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Cervical Spine Involvement in Rheumatoid Arthritis.

by Roberto Russo

Image accessed from ajs.sagepub.comWith recent advances in the treatment of Rheumatoid Arthritis, there are certain manifestations which have become less prominent and as such the current generation of young Rheumatologists have little clinical experience in managing. One such example is the presence of cervical spine instability. I recently inherited an elderly lady who has had RA for many years. In the process of assessing her disease, she reported intermittent neck pain, which I presumed was more likely to relate to osteoarthritis. Nevertheless, I obtained radiographs of the neck, including motion views into flexion and extension. This reported the presence of instability.
RFF April 2013
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Traditional estimates report that about 80% of patients with RA will have cervical spine involvement, where 30% have instability. Of concern is that only half of patients are symptomatic, which most commonly is the experience of occipital headaches. Any symptoms of neurological compromise are obviously concerning features and should prompt urgent evaluation and treatment.

The cause of the instability is the erosion of the alar ligaments that connect the first two vertebral bones that form the atlanto-axial joint. Treatment obviously includes controlling the underlying disease process to minimize the extent of erosion and subsequent instability. However, where there is concern about neurological compromise then stabilization may be required. Whilst this may be achieved with the use of appropriate neck braces, occasionally surgical intervention is necessary. However, intubating these patients for surgery can be a challenge in itself and does pose significant peri-operative risk.

These patients should not undergo any form of manual therapy to the neck, including traction, mobilization, and definitely not manipulation. Therefore, it is imperative for any therapist to be aware of this condition and understand that the absence of symptoms is not necessarily reassuring.