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 Table of Contents  
IMAGES IN RHEUMATOLOGY
Year : 2018  |  Volume : 13  |  Issue : 1  |  Page : 60-61

An early presentation of cervical myelopathy in rheumatoid arthritis


1 Department of Rheumatology, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of Rheumatology, King George Medical University, Lucknow, Uttar Pradesh; Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication26-Feb-2018

Correspondence Address:
Dr. Rasmi Ranjan Sahoo
Department of Rheumatology, King George Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_68_17

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  Abstract 


Keywords: Atlantoaxial instability, odontoid pannus, quadriparesis


How to cite this article:
Dhakad U, Sahoo RR, Bhadu D, Tripathy SR, Srivastava D, Das SK. An early presentation of cervical myelopathy in rheumatoid arthritis. Indian J Rheumatol 2018;13:60-1

How to cite this URL:
Dhakad U, Sahoo RR, Bhadu D, Tripathy SR, Srivastava D, Das SK. An early presentation of cervical myelopathy in rheumatoid arthritis. Indian J Rheumatol [serial online] 2018 [cited 2019 Aug 17];13:60-1. Available from: http://www.indianjrheumatol.com/text.asp?2018/13/1/60/211698



A 51-year-old female, who was diagnosed to have rheumatoid arthritis (RA) for 2 years but was on irregular treatment presented with progressive weakness of right upper and lower limbs for 4 months and left upper and lower limbs for 15 days. She also had pain in the neck which aggravated with coughing and sneezing. Bladder and bowel habits were normal. For these complaints, she consulted a local physician an was advised computed tomography scan of the brain which was apparently normal. She was prescribed aspirin (75 mg), multivitamins. She had discontinued methotrexate, hydroxychloroquine for the past 4 months. On examination, the patient was conscious and oriented. Nervous system examination revealed decreased power of 3/5 in both lower limbs and 4/5 in both upper limbs. There was increased tone in both upper and lower limbs. Deep tendon reflexes were exaggerated with extensor plantar response. All modalities of sensations were decreased below C2 level. Cranial nerves were intact. There was no meningeal and cerebellar signs. Musculoskeletal examination revealed synovitis of metacarpophalangeal joints, proximal interphalangeals, wrists, knees, and ankle joints. Examination of other system was unremarkable.

Laboratory examination revealed hemoglobin 9 g/dl, total leukocyte count 12,730/mm3, differential count N71/L21/M6/E2, platelet count 2.5 lakh/mm3, ESR 100 mm 1st hour, and C-reactive protein 12.5 mg/L (n = 0–6 mg/L). Bone mineral density showed osteoporosis with a T-score of minus 3.7 at lumbar spine. Magnetic resonance imaging (MRI) of the cervical spine revealed atlantoaxial dislocation with odontoid pannus compressing the thecal sac and spinal cord [Figure 1].
Figure 1: Magnetic resonance imaging of the cervical spine with sagittal T1- (left) and T2-weighted images (right). There is odontoid pannus formation with low signal intensity on both T1- and T2-weighted images with compression of the spinal cord. Note the thecal indentation seen at the level of C5–C6 vertebrae

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Based on aforementioned features a final diagnosis of RA with pannus causing atlantoaxial dislocation and cervical myelopathy was made. The patient was advised surgical intervention which she refused. Pulse methyl prednisolone (1 g for 5 days) was given followed by oral prednisolone (1 mg/kg/day). Methotrexate and hydroxychloroquine were restarted. Zoledronic acid was given for the treatment of osteoporosis. Patient was advised to wear hard cervical collar. With this treatment, patient improved. She could stand without support at around 3 weeks and started walking with support at 4 weeks of therapy. Patient was discharged with disease-modifying antirheumatic drugs, prednisolone, nonsteroidal anti-inflammatory drug, calcium and Vitamin D supplementation, and physiotherapy.

The patient was on follow-up for nearly 2 years. The arthritis subsided with methotrexate 25 mg/week, hydroxychloroquin 300 mg daily and steroid was tapered over a period of 5 months. Her muscle power improved and she could walk with support. She was lost to follow-up at the end of 2 years.


  Discussion Top


Although cervical spine involvement in RA is a late manifestation, there are reports of cervical myelopathy occurring early in the disease course.[1] Our patient developed cervical myelopathy within 2 years of disease. The reported prevalence of cervical spine involvement in RA ranges from 9% to 88% and occurs usually after 10 years of disease.[1] The most common cervical spine disease in RA is atlantoaxial instability (65%), basilar invagination (20%), and subaxial subluxation (15%).[2] The proposed mechanism of cervical spine involvement in RA is pannus leading to destruction of the transverse, apical, and alar ligaments. Risk factors for compressive myelopathy in RA are peripheral erosive arthritis and steroid therapy.[3] Our patient had severe peripheral arthritis indicating active disease which would have contributed to odontoid pannus causing cervical myelopathy. Cervical spine disease in RA is often asymptomatic and symptoms can range from localized neck pain to myelopathy. The diagnosis is often made by careful history, physical examination, and imaging. Conventional radiographs of the cervical spine in flexion and extension positions can detect atlantoaxial subluxation. However, MRI has the advantage of detecting bone erosions, marrow edema, synovitis, and early cord compression. MRI of the cervical spine in our patient revealed odontoid pannus with low signal intensity in both T1- and T2-weighted sequences suggesting a fibrotic pannus. One study reported fibrotic pannus in 16% of RA patients with cervical spine involvement whereas 40% had hyprevascular pannus with low signal intensity on T1 and high signal intensity on T2-weighted sequences.[4]

The indications for surgical intervention in RA with cervical spine disease include C2 radiculopathy, to prevent myelopathy, further neurological deterioration in existing myelopathy, and to correct any deformity.[5] As our patient declined surgical intervention, she was managed with pulse methyl prednisolone followed by oral prednisolone, and there was gradual improvement in muscle power.

This case highlights the evaluation of cervical spine involvement in patients of RA even early in the disease course with MRI being the preferred imaging modality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Del Grande M, Del Grande F, Carrino J, Bingham CO 3rd, Louie GH. Cervical spine involvement early in the course of rheumatoid arthritis. Semin Arthritis Rheum 2014;43:738-44.  Back to cited text no. 1
    
2.
Kim HJ, Nemani VM, Riew KD, Brasington R. Cervical spine disease in rheumatoid arthritis: Incidence, manifestations, and therapy. Curr Rheumatol Rep 2015;17:9.  Back to cited text no. 2
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3.
Yurube T, Sumi M, Nishida K, Miyamoto H, Kohyama K, Matsubara T, et al. Accelerated development of cervical spine instabilities in rheumatoid arthritis: A prospective minimum 5-year cohort study. PLoS One 2014;9:e88970.  Back to cited text no. 3
    
4.
Stiskal MA, Neuhold A, Szolar DH, Saeed M, Czerny C, Leeb B, et al. Rheumatoid arthritis of the craniocervical region by MR imaging: Detection and characterization. AJR Am J Roentgenol 1995;165:585-92.  Back to cited text no. 4
    
5.
Mukerji N, Todd NV. Cervical myelopathy in rheumatoid arthritis. Neurol Res Int 2011;2011:153628.  Back to cited text no. 5
    


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