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Lesson of the month
Cervical complications of rheumatoid arthritis
  1. M J Kauppi1,
  2. A Barcelos2,
  3. J A P da Silva2
  1. 1Rheumatism Foundation Hospital, Pikijarventie 1, FI-18120 Heinola, Finland
  2. 2Reumatologia, Hospitais da Universidade, 3000-075 Coimbra, Portugal
  1. Correspondence to:
    Dr M J Kauppi
    markku.kauppireuma.fi

https://doi.org/10.1136/ard.2003.020230

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    CASE HISTORIES

    Case history 1

    A 47 year old housewife presented with a 3 year history of fleeting inflammatory pain and oedema affecting the small joints of the hands symmetrically. She had previously been given a diagnosis of rheumatoid arthritis (RA), and was receiving treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and prednisolone (10 mg/day).

    For the past year she had experienced inflammatory neck pain with a recurrent sense of heaviness and muscle weakness in the upper and lower limbs. Her symptoms were present, especially, during prolonged flexion and were relieved in a favourable posture.

    Examination showed symmetrical arthritis and tenderness of wrist and metacarpophalangeal (MCP) joints in both hands. A reduction of about 30% was seen in the anterior and lateral flexion of the cervical spine. Neurological examination results were, however, normal.

    Laboratory tests showed high acute phase response and negative rheumatoid factor. Radiographs of the hands and feet disclosed osteopenia but no erosions. Further investigations included radiographs of the cervical spine (neutral and flexion position) (figs 1A and B) and an anterior atlantoaxial subluxation (aAAS) was seen. Magnetic resonance imaging (MRI; fig 1C) of the cervical spine showed the aAAS and also space-taking pathological soft tissue (synovitis pannus) around the dens of the axis. The pannus was in contact with the spinal cord, but there was still spinal fluid behind the cord.

    Figure 1

     (A) Lateral view radiograph of the cervical spine (case 1) during flexion. Severe AAS is present (arrows show the anterior aspect of the dens of axis and the anterior arch of the atlas). (B) The AAS disappears during neutral posture. (C) Neutral position MRI examination of the cervical spine with the patient in a supine position. AAS is present, together with inflammatory tissue around the dens, but there is no compression of the spinal cord.

    The patient was referred to a neurosurgeon …

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    Footnotes

    • Series editor: Anthony D Woolf