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6. MRI measurements:
a. Any degree of atlantoaxial impaction on plain lm radiograph warrants
MRI.
b. Cervicomedullary angle:
(1) E ective indicator of cord distortion.
(2) The angle form ed by lines draw n parallel to the anterior border of the
medulla and upper cervical spinal cord.
(3 ) An gles < 135° h ave be en associated w it h myelopat hy.
F. Su b a x i a l s u b l u x a t i o n (Fig. 25.4):
1. Least common deformity in RA (10–20%).
25 Rheumatoid Arthritis 301
b
a
Fi g . 2 5 . 4 ( a ) Illust rat ion a n d (b,c) lat e ra l ra d io g raphs d e m onst ra t ing sub a xial subluxat ion o f t h e cer-
vical spine. (Fig. 25.4 b,c re printed from Imhof H, ed. Spinal Im aging [Dire ct Diagnosis in Rad iology].
St ut t ga rt , Ge rm an y: Ge o rg Th ie m e Verla g ; 2 0 08 : Fig s . 4 .2 , 4 .3 . Rep ro d u ce d wit h p e rm issio n .)
c
302
25 Rh eum at oid Arthritis
2. Synovitis of facet joints, intervertebral disks (spondylodiskitis), and
interspinous ligam ent.
3. Osteophytes are rarely observed.
4. Multilevel involvement:
a. Particularly common at C2–C3 and C3–C4 region.
b. Degenerative involvement typically occurs at C5–C6.
5. End plate erosions are present in 12 to 15% of patients.
6. On lateral plain lm radiographs a canal diameter < 14 mm represents a
higher risk of neurological involvement and warrants MRI.
7. RA patients with a previous upper cervical fusion have an increased risk of
developing subaxial subluxation.
VII. Tr eat m en t con sid e rat io n s.
A. Avo id t h e d evelo p m en t o f a n ir r eve r s ib le n eu r o lo gica l d e cit .
B. Pr e ve n t s u d d e n d e at h fr om u n r e co gn iz e d n e u ra l co m p re ss i o n (~ 1 0 %).
C. Ea rly a g gr ess ive m e d ic a l m a n age m e n t:
1. DMARDs: mechanisms of action in RA are unclear.
a. Methotrexate (MTX).
(1) Inhibits the purine metabolism s, resulting in accum ulation of
adenosine (strong anti-in ammatory e ects).
(2) Inhibits T cell activation and expression of adhesion molecules.
(a) Decreases production of T cell–m ediated in am matory cytokines.
(3) Also inhibits folic acid metabolism .
(a) Patients should consum e folic acid supplem ent during treatm ent.
b. Sulfasalazine.
(1) Associated with increased production of adenosine (similar to MTX).
(2) Free radical scavenger.
(3) Inhibits TNF by inducing macrophage apoptosis.
(4) Appears to suppress B cell function, but not T cells.
c. Hydroxychloroquine (HCQ).
(1) Decreases T cell activation by interfering with antigen-presenting
cells.
(a) As a lipophilic weak base, it trespasses the cell m embrane and
accumulates in lysosomes, increasing the intracellular pH.
i. In m acrophages and dendritic cells, the increase of
int racellular pH inhibits antigen coupling w ith antigenpresenting peptides.
(b) HCQ blocks toll-like receptors (TDR) that are responsible for
activating dendritic antigen-presenting cells.
2. Soft cervical collars:
a. Relieve symptoms but do not prevent disease progression.
D. Predictors of postoperative n eu rological recove r y:
1. Ranawat classi cation (Table 25.2).
a. More severe preoperative neurological de cits are associated with a
poorer neurological recovery.
2. Location of disease.
a. Proximal location of the pathology worsens the prognosis.
