Cervical instability in a patient with rheumatoid arthritis
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Department of Rehabilitation, Medical University of Warsaw, Warsaw, Poland
Department of Rehabilitation, Eleonora Reicher National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
Victoria Perovic-Kaczmarek   

Department of Rehabilitation, Medical University of Warsaw, Warsaw, Poland
Submission date: 2020-05-13
Final revision date: 2020-09-16
Acceptance date: 2020-09-17
Online publication date: 2021-03-18
Rheumatoid arthritis (RA) is a chronic autoimmune connective tissue disease characterized by symmetrical arthritis associated with extra-articular changes. Although peripheral joint involvement is the dominant symptom of RA, many patients develop cervical spine involvement in the course of the disease, manifesting as cervical instability.

The aim of this study is to describe a case of an RA patient with spinal myelopathy to increase awareness of this complication, hoping that its early diagnosis may prevent further serious consequences.

Case study:
A 63-year-old patient, who was diagnosed with RA 18 years ago, was admitted to the Rheumatology Clinic due to suspected exacerbation of rheumatic disease. Functional X-Ray and MRI was performed, which showed instability in the C3–C4 segment with spinal cord compression. Subsequently, the patient underwent cervical spine surgery. After the surgery and rehabilitation, the patient demonstrated neurological improvement.

Results and discussion:
Every patient diagnosed with RA should be educated about the possibility of a complication of cervical instability and be familiar with the neurological symptoms that may result from it. If cervical instability and subsequent cervical myelopathy are detected early, the symptoms may be reversible or significantly reduced by surgical spinal cord decompression and cervical stabilization.

It is very important to perform a functional X-ray of the cervical spine to exclude instability, especially before rehabilitation treatment. Neck pain in patients diagnosed with RA may indicate cervical instability that requires more thorough neurological examination to exclude cervical myelopathy.

Authors declare none conflict of interest.
None declared.
Narváez JA, Narváez J, Serrallonga M, et al. Cervical spine involvement in rheumatoid arthritis: correlation between neurological manifestations and magnetic resonance imaging findings. Rheumatology (Oxford). 2008;47(12):1814–1819.
Joaquim AF, Ghizoni E, Tedeschi H, Appenzeller S, Riew KD. Radiological evaluation of cervical spine involvement in rheumatoid arthritis. Neurosurg Focus. 2015;38(4):E4.
Insko EK, Gracias VH, Gupta R, Goettler CE, Gaieski DF, Dalinka MK. Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma. J Trauma. 2002;53(3):426–429.
Neva MH, Isomäki P, Hannonen P, Kauppi M, Krishnan E, Sokka T. Early and extensive erosiveness in peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis. Arthritis Rheum. 2003;48(7):1808–1813.
McCormick JR, Sama AJ, Schiller NC, Butler AJ, Donnally CJ 3rd. Cervical Spondylotic Myelopathy: A Guide to Diagnosis and Management. J Am Board Fam Med. 2020;33(2):303–313.
Mańczak M, Gasik R. Cervical spine instability in the course of rheumatoid arthritis – imaging methods. Reumatologia. 2017;55(4):201–207.
Ahn JK, Hwang JW, Oh JM, et al. Risk factors for development and progression of atlantoaxial subluxation in Korean patients with rheumatoid arthritis. Rheumatol Int. 2011;31(10):1363–1368.
Krauss WE, Bledsoe JM, Clarke MJ, Nottmeier EW, Pichelmann MA. Rheumatoid arthritis of the craniovertebral junction. Neurosurgery. 2010;66(3 Suppl):83–95.
Narváez JA, Narváez J, Serrallonga M, et al. Cervical spine involvement in rheumatoid arthritis: Correlation between neurological manifestations and magnetic resonance imaging findings. Rheumatology (Oxford). 2008;47(12):1814–1819.
Yan WJ, Liu TL, Zhou XH, Chen XS, Yuan W, Jia LS. [Clinical characteristics and diagnosis of rheumatoid arthritis of upper cervical spine: analysis of 71 cases]. Zhonghua Yi Xue Za Zhi. 2008;88(13):901–904.
Czerny C, Grampp S, Henk CB, Neuhold A, Stiskal M, Smolen J. Rheumatoid arthritis of the craniocervical region: assessment and characterization of inflammatory soft tissue proliferations with unenhanced and contrast-enhanced CT. Eur Radiol. 2000;10(9):1416–1422.
Gurley JP, Bell GR. The surgical management of patients with rheumatoid cervical spine disease. Rheum Dis Clin North Am. 1997;23(2):317–332.
Sunahara N, Matsunaga S, Mori T, Ijiri K, Sakou T. Clinical course of conservatively managed rheumatoid arthritis patients with myelopathy. Spine (Phila Pa 1976). 1997;22(22):2603–2608.
Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am. 1993;75(9):1282–1297.
Ebata S, Sato H, Ohba T, Ando T, Haro H. Postoperative intervertebral stabilizing effect after cervical laminoplasty. J Back Musculoskel Rehabil. 2015;28(2):303–309.
Hsu L. Cervical myelopathy: Overview and management. J Pain Palliat Care Pharmacotherapy. 2012;26(4):371–372.
Gupta A, Taly AB, Srivastava A, Murali T. Non-traumatic spinal cord lesions: Epidemiology, complications, neurological and functional outcome of rehabilitation. Spinal Cord. 2009;47(4):307–311.