Background Rheumatoid arthritis is a chronic systemic inflammatory disease that often affects the cervical spine. Cervical disorders in rheumatoid arthritis (RA) patients have been an important problem for a long time
Objectives investigate association between poor sleep complaints in rheumatoid arthritis patients and subclinical cervical spine involvement measured by MRI and its relation to disease activity in a population-based cross-sectional study.
Methods 200 Egyptian RA patients fullfilling the American college of Rheumatology Criteria 2010 who were under follow up in the rheumatology and pain clinic, Assuit university hospital, Egypt. All patients underwent a complete history and physical examination with a focus on the cervical spine to assess disease duration, age of disease onset, swollen and tender joint counts. ESR, Hb, CRP, RF levels and disease activity was measured using the disease activity score 28 (DAS28). Oswestry-Neck-Pain-Questionnaire were completed. All patients filled out the Pittsburgh sleep quality index to evaluate their sleep quality, anxiety and depression scale. Symptomatic patients and previously diagnosed cervical subluxation were excluded. Radiographs of the cervical spine included lateral views taken in flexion, extension, neutral position of neck and antero-posteriorly and odontoid projection view.Patients suspicious for atlantoaxial affection underwent Magnetic Resonance Imaging to evaluate the cervicomedullary angle, dens erosion, amount of hypervascular –active pannus, atlantoaxial impaction, vertebral plate erosion, subaxial subluxation, apophyseal joints and disc material
Results Asymptomatic cervical spine subluxation was found in 46 of the 200 RA patients (23%). The prevalence among involved patients of, anterior atlanto-axial subluxation, atlantoaxial impaction and subaxial subluxation was 25 (54.3%), 8 (17.4%) and 13 (28.2%), respectively. Posterior subluxation was not detected. There is significant relationship with cervical spine subluxation and sleep disturbance (interruption pattern) (P=0.006). The main baseline risk factor for difficulty falling asleep was anterior atlanto-axial subluxation, whereas for cervical spine subluxation it was higher patient age. Logistic regression confirmed early final awakening and short sleep respectively (HR 1.109, 95% CI 1.120–1.260, p=0.05) and (HR 1.095, 95% CI 0.991–0.998, p=0.005) as independent predictors of anterior atlanto-axial subluxation. The main risk factors for incident hypervascular atlantoaxial joint active pannus was disease activity score and older age. The frequency of early final awakening and short sleep were higher in relation to cervical spine involvement. Male sex, CRP positivity, and older age were risk factors for incident anterior atlantoaxial subluxation.
Conclusions Cervical spine involvement is common and may be asymptomatic indicating routine cervical spine imaging is needed in patients with RA specially patients with sleep disturbances and high disease activity
Delamarter RB, Bohlman HH. Postmortem osseous and neuropathologic analysis of the rheumatoid cervical spine.Spine (Phila Pa 1976) 1994; 19: 2267–2274.
Disclosure of Interest None declared
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