Rheumatism is an inflammatory disease, which can involve the spine but can also involve joints and blood vessels. It is more common in women. Rheumatoid arthritis often involves the small joints of the hands destroying the joint surface. It can also be associated with osteoporosis and cyst formation in the bones, which weakens these. In the spine, the neck is involved in the majority of cases. This can lead to instability causing pain or pressure on nerves or the spinal cord (myelopathy). Within the cervical spine, the first two vertebrae are most commonly involved. It can lead to instability, which is called atlanto-axial subluxation. The thoracic and lumbar spine is rarely involved. Most patients with involvement of the spine have suffered from rheumatoid arthritis for many years (average 10-15 years). Early treatment of rheumatoid arthritis can reduce the risk of later complication not only in the spine. Therefore, it is important that patients with suspected rheumatoid arthritis are assessed and treated by a specialist as soon as possible.
The risk of instability of the spine is compression of the spinal cord (myelopathy). This often leads to clumsiness of the hands and in combination with the arthritis of the hands can be very disabling. Overall, the mobility of patients can reduce significantly and some may become bed bound. A particular complication of atlanto-occipital instability is occipital neuralgia. This is caused by pressure on a nerve which leaves the spine between the first two vertebrae. It causes pain in the upper neck – usually only on one side – which also radiates to the back of the head. It can be sharp and shooting in nature but also feel like a burning pain. Pannus is a term used for a soft tissue mass caused by the rheumatoid arthritis around the odontoid peg. This can lead to pressure on the spinal cord.
An accurate history of the patient’s symptoms is essential. This includes duration and severity of the symptoms, duration and other complications of the underlying rheumatoid arthritis, medication the patient has taken in the past and is currently taking and other medical conditions in particular diabetes and heart conditions which can cause complications during or following surgery.
A thorough clinical examination is necessary to establish the extend of neurological involvement but also of the musculo-skeletal system. It is especially important to detect even subtle signs of myelopathy as this has an impact on the management strategy.
The question whether a patient suffers from rheumatoid arthritis should be well established and where there is any doubt patients will need tests to make a clear diagnosis. In my opinion, all patients with suspected rheumatoid arthritis should be seen by a specialist /rheumatologist) in particular before any surgical intervention is planned! These tests usually include blood test (rheumatoid factors and may include x-rays).
For the spine flexion and extension x-rays and MRI-scan of the relevant part of the spine are important. These will show any abnormal movement in particular in the cervical spine. It will also show compression of the spinal cord although it is important to remember that the MRI might be normal because it is taken with the patient lying with the neck straight. As the instability usually occurs in flexion, i.e. the head bend forward it might not show, hence the flexion and extension views.
Medical treatment forms the basis for patients with rheumatoid arthritis. This varies significantly depending on the severity and progression of the disease. Many patients require steroid medication and other powerful drugs which can significantly improve the outlook for patients with this potentially very disabling disease. Surgery is nowadays only necessary in a small number of patients thanks to the early detection and effective treatment of most patients.