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Rheumatoid Arthritis of the Cervical Spine


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  • Chapter Synopsis

  • Rheumatoid arthritis is a chronic autoimmune inflammatory polyarthritis that often involves the joints of the upper and subaxial cervical spine. The common spinal manifestations include atlantoaxial subluxation, rheumatoid basilar invagination, and subaxial subluxation.

  • Important Points

  • Selection of the appropriate approach, technique, and construct depends on the severity of symptoms and preoperative reducibility of the subluxation or basilar invagination, or both.

  • Clinical and Surgical Pearls

  • Because this disease preferentially affects the upper cervical spine, knowledge of the neurovascular anatomy at the craniocervical region that often is disrupted is key to successful surgical management, feasibility, and selection of the appropriate surgical construct.

  • Clinical and Surgical Pitfalls

  • Assessment of bone quality should not be overlooked in patients with rheumatoid arthritis, and efforts should be made to optimize bone health by using a multidisciplinary strategy.

Rheumatoid arthritis is a chronic autoimmune inflammatory polyarthritis of the peripheral joints. It often involves the joints of the upper and subaxial cervical spine and has a variety of pathologic entities and a spectrum of clinical presentations. The introduction of disease-modifying antirheumatic drugs (DMARDs) and of agents that block tumor necrosis factor-α (TNF-α) altered the natural history of the disease by preserving the integrity and function of the joints. Thus, the incidence and severity of rheumatic spinal disorders encountered by most spine surgeons have decreased since the 1990s.

In-depth knowledge of the pathophysiology, natural history, and management of the spinal disorders that result from this chronic disease is important and facilitates decision making when treating these disorders, which can be challenging and complex. Involvement of the cervical spine in patients with rheumatoid arthritis is also associated with higher morbidity and mortality than is similar cervical spine involvement in patients who do not have rheumatoid arthritis. The goal of this chapter is to describe the pathophysiology and clinical presentation of patients with rheumatoid arthritis–related involvement of the cervical spine, more specifically atlantoaxial subluxation, occipitoatlantoaxial impaction, and subaxial subluxation.

Pathophysiology

Approximately one fourth of patients with rheumatoid arthritis will have at least radiographic involvement of the cervical spine, mainly the upper cervical spine. The synovial joints between the transverse atlantal ligament and the odontoid process, the alar ligament, and the joints between the anterior arch of the atlas and the odontoid are frequently affected. With chronic inflammation, the transverse ligament weakens and eventually ruptures. Decalcification also takes place and erodes the odontoid. This process results in various degrees of atlantoaxial subluxation.

The atlanto-occipital and atlantoaxial joints can also be affected. With destruction and collapse of these joints and lateral atlantal masses, the odontoid process telescopes rostrally, with resulting occipitoatlantoaxial impaction or basilar invagination. Subaxially, the facet joints can be involved, leading to variable degrees of subaxial subluxations and deformity. However, because of the presence of intervertebral disks, which are spared in this inflammatory process, subaxial subluxation is usually a late manifestation of the disease.

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