Inflammatory conditions

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The most common inflammatory condition leading to spinal cord compression is rheumatoid disease, which affects approximately 1% of the population in Western Europe. The cervical spine is involved in a substantial percentage of patients with rheumatoid disease and the incidence and severity increase directly with the duration of the disease. The most common site of involvement is at the occipito-Cl/C2 level, although all levels of the cervical spine may be involved.16

The fluctuating progress of the condition gradually destroys the joint tissues and articular surfaces and leads to subluxation or even dislocation. This is frequently seen in the fingers and wrist joints of patients with rheumatoid disease, but also occurs at the occipito-CI/C2 level.

The most common form of dislocation is anterior subluxation of Cl on C2, and this may be fixed or mobile depending on the activity of the inflammatory process1719 (Figure 10.3). Eventually the condition "burns out" and the joints may become ankylosed in an abnormal position. Loss of height of the lateral masses of C1 results in vertical translocation of the odontoid process and this occurs in about 10% of the affected population. Less frequently occurring abnormalities include posterior subluxation of C1 on C2 where the odontoid is totally eroded and the atlas can move posteriorly relative to the body of C2. Asymmetrical involvement of the lateral mass joints may lead to rotational deformities or lateral subluxations.20 The demonstration of these different types of atlantoaxial abnormality was enormously enhanced by the advent of CT myelography, including sagittal plane reconstruction. Magnetic resonance scanning is now more commonly used. Either type of study may be carried out in flexion and extension to demonstrate instability.21,22

With any subluxation in this region or in the subaxial region, spinal canal compromise may occur, causing a myelopathy (Figure 10.4). Although pain and radiographic abnormalities are common in rheumatoid disease, extensive epidemiological and clinical studies have shown no sure method of predicting which patients will deteriorate neurologically and which patients, even with relatively severe radiological involvement, will never develop neurological signs and symptoms. More recent work suggests that measurement of cord diameter or area may prove to be a better predictor of the requirement for surgical intervention and of surgical outcome than clinical markers.23,24

Cervical Myelopathy Signs And SymptomsCervical Myelopathy Gait Disturbance

Figure 10.3 Plain lateral cervical spine radiograph performed in flexion (a) and extension (b). This patient with rheumatoid arthritis has anterior subluxation of C1 on C2 in flexion with complete reduction in extension. Note the compromise of the spinal canal between the posterior surface of the odontoid process and the posterior arch of C1 in the flexion film

Figure 10.3 Plain lateral cervical spine radiograph performed in flexion (a) and extension (b). This patient with rheumatoid arthritis has anterior subluxation of C1 on C2 in flexion with complete reduction in extension. Note the compromise of the spinal canal between the posterior surface of the odontoid process and the posterior arch of C1 in the flexion film

Subluxated Cervical Mri
Figure 10.4 MRI (1-5T Siemens Magnetom, T1 weighted scan). Subaxial spinal cord compression presenting as gait disturbance and loss of coordination over a period of weeks

Acute spinal cord compression is not common in rheumatoid disease although there are anecdotal cases of patients suddenly collapsing with paralysis and succumbing due to gross odontoid subluxation. Usually neurological symptoms develop over a period of weeks or even months, but a few patients do develop neurological signs and deteriorate with progressive myelopathy over a period of days. They present with deterioration in gait quality and complain of sensory alteration or sensory loss, including loss of manual dexterity. A clear clinical history is of paramount importance in confirming the myelopathy, since severe widespread synovial joint involvement frequently precludes accurate assessment of deep tendon reflexes and muscle power.

Patients can often distinguish between new symptoms such as loss of strength, paraesthesia, or significant gait deterioration and identify these separately from the symptoms of multiple joint involvement with which they are already very familiar. Isolated tendon reflexes may be elicited, although plantar responses are almost never obtainable because of local joint involvement or previous surgery. Vertical subluxation of the odontoid process may occasionally give rise to lower cranial nerve signs and symptoms. Formation of a fibrous inflammatory mass (often erroneously referred to as pannus) around the odontoid process can also cause compression of the high spinal cord or lower medulla. The differential diagnosis of speech difficulty and dysphonia includes rheumatoid involvement in the temporomandibular and cricoarytenoid joints.25,26 In one of the largest series of rheumatoid patients that has been studied neurologically, nystagmus only occurred in those patients with a pre-existing Chiari I malformation.23

When a cervical myelopathy is confirmed in a patient with rheumatoid disease, the most common cause is anterior atlantoaxial subluxation. This can be confirmed easily and rapidly by a plain lateral radiograph of the cervical spine taken in flexion and extension. This shows bone movement and position, whereas demonstration of soft tissue involvement requires the use of CT myelography or MRI. The purpose of management in this situation is to reduce compression on the cervical cord and in most cases this can be achieved by extending the upper cervical spine and bringing the Cl and C2 vertebrae into more normal alignment. It cannot be assumed, however, that because vertebral alignment has been restored, spinal cord compression has been reduced. This becomes apparent once scanning of the region has been carried out. A spine surgeon should be consulted at this point for decisions concerning continued immobilisation or surgical decompression, fixation, and fusion.

There are a variety of surgical approaches to the craniocervical junction. The odontoid region can be approached directly by the transpharyngeal route in order to decompress the anterior cervicomedullary region directly. It is recommended that this should be followed by a posterior stabilising operation to generate fusion of Cl and C2 or occipital bone to C2.27-29 If the spinal cord compression is primarily posterior, a standard posterior approach and decompression with or without stabilisation may be preferable. For many patients a posterior

C1-C2 fixation and fusion is sufficient.30-35 Subaxial spinal cord compression is less common than at C1-C2, but also may require a combination of anterior and posterior surgery. A careful history sometimes elicits an episode of trauma that was initially thought to be trivial. Extreme caution must be exercised in reducing deformities at this level. Overzealous attempts at reduction may result in cord injury in the setting of chronic spinal deformity secondary to rheumatoid disease or other inflammatory conditions such as ankylosing spondylitis. At all levels the aim is to directly decompress the spinal cord, to restore vertebral alignment, and to prevent further malalignment.

The postoperative mortality and morbidity rates are greatest in those patients who are severely neurologically affected, that is, tetraparetic and unable to walk.24 The systemic effects of rheumatoid disease, especially interstitial pulmonary involvement, may adversely affect postsurgical recovery. In those patients in whom the myelopathy is recognised and treated in the early stages the outlook for recovery is good and postoperative mortality is low.17

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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