25 Rheumatoid Arthritis 303
Ta b l e 2 5 . 2 Ra n a w a t c la s s i c a t io n o f rh e u m a t o id m ye lo p a t h y
Cl a s s Cl i n i c a l c h a r a c t e ri s t i c s
I No ne ural d e cit
II Su b je c t ive we a kne ss wit h h yp erre e xia a n d d ysest hesia
IIIA Ob je c t ive w e a k n e ss a nd lo n g - t ra ct s ig n s ; a m b u la t o ry p at ie n t
IIIB Ob je ct ive we akn ess a nd lo ng -t r a ct s ig ns ; n on a m b u la t o r y p at ie n t
3. PADI.
a. Preoperative.
(1) A PADI < 10 mm is associated w ith poor prognosis.
(2) In patients with isolated atlantoaxial subluxation with PADI > 10 mm
predicted improvement was at least one Ranawat class.
(3) In com bined atlantoaxial subluxation and impaction recovery was
associated with a PADI ≥ 13 mm.
(4) All patients with a PADI ≥ 14 mm dem onstrate signi cant motor recovery.
4. Factors that do not predict neurological recovery.
a. Age.
b. Gender.
c. Duration of paralysis.
d. Preoperative AADI.
VIII. In d icat io n s fo r su rgica l s t a biliz a t ion .
A. Sp in al in st ab ilit y w it h a cco m p a nyin g:
1. Intractable pain.
2. Neurological defect.
B. Ra d io gr a p h ic p ar am e te rs (r e ga r d le ss o f n eu r o lo gic a l in vo lve m e n t ) .
1. Atlantoaxial subluxation with PADI ≤ 14 mm.
2. Superior odontoid migration ≥ 5 mm.
3. Subaxial subluxation with sagittal canal diameter ≤ 14 mm.
4. Ce r vicom ed u llar y an gle < 135°.
IX. Su rgica l st abilizat ion .
A. Ge n er a l co n sid e r at io n s.
1. Preoperative halo traction can provide pain relief, correct deformity, and
arrest or reverse neurological deterioration.
2. Awake beroptic intubation without neck extension is indicated.
B. Sp e ci c co n d it io n s.
1. Atlantoaxial subluxation (Fig. 25.5).
a. Posterior atlantoaxial fusion.
b. C1–C2 transarticular screw xation (Magerl).
(1) May not be technically possible depending on the deform ity and
course of the vertebral arter y.
c. C1–C2 lateral m ass/pedicle screw xation (Harm s construct).
304
25 Rh eum at oid Arthritis
Fi g . 2 5 . 5 Te c h n i q u e s f o r p o s t e r i o r c e r v i c a l s c r e w x a t i o n , i n c l u d i n g t h e M a g e r l , S o n n t a g , a n d H a r m s
techniques.
2. Superior migration of the odontoid (Fig. 25.6a).
a. Posterior occipitocervical fusion.
b. Anterior decompression via transoral resection of the odontoid is
indicated when there is evidence of signi cant anterior pannus or
marked vertical translocation of the odontoid (> 5 mm).
3. Subaxial subluxation.
a. Posterior cervical fusion with lateral instrumentation.
(1) Rarely, w hen notable subluxation is present and cannot be reduced,
anterior decompression with corpectomy and reconstruction with
strut bone grafting may be indicated (Fig. 25.6b,c).
X. Po s t op er at ive o u tco m e s .
A. Re ce n t im p r ove m e n t in o u tco m es.
1. Earlier diagnosis.
2. Decrease in use of corticosteroids.
3. Improvement with combination DMARDs treatment.
4. Better instrumentation.
B. Occip it oce r vi c a l fu s io n fo r at la n t o a x ia l im p ac t io n ( Ca se y e t a l) .
1. Better outcomes compared with those without occipital fusion.
2. Forty- ve percent demonstrated neurological improvement.
25 Rheumatoid Arthritis 305
Fi g . 2 5 . 6 ( a ) Preoperative sagittal magnetic
resonance im aging of a 76-year-old m an with
rheumatoid arthrit is who presented to the
emergency room with the inability to swallow
and speak. A large rheum atoid pannus is noted
to cause upper cervical cord compression
and destruction of the dens. (b,c) Postoperative anteroposterior and lateral radiographs
demonstrating occipital cervical xation (C2
pedicle screws and C3–C6 lateral mass screws).
