Early and extensive erosiveness in peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis.
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OBJECTIVE: To study the prevalence of cervical spine subluxations and predictive factors for atlantoaxial subluxations (including anterior atlantoaxial subluxation and atlantoaxial impaction, i.e., vertical subluxation) in patients with rheumatoid arthritis (RA) who were treated early and continuously with disease-modifying antirheumatic drugs for 8-13 years. METHODS: Radiographs of the cervical spine were obtained in 103 of 110 patients (the 110 surviving patients of the original 135-patient cohort) at their 8-13-year followup visits. The prevalence of cervical spine subluxations was determined. Demographic variables and the first 5-year serial data concerning disease course were analyzed in a logistic regression model to find predictive factors for atlantoaxial subluxations. RESULTS: Atlantoaxial subluxations were found in 14 patients (14%), and 5 patients (5%) had subaxial subluxations. Older age at baseline, greater disease activity during the first 5 years, and early erosiveness in peripheral joints predicted the development of atlantoaxial subluxations. Patients who had >or=10% of the maximum possible radiographic damage (by Larsen score) in peripheral joints at 5 years were 15.9 times more likely to develop atlantoaxial subluxations at 8-13 years than patients whose peripheral joint damage remained <10% of the maximum. CONCLUSION: Compared with historical control RA cohorts, a lower prevalence of cervical spine destruction was found in the present group of patients. Rapid erosiveness in peripheral joints was the best predictor for atlantoaxial subluxations. Extensive erosiveness in peripheral joints should alert rheumatologists to the possible development of atlantoaxial subluxations in patients with RA. (+info)
We report a rare case of high cervical intramedullary ependymal cyst in a young boy. This was associated with atlantoaxial dislocation. After partial removal and marsupialization, the cyst recurred and needed radical total resection. (+info)
Rheumatoid arthritis in Spain: occurrence of extra-articular manifestations and estimates of disease severity.
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OBJECTIVES: To characterise RA in a sample of Spanish patients by estimating mean clinical activity, functional ability, and radiological damage, and current and cumulative prevalence of extra-articular manifestations. METHODS: Cross sectional analysis of a cohort of patients with RA randomly selected from the clinical databases of 34 centres. Standard definitions and measurements were used, and radiographs read centrally. Estimates and confidence intervals were adjusted to sampling. RESULTS: Data were available for 788 patients. Extra-articular RA was present in 285 (36.2%) patients. Cumulative prevalence and 95% confidence intervals of extra-articular manifestations were estimated: nodules 24.5% (21.5 to 27.5), Sjogren's syndrome 17.0% (14.4 to 19.6), atlantoaxial subluxation 12.1% (9.8 to 14.4), carpal tunnel syndrome 10.7% (7.8 to 13.6), interstitial lung disease 3.7% (2.4 to 5.0), serositis 2.5% (1.4 to 3.5), eye disease 2.5% (1.1 to 3.9), vasculitis 1.3% (0.5 to 2.1), amyloidosis 0.6% (0.1 to 1.2), and Felty's syndrome 0.3% (<0.6). Mean (SD) activity/progression indexes were: DAS28-3 3.4 (1.2), HAQ 1.6 (0.4), Larsen score 54.7 (26.4). Less than 5% of the patients were in remission. 205 (72%) patients were receiving disease modifying antirheumatic drugs (DMARDs). CONCLUSION: Spanish patients with RA ever seen by a rheumatologist have, on average, a moderate degree of activity, despite widespread use of DMARDs. Measures of the degree of progression do not show a benign disease. The proportion of extra-articular manifestations in Spanish patients with RA is similar to that found in other Mediterranean populations, and lower than that reported in Anglo Saxon countries. (+info)
Schwannoma of the craniocervical junction: surgical approach of two cases.
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We report two cases of craniocervical junction schwannomas with a special focus on the surgical approach. The patients underwent a far-lateral approach in the sitting position that facilitated the lesion removal. This report is meant to improve the understanding of this surgical technique as well as improve awareness of its usefulness for similar cases. (+info)
Interlaminar fixation using the atlantoaxial posterior fixation system (3XS system) for atlantoaxial instability: surgical results and biomechanical evaluation.
