Neck pain and rheumatoid arthritis
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
Click here: Second Opinion Arthritis Treatment Kit
The spine is made of a stack of bones called vertebrae.
A bony ring attaches to the back of the vertebral body, forming a canal.
When the vertebra bones are stacked on top of each other, the canal forms a long tube that surrounds and protects the spinal cord as it passes through the spine.
An intervertebral disc sits between each vertebral body. The disc works like a shock absorber. Between each two vertebra are two synovial joints called facet joints. Together with the disc, these joints connect the two vertebra together and allow motion at each level of the spine.
The first two cervical vertebrae are very specialized to allow rotation of the head. The first cervical vertebra (or C1) is called the atlas. The second cervical vertebra (C2) is called the axis. The C1 vertebra connects the skull to the cervical spine. Between C1 and the skull are synovial joints.
The C1 vertebra is formed like a ring that sits on top of C2. The C2 vertebra has a bony finger that fits into the front portion of the ring of the C1 vertebra. This bony finger is called the odontoid process. It is held in place by a ligament that holds it tightly to the front of the ring of C1. The spinal cord enters the skull through a hole in the base of the skull called the foramen magnum. Two blood vessels also enter the foramen magnum, one on the left and one on the right. These blood vessels, called the vertebral arteries, supply the posterior portion of the brain.
The most common type of arthritis to affect the neck is osteoarthritis. This is primarily a wear-and-tear type of arthritis.
Rheumatoid arthritis is a chronic inflammatory autoimmune-based disease that affects all of the synovial joints in the body. The cervical spine (neck) contains synovial joints. The damage caused by rheumatoid disease can vary from minimal symptoms to life threatening pressure on the spinal cord.
The problems that arise in the neck are primarily due to destruction of the synovial joints by the rheumatoid arthritis. As the joints are destroyed, the connection between each vertebra becomes unstable. The upper vertebra is able to slide forward on top of the one below. This slippage is called spondylolisthesis. In the lower part of the neck below C2 this can lead to pressure on the nerve roots and the spinal cord.
Instability is most serious between the C1 and C2 vertebrae. As the facet joints and the ligaments that hold the odontoid in the front of the ring of the C1 vertebra are destroyed, the C1 vertebra slides forward. If this instability becomes too great the odontoid may push into the spinal cord.
The connection between the skull and the C1 vertebra may become affected. The destruction of the joints between the skull and the C1 vertebra allows the skull to "settle." When this occurs the bony knob of the C2 vertebra (the odontoid) begins to move up into the skull and can put pressure on the spinal cord as it leaves the skull through an opening called the foramen magnum. The vertebral arteries may also be compressed by the odontoid.
The symptoms of rheumatoid arthritis in the cervical spine are extremely varied. Pain is the earliest symptom and may be part of the overall joint inflammation that occurs with the arthritis. As the disease progresses, symptoms of spinal cord compression occur.
Pain at the base of the skull is common and can indicate that the nerves that exit the skull and the upper spine are being irritated or compressed. Pressure on the vertebral arteries can lead to loss of consciousness when the blood flow is compromised.
A change in gait can signal increasing pressure on the spinal cord. In some cases this can be a spastic gait with weakness and problems with balance. This is an indication that the spinal cord is being compressed. Tingling, weakness, or a loss of coordination can affect the arms or legs. Changes in bowel or bladder function such as incontinence or inability to urinate can also occur.
The diagnosis of rheumatoid cervical spine problems begins with a thorough history and physical examination. Changes in ability to walk can be a valuable clue. Also, changes in bowel or bladder function are also important. Any neurological symptoms that have changed such as weakness, numbness, or loss of fine motor skills are important. On exam, changes in reflexes may also be a sign.
An important part of evaluating the neck includes X-ray of the cervical spine. This may include special X-rays These are called flexion and extension X-rays and can show how much instability is present.
The MRI scan is the most important test for showing the nerves and soft tissues of the cervical spine.
Finally, special electrical tests may be ordered. These tests are useful to determine how the spinal cord is functioning.
The major non-surgical treatment of the cervical spine problems associated with rheumatoid arthritis begins with good control of the rheumatoid arthritis.
Once there is evidence that the rheumatoid arthritis has affected the stability of the cervical spine, the most important part of spine care is close followup. Mild instability with no evidence that the instability is causing any pressure on the nerves or spinal cord may not require any additional treatment. Patients with X-ray signs of instability may need to protect their neck with a special neck brace, especially when riding in a car. This is mainly to prevent damage to the spinal cord should a cervical spine injury occur.
When signs of pressure on the spinal cord become apparent, many surgeons feel that surgical stabilization should be considered. The goal of surgery is to stabilize the unstable portion of the cervical spine, to remove pressure from the spinal cord and to relieve the pain caused by the underlying instability.
Surgery that fuses C1 and C2 together reduces neck rotation up to 50 percent. Posterior cervical fusion stops all forward and backward motion between the fused vertebrae.
These operations are extremely complex and carry significant risks.
When the instability involves the lower cervical spine (C3 to the bottom of the cervical spine) a posterior fusion is usually preferred. A fusion of the spine is also called an arthrodesis. Bone graft taken from the hip is placed between and across the back of the vertebrae to be fused. These vertebrae are held together with metal hardware.
When the primary problem is instability between the C1 and C2 vertebrae, a fusion between these two spine bones is usually done. The goal is to stop the progression of the instability and relieve pressure on the spinal cord.
The most serious condition from rheumatoid arthritis of the cervical spine is the settling that occurs when the joints between the skull, the C1 vertebra, and the C2 vertebra are destroyed. Settling allows the odontoid to place more pressure on the spinal cord and brain stem and this can lead to paralysis and even sudden death.
The surgical procedure to stabilize this situation requires a fusion between the skull and the first three cervical vertebrae (C1, C2, and C3).
A successful fusion stops the instability and protects the spinal cord from additional pressure.
The fusion usually takes at least 12 weeks to become stable, but it may take as long as one year.
In some cases of advanced rheumatoid arthritis of the cervical spine, the posterior fusion alone is not enough to take the pressure off of the spinal cord. This happens in two situations.
First, the cranial settling may be so great that a fusion cannot remove the pressure that the odontoid is placing on the spinal cord.
Second, the pannus that occurs due to the rheumatoid arthritis may put pressure on the spinal cord. Pannus is inflammatory tissue formed by the synovium (joint lining). It grows and expands like a tumor. As it grows larger it can put pressure on the spinal cord. Usually, once a fusion has been successful the pannus actually shrinks, and the pressure on the spinal cord is reduced.
If either of these conditions is causing pressure on the spinal cord, a second operation may be needed. The operation must be done using the front of the spine approach. When surgery on the front of the spine is necessary, it must be performed through the back of the mouth. This is called a transoral (through the mouth)approach.
The operation begins with the transoral approach when pressure must be removed from the front of the spinal cord. This is followed by a posterior fusion as part of the same operation.
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