Th e p at ie n t w a s d e co m pre ss e d w it h C2 – C4
lam inect o m ies an d tract io n , allowin g re st o rat ion of norm al cervical lordosis.
a
b c
3. Ninety-seven percent demonstrated pain relief.
4. Progression of subaxial instability below the level of fusion was the main
cause of failure (reoperation).
5. Perioperative mortality was 10%.
C. An t er io r a n d /o r p os t e r io r d eco m p re ss i o n a n d fu si o n fo r s u b a xia l s u blu xa t io n
(Olerud et al).
1. Neck pain was typically relieved.
2. Myelopathy was associated with worsened outcomes.
3. Surgery is recommended before patients develop myelopathy.
306
25 Rh eum at oid Arthritis
D. Gen eral com plicat ions.
1. High infection rate (25%).
2. Pseudarthrosis (poor bone quality).
3. Adjacent-level instability.
Sugg este d Reading
Bo r e n st e i n D. In a m m a t o r y a r t h r it id e s o f t h e sp in e : s u rg i c a l ve r s u s n o n su r gica l t r ea t -
m en t. Clin Or t h op Relat Res 2 006 ;443(443):2 08– 221
Cip r ia n i P, Ru scit t i P, Ca r u b b i F, Lia ko u li V, Gia co m e ll i R. Me t h o t re xa t e in r h e u m at oid a r -
thritis: optimizing therapy among di erent formulations. Current and emerging parad igm s. Clin The r 2014;36(3):427–43 5
Ka u p p i M J, Ne va MH , La i h o K, e t a l; FIN- RACo Tr ia l Gr o u p . Rh e u m a t o id a t la n t o a x ia l su b -
luxation can be preven ted by intensive use of tradit ional disease m odifying antirheum atic d r ugs. J Rhe u m atol 2009;36(2):273–278
Kim DH , Hil ib ra n d AS. Rh e u m a t o id a r t h r it is in t h e ce r vi c a l sp in e . J Am Aca d Or t h o p Su r g
2005;13(7):463–474
Ziko u AK, Ala m a n os Y, Ar g yr o p ou lo u MI, e t a l. Ra d io lo g ica l ce r vic a l sp in e in vo lve m e n t
in pat ien t s w ith rh eu m atoid arth r itis: a cross sect ion al st udy. J Rheum atol 20 05;
32(5):801–806
26 Seronegative Spondyloarthropathies
26.1 General Considerations
I. In t r o d u ct ion .
A. Gr o up o f in a m m at or y d is o rd e r s a e ct in g va r io u s join t s a n d p er ia r t ic u la r st ru ct u re s .
B. Ex t ra skele t al m a n ife st at io n s:
1. Gastrointestinal (GI).
2. Skin.
3. Ocular.
4. Cardiac.
5. Respiratory.
C. Th e m a jo r it y o f ca se s a re HLA- B2 7 (+) a n d r h e u m a t oid fa ct or (RF) (−).
D. Most laborator y n d in gs are n onsp e ci c.
II. Ank ylo sin g sp on d ylit is (Fig. 26.1).
1. Mainly predominant during second and third decades of life.
abc
Fi g . 2 6 . 1 ( a ) Lateral radiograph of a patient with ankylosing spondylitis with severe sagittal plane
im balance. (b) Anteroposterior radiograph following an L2 pedicle subt raction osteotom y. (c) Lateral
radiograph shows the osteotomy site at L2 with correction of the positive sagit t al balance. (Fig. 26.1a
from Im hof H, e d. Spinal Im aging (Dire ct Diagnosis in Radiology). Stut tgart, Germ any: Georg Thiem e
Ve r l a g ; 2 0 0 8 : F i g . 4 . 1 8 . Re p r o d u c e d w i t h p e r m i s s i o n . )
307
308
26 Seronegative Spondyloarthropathies
2. Males > females.
a. Men typically present a more severe disease expression.
b. Prevalence is 1 in 1,000.
c. Mostly Caucasian (HLA-B27).