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This study evaluated the surgical results for patients with atlantoaxial instability due to various lesions treated using the atlantoaxial posterior fixation system (3XS system; Kisco DIR, Paris, France), together with a biomechanical study of this system. The strength of the 3XS system during torsion was examined using a biomechanical simulation model. The 3XS system consists of a transverse unit, hooks, and rods. The lower part of the biomechanical simulation machine was rigidly fixed and the upper part was movable, allowing torsion to be applied until the point of failure. The test was started at 1.5 newton-meters, thought to be the maximum load on the upper cervical spine. The 3XS system tolerated torsion of up to 20 newton-meters, but became deformed. The instrument was fractured at 30 newton-meters. Fifteen patients, four with atlantoaxial instability, seven with os odontoideum, and four with odontoid fractures, underwent surgery using the 3XS system and an iliac bone fragment inserted between the C-1 and C-2 laminae. Postoperative rigid fixation of the lesion and optimal cervical alignment was obtained in all patients, and the patients were discharged within 2 weeks after surgery. Follow-up radiography showed bony fusion between C-1 and C-2 in all patients. Posterior fixations between C-1 and C-2 using the 3XS system were easy to perform and no surgical complications were encountered. The biomechanical study showed the 3XS system can tolerate torsions unlikely to occur during rotation movements in the atlantoaxial region in humans. The surgical use of the 3XS system for the treatment of atlantoaxial instability has several advantages. (+info)
Atlantoaxial dislocation in idiopathic cervical dystonia.
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We report a case of severe cervical spondylosis and atlantoaxial dislocation (AAD) in association with idiopathic cervical dystonia (ICD) in a middle-aged male. To our knowledge, this is the first case of ICD reported in association with AAD. (+info)
The jigsaw sign. A reliable indicator of congenital aetiology in os odontoideum.
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There is evidence in the literature for both a congenital and a post-traumatic aetiology for os odontoideum. In no series published to date has CT been used to aid in the diagnosis. This is a prospective study of the history of trauma and presence of diagnostic features on CT of 18 consecutive cases with os odontoideum. Our objective was to derive clinically useful radiological features enabling accurate differentiation between congenital and post-traumatic aetiologies. A mid-sagittal CT reconstruction of the atlanto-dens joint was obtained. Hypertrophy of the anterior arch of the atlas was quantified by measurement of the arch-peg-area ratio. The presence of dysplastic features (a positive "jigsaw" sign) of the atlanto-axial joint were noted. These included narrowing of the cartilage space and interdigitation of the two joint surfaces. A history of a potential traumatic aetiology was only obtained in one of the 18 (6%) in our series. A significant elevation of the arch-peg ratio was found when comparing this series to 85 controls. And a positive jigsaw sign was observed in 75% of cases. These features were not seen in paediatric cases of atlanto-axial instability, including odontoid non-union. In conclusion, an elevated arch-peg ratio and the presence of a jigsaw sign are sensitive and specific diagnostic criteria for os odontoideum. This series supports a congenital aetiology for this condition. (+info)
Therapeutic options and results following fixed atlantoaxial rotatory dislocations.
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Atlantoaxial rotatory dislocation (AARD) represents a rare pathological condition of the upper cervical spine that is frequently misdiagnosed, leading to a delay in therapy. In a long-term assessment of clinical and radiological results, three different therapeutic options with regard to the length of the dislocation-therapy interval (DTI) were evaluated. Twenty-six patients were treated for AARD from December 1988 until April 2000. Proper diagnosis was established after an average interval of 15 months. Three different therapeutical protocols were followed in order to reduce the dislocation: (1) closed transoral reposition under general anesthesia; (2) temporary transoral fixation utilizing the Harms T-plate; (3) definitive transoral fusion. The eight patients treated by closed reduction had the best pain relief. The average visual analogue scale (VAS) score was 96.6 points, while the rotatory motion of the upper cervical spine, as assessed by dynamic MRI, was 25.3 degrees to each side. The length of the dislocation-therapy-interval (DTI) averaged 1.4 months. A mean VAS Score of 92.3 points was recorded in the ten patients treated with a temporary fixation of C1/C2. In this subgroup the DTI had an average length of 5.3 months. The mean rotation to each side was 13.9 degrees . In the eight patients who underwent definitive fusion the mean VAS score was 60.6 points, while the average length of the DTI was 40.5 months. In conclusion, the clinical outcome and the subjective well-being following AARD deteriorates with increasing length of the dislocation-therapy interval. (+info)