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• CERVICAL SPINE INVOLVEMENT IS RARE IN EARLY ARTHRITIS, BUT MAY EXIST WITHOUT SYMPTOMS AND CLINICAL S
  Markku J Kauppi
  Published on: 20 July 2006

• Published on: 20 July 2006

  CERVICAL SPINE INVOLVEMENT IS RARE IN EARLY ARTHRITIS, BUT MAY EXIST WITHOUT SYMPTOMS AND CLINICAL S

  • Markku J Kauppi, MD, PhD
  • Other Contributors:
    • Erja M Lehto

  Dear Editor,

  We read with interest the article by Dr van Eijk et al, in which they confirmed that cervical spine disorders are rare in early arthritis nowadays.[1] Their series consisted of 258 patients with a history of 2 or 5 years of chronic arthritis, and only seven cases with significant cervical spine involvement were found by 4 radiographs taken of each patient. It is easy to agree that there is no need for...

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  Dear Editor,

  We read with interest the article by Dr van Eijk et al, in which they confirmed that cervical spine disorders are rare in early arthritis nowadays.[1] Their series consisted of 258 patients with a history of 2 or 5 years of chronic arthritis, and only seven cases with significant cervical spine involvement were found by 4 radiographs taken of each patient. It is easy to agree that there is no need for routine screening for these disorders in the first years of chronic arthritis. However, one should be cautious with their suggestion that cervical spine radiographs be restricted to patients with symptoms or signs indicative of the cervical involvement.

  Several former papers have represented patients with clinically significant atlantoaxial subluxation (AAS) without any typical symptoms or signs of cervical origin.[2-3] Dr van Eijk et al mentioned that only three out of their seven cases with cervical involvement reported non-specific pain, and none had neurological symptoms or signs. Nevertheless, they found patients with clinically important AAS, including one very severe case (13 mm).

  Specific neurological signs or symptoms cannot be the only indications to take cheap and rather safe plain radiographs aiming to diagnose potentially dangerous critical instability in the neck. The cervical involvement is caused by a chronic active inflammation and associated to a destructive disease, which was reported also by van Eijk et al.[1, 4-5] The number of patients with a refractory disease will probably be lower in the future, but in such cases, cervical spine radiographs may be indicated during the first 5 years of the disease even without cervical symptoms or signs.

  All the seven abnormalities (subluxations) reported by van Eijk et al were probably diagnosed by the dynamic lateral view radiographs, however they always took also two anteroposterior (AP) views (high and low). Based on their findings and our own experiences (still unpublished data), we suggest that a routine radiological examination of the cervical spine in chronic arthritis should include lateral view radiographs in full flexion and extension, but the AP radiographs are probable needed only in advanced cases and for individual reasons.

  Physicians should be aware of the possibility that significant cervical spine subluxations may develop even without symptoms or signs in cases with severe inflammation. Dynamic radiographs should be taken when such abnormalities are suspected, but it is wise to avoid unnecessary radiation.

  References

  1. van Eijk IC, Nielen MMJ, van Soesbergen RM, Hamburger HL, Kersten PJS, Dijkmans BAC, van Schaardenburg D. Cervical spine involvement is rare in early arthritis. Ann Rheum Dis 2006;65:973-4.

  2. Neva MH, Häkkinen A, Mäkinen H, Hannonen P, Kauppi M, Sokka T. High Prevalence of Asymptomatic Cervical Spine Subluxations in Patients with Rheumatoid Arthritis Waiting for Orthopaedic Surgery. Ann Rheum Dis 2006;65:884-8.

  3. Häkkinen A, Neva MH, Kauppi M, Hannonen P, Ylinen J, Mäkinen H. Jäppinen I, Sokka T: Decreased muscle strength and mobility of the neck in patients with rheumatoid arthritis and atlantoaxial disorders. Arch Phys Med Rehabil. 2005;86:1603-8.

  4. Neva MH, Isomäki P, Hannonen P, Kauppi M, Krishnan E, Sokka T. Early and extensive erosiveness in peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis. Arthritis Rheum 2003;48:1808-13.

  5. Naranja A, Carmona I, Gavrila J, Balsa A, Belmonte MA, Tena X et al . Prevalence and associated factors of atlantoaxial luxation in a nation wide sample of rheumatoid arthritis patients. Clin Exp Rheumatol 2004;22:427-32.

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  Conflict of Interest:
  None declared.

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