Introduction:
Rheumatoid arthritis (RA) is a chronic inflammatory illness that usually affects the synovial joints, ligaments, and bones but can impact nearly any organ system. Although RA mostly affects the peripheral joints, it can also have significant systemic consequences for the pulmonary, hematologic, and cardiovascular systems. The involvement of the cervical spine is particularly relevant because, if ignored, it can result in severe neurologic morbidity, a decline in quality of life, and potentially even sudden death from cardiac arrest, stroke, or obstructive hydrocephalus.
What Is the Prevalence of Rheumatoid Cervical Spondylitis?
About 1 % to 2 % of adults worldwide are thought to be affected by RA. There are approximately 1.5 million adult cases of RA in the United States, and every year, about 41 new cases of the disease are diagnosed per 100,000 people over the age of 18. Although minor peripheral joints show the most noticeable signs of RA, the cervical spine is the second most frequently affected area. When RA was first identified in 1890, Garrod observed that 178 (or 35%) of the 500 patients had cervical spine involvement.
However, more recent estimates indicate that up to 80 % of people with RA show radiographic cervical spine involvement. Persistent cervical spine inflammation first causes pannus development and fibrovascular tissue growth, which in turn causes ligamentous laxity and bone degradation. This cascade may result in subaxial subluxation (SAS), cranial settling (CS), atlantoaxial instability (AAI), or a combination of the three conditions that cause cervical spinal instability. Moreover, RA can result in atraumatic odontoid erosion or fracture as well as inflammatory discitis.
What Is the Anatomy of the Cervical Spine?
An axial rotation of 60° is attributed to the C1 to C2 complex. The articulations and ligaments of the occipitoatlantoaxial complex manage movement limitation and mobility. The tectorial membrane holds the C1 ring in place when it articulates with the skull base through the occipital condyles. Atlas (C1) is also attached to the skull through the anterior atlantooccipital membrane, which joins the anterior arch of C1 to the anterior border of the foramen magnum. Furthermore, the posterior atlantooccipital membrane connects the posterior arch of C1 to the posterior edge of the foramen magnum.
Atlas (C1) and axis (C2) articulate multiple times to strengthen the occipitoatlantoaxial complex. The transverse ligament restrains the anterior translation of C1 relative to C2, preventing the dens from becoming attached to the anterior arch of C1 by a strap mechanism. This synovial joint unites the anterior arch of C1 with the odontoid process of C2. RA can cause damage to this architecture, leading to craniocervical instability and neurologic compression.
What Are the Signs and Symptoms of Rheumatoid Cervical Spondylitis?
In general, neck pain is a prevalent complaint. Though they may not exhibit any symptoms, patients with rheumatic cervical spine involvement typically have stiffness and non-specific neck pain, occasionally accompanied by C2 neuralgia. Compression of a vital neurological structure, such as the spinal cord and medulla, along with the nerve roots, can result from severe CS, AAI, SAS, and other misalignment injuries to the cervical spine. This can result in a wide range of neurological symptoms, signs, and problems, including brain stroke, sudden death, hydrocephalus, nerve root pain, paresis, and tetraplegia.
How Is It Diagnosed?
Rheumatoid arthritis involves the involvement of the cervical spine and is diagnosed radiologically. The most significant examination method is lateral view plain radiography obtained with the neck fully extended. Nearly all of the deformities and subluxations are visible. Neutral position radiographs alone could not diagnose about 50 % of unstable CS patients. Lateral view radiographs recorded in the neutral position or during full extension can show a reduction of unstable subluxations. In an open-mouth anteroposterior projection, the atlantoaxial facet joints can be seen.
Magnetic resonance imaging (MRI) is the most effective method when evaluating cervical spine compressions and active synovitis. MRI dynamic evaluation is challenging, and therefore, it is unreliable for determining the degree of subluxation. MRIs are not always available. Because MRIs are still quite costly and time-consuming, they should only be used in extreme circumstances, particularly as a preoperative evaluation. Computed tomography may be helpful when examining skeletal structures, such as those in atypical subluxations.
What Is the Treatment for Rheumatoid Cervical Spondylitis?
Usually, conservative measures are taken to treat rheumatoid cervical problems. The goals are symptom relief and stopping or slowing the abnormality's development. The best conservative care is multidisciplinary and includes education for the patient, symptomatic treatments (NSAIDs, light massage, etc.), disease activity control (glucocorticoids, new biological agents, and disease-modifying antirheumatic drugs (DMARDs), physical exercises (isometric muscle training, posture method, etc.), collars, and occupational therapy (practical aids, ergonomics, etc.). Surgery is only required in cases where conservative measures fail to alleviate severe symptoms or when there are developing cervical-related neurological problems. Conventional Ranawat scales can be used to assess neurological involvement and pain while determining the individual's clinical condition. However, they are relatively sensitive for modern therapeutic applications. In cases where there is a high danger of neurological consequences due to extremely severe anomalies, surgery may also be recommended. The decision to operate is determined on an individual basis.
How Does Diet Help With Rheumatoid Cervical Spondylitis?
Patients can also influence their gut microbiome by changing their diet due to the lack of concrete evidence and the fact that different people have varying reactions to the same diet. Considering the harm rheumatoid arthritis can do to the body's cardiovascular system, a heart-healthy diet is recommended. There is a lot of anecdotal data supporting the anti-inflammatory properties of turmeric, vegan diets, and giving up fast food, processed foods, dairy, and gluten for arthritis. Omega 3 fatty acids, present in fatty fish like salmon, are generally believed to have anti-inflammatory properties.
Conclusion
Only a small proportion of individuals require surgery for rheumatoid cervical spine abnormalities because they are so widespread, particularly in less severe situations.
It is important to treat these less severe illnesses conservatively to help patients cope with their abnormalities because they may worsen and raise the risk of complications. Ignoring these disorders is not an option. In cases that are severe and unresponsive, surgery is necessary and needs to be done before irreversible brain damage occurs.