B. Pa t h oge n es is .
1. HLA-B27 positive in 88 to 96% of patients (nonspeci c).
a. Eight percent of general population.
2. Synovitis from lymphocyte and plasma cell in ltrate.
3. Chronic in ammatory changes (cartilage destruction and bony erosion) to
the axial skeleton.
a. Bilateral sacroiliitis is the most common and earliest sign of disease
(pathogn om onic).
b. Enthesitis at tendon bony insertions.
C. Clin ic a l n d in gs .
1. Insidious onset:
a. Symptoms are generally present for 3 months.
2. Symptoms include low back pain and sti ness.
a. Worsened in the morning and improve with activity.
3. Fifteen to 25% have peripheral joint arthritis.
4. Forward- exed posture:
a. Decreased lumbar lordosis.
b. Increased thoracic kyphosis.
5. Physical ndings:
a. Limited range of motion of the lumbar spine (Schober’s test).
b. Decreased chest expansion (< 7–8 cm).
c. Positive sacroiliac stress maneuver (Patrick’s test).
d. Rigid kyphotic spine.
(1) Most e ective measure of spinal deform ity is the chin–brow to
vertical angle.
(2) Occiput to wall test (cervical spine involvem ent).
e. Compensatory hip exion contractures.
f. Ten d er n ess ove r t h e isch ia l t u be rosit y, great er t roch an ter, a n te r io r -
superior iliac spine (ASIS), and iliac crest (enthesitis).
6. Extraskeletal manifestations:
a. General complaints
(1) Fatigue.
(2) Weight loss.
(3) Low -grade fever.
b. Gastrointestinal.
(1) In am matory bowel disease.
c. Cardiac.
(1) Cardiac conduction defects.
(2) Aortitis.
d. Acute iritis (most common extraskeletal complaint).
(1) Pain.
(2) Photophobia.
26 Seronegative Spondyloarthropathies 309
(3) Blurred vision.
e. Pulmonary brosis (cause of death in 10% of patients).
(1) Dyspnea and cough.
f. Am yloid osis.
D. Laborat or y n d in gs.
1. HLA-B27 (~ 90%): often not ordered due to high cost.
2. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
3. Anemia of chronic disease (normochromic/normocytic).
4. RF (−).
5. Antinuclear antibody (ANA) (−).
E. Ra d io gr a p h ic n d in gs (Fig. 26.2 and Fig. 26.3) (Table 26.1).
ab
c
Fi g . 2 6 . 2 ( a , b ) Radiog raph d e m onstrat in g sclerosis an d e rosion at t h e sa cro iliac joint . (c) Axial co m -
puted tomographic image demonstrating erosions at the sacroiliac joint. (From Bohndorf K, Imhof H,
Pope TH Jr. Musculoske let a l Im aging : A Concise Mult im o d alit y Ap p ro a ch . St u t t gar t , Germ an y: Ge o rg
Th ie m e Verla g ; 2 0 0 1 : Fig s. 9 .1 1 2 , 9 .1 1 3 . Re p ro d uce d w it h p e rm is sio n .)
310
26 Seronegative Spondyloarthropathies
Fig . 2 6 . 3 An t e r o p o s t e r io r r a d io g r a p h d e m o n s t r a t in g
bamboo spine in a patient with ankylosing spondylitis.
(From Im hof H, ed. Spinal Imaging [Direct Diagnosis in
Ra d io lo g y ]. St u t t g a r t , Ge r m a n y : Ge o r g Th ie m e Ve r la g ;
2008: Fig. 4.27. Reproduced with permission.)
F. Tr e a t m e n t .
1. Nonoperative.
a. Physical therapy.
(1) Extension exercises.
(2) Sw imm ing.
b. Respiratory therapy.
(1) Breathing exercises.
(2) Cessation of sm oking.
c. Medications.
(1) Nonsteroidal anti-in am matory drugs (NSAIDs).
(a) Symptomatic pain relief.
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