Rheumatoid arthritis

Cure Arthritis Naturally

Cure Arthritis Naturally

Get Instant Access

Rheumatoid arthritis is a progressive chronic systemic inflammatory disorder affecting primarily the synovial joints. Women are three times more commonly affected than men. Characteristically, it is a symmetrical inflammatory arthropathy affecting peripheral small joints, i.e. hands and feet, which may also affect larger joints (hips, knees and elbows). It usually commences with progressive pain, stiffness and joint swelling. Early findings include periarticular soft tissue and tendon sheath swelling. Deformities include the swan-neck and boutonniere deformities, ulna 182 deviation at the MCP joints and carpal drift in volar and palmar directions.

Bony changes include symmetric narrowing of the joint space associated with marginal or central erosions and periarticular osteopenia. Subchondral sclerosis is minimal or absent and formation of osteophytes is usually lacking unless end-stage disease is present. The usual joints that are affected are the MCP joints, the radial and ulnar styloid processes, distal radial ulna joints, and the carpus where ankylosis or bony resorption and erosions may occur.

More than 80% of patients with moderate to severe rheumatoid arthritis have radiographic evidence of cervical-spine involvement (Figs 4.19 and 4.20). Do not assume the cervical spine is normal. The most characteristic radiographic findings involve the odontoid process, atlanto-axial joint and apophyseal joints of the subaxial spine. The erosive changes usually affect the odontoid process resulting in loosening the insertion of the transverse ligament of the atlas. This leads to instability allowing anterior subluxation of the atlas on the axis. This may result in cervical spinal cord compression. This is frequently accompanied by a vertical translocation of the odontoid process, also known as cranial settling or basilar impression (depending on which literature you read). The laxity of the transverse ligament is usually apparent on the lateral radiograph. The findings are accentuated by flexion when there is a marked increase in the atlantodental interval. It often requires surgical^^^^H 4 intervention with the usual procedure being a posterior fusion [5, 6].

Atlanto-axial subluxation in rheumatoid arthritis is usually progressive and the greater the degree of myelopathy, the higher the risk of sudden death. The end result of vertical migration of the odontoid process (cranial settling) leads to compression of the pons and medulla. Rheumatoid granulation (inflammatory panus) behind the odontoid also contributes to this effect and vertebral artery obstruction may also play a role. The degree of erosion of C1 usually correlates with the extent of superior migration of the odontoid process [6].

MRI is the best test to evaluate the compression of the upper cord and pons/medulla as this best demonstrates the location of the odontoid process, extent of inflammatory pannus, and associated edematous changes to the spinal cord [6] (Figs 4.21 and 4.22). Commonly, rheumatoid arthritis may affect the apophyseal joints or disc spaces in the subaxial cervical spine, further changes include subluxation, bone destruction or even ankylosis. If the discs are involved, there may be erosion or even fusion.

Pulmonary manifestations include unilateral pleural effusions, pulmonary fibrosis (Figs 4.23 and 4.24) affecting the lower lobes, rheumatoid nodules which may be single or multiple and are commonly subpleural in location. Caplan's syndrome is rheumatoid nodules in the lungs of coal miners with silicosis. The most common early manifestation is bronchiolitis obliterans (respiratory bronchiolar inflammation with air trapping/mosaic perfusion, bronchiectasis) [10]. This is usually identified on high-resolution CT scans with expiratory views. Pulmonary complications in rheumatoid arthritis are most commonly seen in men with seropositive disease. 183

The anaesthetist should always assess neck movement in patients with rheumatoid arthritis. Recent flexion/extension neck views or MRI should be examined for evidence of the separation of the odontoid peg from the atlas, or subluxation of cervical vertebrae. If the neck is unstable, the case should be managed by a consultant anaesthetist. If the patient has temperomandibular joint involvement reducing mouth opening, then the airway management becomes even more problematical. Regional techniques should always be considered. If intubation is required, then awake fibre-optic intubation may be used. If the neck is unstable, a hard collar and sandbags should be used while the patient is unconscious to prevent neck movement.

Fig. 4.21 MRI (T1) of cervical spine in rheumatoid arthritis. There is added tissue of intermediate signal (arrows) between the dens and anterior arch of C1, with widening of the anterior atlanto-axial interval, with erosion of the dens (dotted arrow) and compression on the spinal cord.

Fig. 4.21 MRI (T1) of cervical spine in rheumatoid arthritis. There is added tissue of intermediate signal (arrows) between the dens and anterior arch of C1, with widening of the anterior atlanto-axial interval, with erosion of the dens (dotted arrow) and compression on the spinal cord.

Odontoid Pannus Mri

Fig. 4.22 MRI (T2) of cervical spine in rheumatoid arthritis. Images show high-signal material anterior (arrow) to the odontoid process. This indicates an inflammatory pannus. Pannus can also be present around the attachments of the transverse and cruciate ligaments. MRI is also useful for showing degree of compression on the cervical cord, and also demonstrates increased signal within the cord, due to cervical myelopathy (dotted arrow).

Fig. 4.22 MRI (T2) of cervical spine in rheumatoid arthritis. Images show high-signal material anterior (arrow) to the odontoid process. This indicates an inflammatory pannus. Pannus can also be present around the attachments of the transverse and cruciate ligaments. MRI is also useful for showing degree of compression on the cervical cord, and also demonstrates increased signal within the cord, due to cervical myelopathy (dotted arrow).

Pannus Related Bone Degradation

Was this article helpful?

0 0
Arthritis Relief and Prevention

Arthritis Relief and Prevention

This report may be oh so welcome especially if theres no doctor in the house Take Charge of Your Arthritis Now in less than 5-Minutes the time it takes to make an appointment with your healthcare provider Could you use some help understanding arthritis Maybe a little gentle, bedside manner in your battle for joint pain relief would be great Well, even if you are not sure if arthritis is the issue with you or your friend or loved one.

Get My Free Ebook


Post a comment