Evolving Management of Cervical Spine Instability in RA

Sports medicine experts, emergency medicine physicians, and orthopedic surgeons are reporting that their experiences with cervical spine instability related to rheumatoid arthritis are evolving.

Sports medicine experts, emergency medicine physicians, and orthopedic surgeons are reporting that their experiences with cervical spine instability related to rheumatoid arthritis (RA) are completely different today than they were 10 years ago. Cervical spine instability due to RA is now far less common because of the advent of disease-modifying antirheumatic drugs (DMARDs).

“We don’t see as many patients as we used to.  In fact, I see one-tenth of what I used to do,” said Jung Yoo, MD, chairman of Department of Orthopedics and Rehabilitation, Oregon Health & Science University (OSHU),  and co-director of the OHSU Spine Center, Portland, Oregon.

RA often involves the cervical spine and chronic synovitis may cause bony erosion and ligamentous laxity.  This results most commonly in anterior atlantoaxial subluxation (AAS).  However, other manifestations may include cranial settling and subaxial subluxation. 

“[Patients with RA] with any of these three conditions can have as presenting symptoms pain and neurologic changes ,however often can be asymptomatic as well,” Dr Yoo said in an interview with Rheumatology Advisor.  “The presence of spinal cord is compression is the key element in caring for these patients.” He said all patients should be evaluated for spinal cord compression prior to any manipulation or surgery. 

Dr Yoo said it is important to note that radiographs, MRIs, and computed tomography scans don’t tell the clinician the whole story because these studies are done in a static manner. MRI can diagnose spinal cord compression in any of these three conditions, however for C1-2 subluxation, a dynamic study is needed to demonstrate the instability.

Although real time fluoroscopy can be used, it is more frequent that two static lateral cervical spine films (one in full extension and one in full flexion) is done to demonstrate sagittal migration of the odontoid in relation to the atlas suggesting possible compression of the spinal cord. 

“With these sets of radiographic studies and understanding of what types of pathology is common in RA, it is not difficult to determine the stability of the cervical spine and spinal cord for these patients when undergoing any surgery,” said Dr Yoo.

A New Landscape Has Emerged 

Scott Duncan, MD, MPH, MBA, chief of orthopedic surgery at Boston Medical Center, Massachusetts and chair of the department of orthopedic surgery at Boston University School of Medicine, Massachusetts, said DMARDS have changed his job.  He said RA is not wreaking its havoc like it did in the past. “Our rheumatologists have put us out of business,” Dr Duncan said in an interview with Rheumatology Advisor.

He said the over the past 15 years the landscape has changed dramatically.  However, the debate continues over how best to manage these patients. Dr Duncan said clinicians must take extra precautions because of the cervical spine issues.  He said most individuals can extend their necks with no problems.  However, with some RA patients you can compromise the cord.  It gets crushed and squeezed.

“Many won’t operate on the rheumatoid cervical neck until they absolutely have to,” said Dr Duncan.  However, he said every case is unique and how patients are managed is based on many different criteria.  “Operate early proponents are trying to prevent the potential problems, which are serious and non-reversible.”

New York researchers have found that operative intervention before the onset of advanced myelopathy can result in improved outcomes compared to the surgical stabilization of patients whose conditions are more advanced.  In addition, they report that a multidisciplinary approach involving rheumatology, surgery, and rehabilitation can be the best approach for optimizing outcomes .1 

When patients with RA are being evaluated and treated for cervical instability, spine experts work very closely with rheumatologists. Dr Duncan said the rheumatologists are the key to optimal outcomes. “They guide how to deal with musculoskeletal issues. So, the rheumatologists call most of the shots.  This is where the care team takes over.  The patients are osteopenic, if not osteoporotic, and the treatments can be challenging for a spine surgeons,” he indicated.