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• Cervical complications of rheumatoid arthritis
  Djurdja Babic-Naglic
  Published on: 23 February 2005

• Published on: 23 February 2005

  Cervical complications of rheumatoid arthritis

  • Djurdja Babic-Naglic, MDPhD
  • Other Contributors:
    • Bozidar Curkovic

  Dear Editor,

  We read with interest the article by Kauppi, Barcelos and da Silva which discussed the importance of the specific evauation of the cervical spine in the patients with rheumatoid arthritis (RA) [1]. Magnetic resonace imaging (MRI) is becoming surgical golden standard for the confirmation of compressive cervical myelopathy but is expensive and time consuming. Functional MRI is the most reliable exami...

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  Dear Editor,

  We read with interest the article by Kauppi, Barcelos and da Silva which discussed the importance of the specific evauation of the cervical spine in the patients with rheumatoid arthritis (RA) [1]. Magnetic resonace imaging (MRI) is becoming surgical golden standard for the confirmation of compressive cervical myelopathy but is expensive and time consuming. Functional MRI is the most reliable examination but almost impossible to perform in majority of patients with atlantoaxial instability and long lasting RA. Forward atlantoaxial subluxation is the most frequent dislocation and easy to detect on standard and dynamic radiograms of the cervical spine. Steel's rule of third is plausible screening method for assessment of sagittal spinal canal in C1 level (in sagittal diameter of atlas one third of the space occupies dens, one third spinal cord and one third is free space that allows secure movements in this region) [2]. Theoretically the maximal and still safe atlantodental distance could be one third of the atlas saggittal diameter [2, 3]. This is partial explanation for low incidence of neural complications in patients with RA of craniovertebral junction. The aim of clinical evaluation is to detect early signs of neural involvement. Somatosensory evoked potentials (SSEPs) represent a neuroelectrophysilogical method that estimate the function of the posterior column of the spinal cord [4, 5, 6, 7, 8]. It allows early detection of disorders of cervical neural pathways before the clinical symptoms develop. SSEPs could be perforemed in neutral and dynamic fashion what gives information is there any compressive moment in different positions [5].

  In our department we are following the next steps in the approach to the patient with RA and cervical spine involvement: 1. radiological assessment (standard and lateral flexion-extension views of cervical spine and open mouth views of dens) of all patients with RA and cervicogenic symptoms regardless of the duration of disease and all patients with RA lasting 5 years and more; 2. SSEPs for median nerve in standard and functional position of patient' head when there is radiologically significant atlantoaxial dislocaton (> 4mm or more in maximum flexion) or any other changes related to RA activity; 3. MRI is last step depending of the previous findings; 4. consideration of more agressive pharmacological treatment, cervical orthosis or surgery. Neuroradiological analyses visualise bone displacment and erosions, proliferative rheumatoid tissue and compression of spinal cord but do not express functional integrity of neural pathways. SSEPs is an accepted method for evaluating sensory functions of the central nervous system with the possibility to detect subclinical disorders. SSEPs should be registered in neutral position, flexion and rotations of the cervical spine.

  We investigated 56 female hospital patients with RA who were admitted to the Department of Rheumatology, University Hospital Rebro, Zagreb, Croatia during one year [5]. Twenty five (44%) had forward atlantoaxial subluxation ranging from 4 to 17 mm. A total of 12 patients had pathological SSEPs latencies for median nerve and among them 11 had neck symptoms, 6 had abnormal neurological findings and 6 had forward atlantoaxial subluxation. The pathological SSEPs findings were provoked by movements of the neck in 9 out of 12 patients. In conclusion, we would like to add radiological analysis of cervical spine according Steel's rule of third and SSEPs functional examination as valuable diagnostic tool for evaluation of rheumatoid cervical spine. SSEPs results help to identify patients with cervical cord dysfunction before detectable clinical signs develops and thus contribute to the therapeutic decision making.

  Ð Babiæ-Nagliæ¹, B Æurkoviæ ¹

  Department of Rheumatology University Hospital Rebro Zagreb Croatia
  Correspondence to: Prof. Ðurða Babiæ-Nagliæ, MD Kišpatiæeva 12 Zagreb 10000 Croatia dnaglic@kbc-zagreb.hr

  References

  1. Kauppi MJ, Barcelos A, da Silva JAP. Cervical complications of rheumatoid arthritis. Ann Rheum Dis 2005; 64: 355-358.

  2. Steel HH. Anatomical and mechanical consideartions of the atlantoaxial articulations. J Bone Surg 1968; 50: 1481-1482.

  3. Babiæ-Nagliæ Ð, Potoèki K, Æurkoviæ B. Clinical and radiological features of atlantoaxial joints in rheumatoid arthritis. Z Rheumatol 1999; 58: 196-200.

  4. Giraud P, Mauguiere F. Somatosensory evoked potentials in rheumatoid polyarthritis with radiologic involvement of the cervical spine. Neurophysiol Clin 1997; 27: 33-50.

  5. Babiæ-Nagliæ Ð, Nesek-Maðariæ V, Potoèki K, Lelas-Bahun N, Æurkoviæ B. Early diagnosis of rheumatoid cervical myelopathy. Scand J Rheumatol 1997; 26: 247-52.

  6. Tsiptsios I, Fotiou F, Sitzoglou K, Fountoulakis KN. Neurophysilogical investigation of cervical spondylosis. Electromyogr Clin Neurophysiol 2001; 41: 305-13.

  7. Hayashida T, Ogura T, Hase H, Osawa T, Hirasawa Y. Estimation of cervical cord disfunction by somatosensoray evoked potentials. Muscle Nerve 2000; 23: 1589-1593.

  8. Dvorak J, Sutter M, Herdmann J. Cervical myelopathy: clinical and neurophysiological evaluation. Eur Spine J 2003; 12 (suppl 2): S181-187.

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  Conflict of Interest:
  None declared.

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