PADI : red line All cervical spinal levels - cord: 10 mm - CSF: 2 mm - dura: 2 mm - PADI > 14 mm (avoid cord compression) - spinal canal: 17-29 mm at C1 PADI : red line

12. AAS Flexion Neutral PADI : red line

13. Vertical subluxation

14. McGregor´s line - Odontoid tip > 4.5 mm Vertical subluxation

15. Ranawat method ( ♂ > 15 mm & ♀ > 13 mm) Vertical subluxation

16. Clark’s stations Vertical subluxation

17. cervicomedullary angle ( normal range: 135° to 175°) Vertical subluxation

18. Odontoid erosions

20. Subaxial subluxation Cervical Height Index (CHI) - subluxations at multiple levels - loss of disk height - bony collapse - CHI < 2 (neurologic compromise) Subluxation > 1mm > 3,5 mm !!!

21. Subaxial subluxation Zikou AK, et al.J Rheumatol 32: 801-806, 2005.

22. Apophyseal joints ( erosions - ankylosis) Intervertebral disk - space narrowing Irregularity of the subchondral margins of the vertebral bodies Erosion and sclerosis Corticosteroid - ischemic necrosis of bone - vertebral collapse Sudaxial spinal involvement

23. Zikou AK, et al.J Rheumatol 32: 801-806, 2005.

24. Magnetic Resonance Imaging Major indications for c-spine MRI in RA: - abnormal measurements on plain radiographs - unremitting suboccipital /cervical pain - progressive / severe subluxations - symptoms of cord/brainstem/vert. art. compression MRI : evaluation of the spinal cord and neural elements - Presence and effect of pannus on the spinal cord - Spinal cord signal can be assessed (edematous spinal cord changes: poor clinical status, poor prognosis & poor postoperative outcome) RA & C-Spine Imaging

25. “pannus” AAS

26. Odontoid erosions - “pannus”

27. Zikou AK, et al. Clin Exp Rheumatol 23: 665-670, 2005. Odontoid erosions - “pannus”

28. Zikou AK, et al. Clin Exp Rheumatol 23: 665-670, 2005. Subaxial subluxation

29. Subaxial subluxations AAS

30. Brainstem compression - myelopathy

31. Plain radiography : Flexion / extension views - the level of involvement - evidence of instability Further imaging with MRI : pannus & spinal cord The major role for MRI : pre & after operative assessment AADI > 9 mm or PADI < 14 mm Vertical subluxation Subaxial subluxation > 3,5 mm Take home messages

33. **Zikou AK, et al. Magnetic resonance imaging findings of the cervical spine in patients with rheumatoid arthritis: a cross sectional study. Clin Exp Rheumatol 23: 665-670, 2005. *Zikou AK, et al. Radiological cervical spine involvement in patients with rheumatoid arthritis: a cross sectional study. J Rheumatol 32: 801-806, 2005. * 165 RA pts ( 143 ♀ / 22 ♂) mean age: 59,6 ± 12,5 yrs disease duration: 12,3 ± 7,9 yrs RF (+) : 63,6% Radiological findings: 146 pts - AAS: 20,6% - Odontoid erosions: 2,4% - Sudaxial subluxations: 43,6% - Disk space narrowing: 66,1% - Vertebral plate erosions - sclerosis: 43,6% C - spine involvement: frequent finding mild severity ** 51 RA pts ( 42 ♀ / 9 ♂) mean age: 56,5 ± 10,4 yrs disease duration: 12,4 ± 8,5 yrs RF (+) : 64,7% clinical signs : c-pain & stiffness 30% Rx / MR findings: 40 / 44 pts - Peridental pannus: 88% - Odontoid erosions: 23,5% - AAS: 13,7% - Brainstem compression: 5,9% - Sudaxial subluxations: 10% Peridental pannus correlated (p<0,05) with: - DAS-28 - RF(+) - Erosive changes hand-wrist (Larsen criteria)