How does RA affect the cervical spine

The cervical spine is composed of 32 synovial joints. The occiput-C1 and C1-C2 articulations rely on soft tissue integrity for stability. In the subaxial cervical spine, the facet joints are true synovial joints. Rheumatoid pannus produces enzymes that destroy cartilage, ligaments, tendons, and bone. This synovitis leads to spinal instability, subluxation, and spinal deformity. Secondarily, the discs in the subaxial spine degenerate, which may result in additional facet joint subluxation and/or ankylosis. Spinal cord and brainstem compression may develop secondary to static or dynamic spinal deformities or from direct pressure by synovial pannus.

Three types of cervical deformities develop secondary to rheumatoid disease:

1. Atlantoaxial (C1-C2) Subluxation (AAS): Most common type, responsible for 65% of deformities. The subluxation may be reducible or fixed.

2. Atlantoaxial impaction (AAI): Also termed superior migration of the odontoid, cranial settling, or pseudobasilar invagination. Second most common type, responsible for 20% of cervical rheumatoid deformities.

3. Subaxial subluxation (SAS): Responsible for 15% of deformities. May occur at multiple levels leading to a staircase deformity (Fig. 68-1, Fig. 68-2).

Rheumatoid Arthritis Anaesthesia Spine

Figure 68-1. A, Dynamic radiographic series of a 68-year-old patient with rheumatoid arthritis. The black arrows indicate the spinolaminar line. Anterior subluxation occurs in flexion, and slight posterior atlantoaxial subluxation is revealed in extension. Note the increased atlantodens interval (ADI), reduced space available for the cord (SAC), and broken spinolaminar line at C1-C2 in flexion. The subaxial spine is stable. Continued

Figure 68-1. A, Dynamic radiographic series of a 68-year-old patient with rheumatoid arthritis. The black arrows indicate the spinolaminar line. Anterior subluxation occurs in flexion, and slight posterior atlantoaxial subluxation is revealed in extension. Note the increased atlantodens interval (ADI), reduced space available for the cord (SAC), and broken spinolaminar line at C1-C2 in flexion. The subaxial spine is stable. Continued t

Figure 68-1, cont'd. B, Severe erosion of the dens is seen on the sagittal computed tomography (CT) reconstruction. C, T1 (1) and T2 (2) magnetic resonance imaging (MRI) sequences of the craniocervical junction. The florid pannus has eroded the dens and, combined with the subluxation, contributes to the degree of stenosis seen at the C1-C2 level. Abnormally increased signal in the spinal cord is evident in the T2 image.

Figure 68-1, cont'd. B, Severe erosion of the dens is seen on the sagittal computed tomography (CT) reconstruction. C, T1 (1) and T2 (2) magnetic resonance imaging (MRI) sequences of the craniocervical junction. The florid pannus has eroded the dens and, combined with the subluxation, contributes to the degree of stenosis seen at the C1-C2 level. Abnormally increased signal in the spinal cord is evident in the T2 image.

Figure 68-2. Lateral cervical radiograph of a rheumatoid patient (the cervical vertebrae are numbered). Note (1) atlantoaxial impaction (vertical atlantoaxial subluxation) with proximity of the base of the dens (C2) to McGregor's line and the paradoxically small atlantodens interval (ADI), the space between the anterior ring of C1 and the dens; (2) C3-C4 ankylosis; and (3) multilevel subluxations giving rise to the staircase appearance.

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