Efficacy of Atlantoaxial Joint Glucocorticoid Injection in Patients with Rheumatoid Arthritis: A Randomized Trial.

BACKGROUND: The atlantoaxial joint (AAJ) plays a pivotal role in the cervical spine motion. Unfortunately, it is the most common cervical spine joint that is affected in patients with rheumatoid arthritis. Inflammation of the AAJ results in neck disability, nerve root compression, and finally spinal cord compression. OBJECTIVES: We aim to evaluate the efficacy of intraarticular triamcinolone injection of the AAJ on neck pain and disability. STUDY DESIGN: A prospective randomized, controlled clinical trial. SETTING: An interventional pain unit in a tertiary center at a university hospital in Egypt. METHODS: Sixty patients with rheumatoid arthritis complaining of AAJ arthritis were randomized into 2 groups. Group AAJI (n = 30) received AAJ injection with 1.0 mL of a mixture of 0.5 mL of bupivacaine 0.5% and 0.5 mL of 20 mg of triamcinolone, in addition to oral placebo tablets (2 tablets every 8 hours for one week). Group SS (n = 30) received systemic steroids, oral prednisolone tablets (5 mg, 2 tablets every 8 hours for one week), in addition to AAJ injection with 1.0 mL of a mixture of 0.5 mL of bupivacaine 0.5% and 0.5 mL of normal saline solution. The percentage of patients who showed >/= 50% reduction of their visual analog scale (VAS) pain score (measured at 1, 2, and 3 months postoperatively), VAS pain score and neck disability index (NDI) (measured at 2, 4, 6, 8, and 12 weeks postoperatively), and the magnetic resonance imaging (MRI) changes of AAJ (assessed 4 weeks postoperatively) were all evaluated. RESULTS: There was significant reduction in the percentage of patients who showed ≥50% reduction of their VAS pain score postoperatively in group AAJI compared with group SS at one month (75% vs. 46.45%; P = 0.033), 2 months (60.7% vs. 25%; P = 0.009), and 3 months (53.6% vs. 17.9%; P = 0.007). There was significant reduction in overall VAS and overall NDI in group AAJI compared with group SS (mean ± standard error) (41.5 ± 2.6 vs. 52.1 ± 2.6; P = 0.005) and (43.7 ± 3.1 vs. 52.4 ± 3.1; P = 0.040), respectively. Analysis of postoperative MRI findings revealed significant improvement of bone marrow edema in group AAJI (AAJI vs. SS) (71.4% vs. 42.9%; P = 0.033), also the synovial enhancement disappeared significantly in group AAJI compared with group SS, (16/22 [72.7%] vs. 10/23 [43.5%]; P = 0.026), moreover, there was a significant reduction in pannus size in group AAJI compared with group SS, (6/10 [60%] vs. 1/9 [11%]; P = 0.041). LIMITATIONS: The study follow-up period was limited to only 3 months. CONCLUSIONS: For acutely inflamed AAJ due to rheumatoid arthritis, AAJ steroid injection is a potential therapeutic option; it decreased cervical neck pain, improved neck mobility, and hastened recovery of the joint from an acute inflammatory stage. KEY WORDS: Rheumatoid arthritis, atlantoaxial joint injection.

Predictors for progression of two different types of cervical lesions in rheumatoid arthritis treated with biologic agents.

BACKGROUND: Biologic agents (BAs) enabled not only a reduction of disease activity but also a slowing down of structural damage to the joints in patients with rheumatoid arthritis (RA). However, the incidence of cervical lesions in patients with RA is still high. PURPOSE: To elucidate the predictors for the progression of two different cervical lesions in patients with RA under BA treatment. METHODS: Of 151 subjects who received more than two years of continuous BA treatment, 101 subjects who had cervical X-ray images taken at baseline and final visit were enrolled. The mean disease duration and mean radiography interval were 10.6 years and 4.4 years, respectively. The existence and progression of cervical lesions (atlanto-axial subluxation [AAS], vertical subluxation [VS], and subaxial subluxation [SS]) were investigated. And predictors for the AAS or VS progression were analyzed by multivariate logistic regression analysis. RESULTS: The incidence of cervical lesions at baseline were no pre-existing cervical lesion (none) in 50 cases (50%), AAS only in 32 (32%), both AAS and VS in 12 (12%), and VS only in 7 cases (7%). In the none group, only 4 cases of AAS progression (8%) was observed during the follow-up. In contrast, in the groups with pre-existing cervical lesions, a high incidence of VS progression was observed (63% in the AAS only group, 58% in the AAS + VS group, and 71% in the VS only group). Multivariate regression analysis demonstrated that the DAS-CRP value at baseline (odds ratio [OR] = 9.23) and matrix metaloprotease-3 level at baseline (OR = 1.01) were significant predictors for the progression of AAS, and pre-existing AAS (OR = 18.38) was a sole significant predictor for the progression of VS. CONCLUSIONS: Cervical lesions progressed irrespective of disease activity after AAS development. Strict disease control before the development of AAS is crucial for preventing further progression and development of cervical lesions.

Predictors for the progression of cervical lesion in rheumatoid arthritis under the treatment of biological agents.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To clarify the effect of biological agents (BAs) on the development and progression of cervical lesions in patients with rheumatoid arthritis (RA) and to identify biomarkers that accurately predict disease progression. SUMMARY OF BACKGROUND DATA: The introduction of BAs changed the paradigm of RA treatment. However, their effects on cervical lesions in patients with RA have not been studied. METHODS: Ninety-one subjects who had received BAs for 2 years or more were enrolled. Mean radiographical interval was 3.9 years. Disease activity was evaluated by disease activity score-C-reactive protein levels, and matrix metalloproteinase-3 levels. Cervical lesions were defined as an atlantodental interval more than 3 mm for atlantoaxial subluxation (AAS), Ranawat value less than 13 mm for vertical subluxation (VS), and anterior or posterior listhesis more than 2 mm for subaxial subluxation. Disease progression was defined radiographically as an increase in the atlantodental interval more than 2 mm for AAS, a decrease in both Ranawat and Redlund-Johnell values more than 2 mm for VS, and an increase in listhesis more than 2 mm for subaxial subluxation. We used multivariate regression techniques to assess predictors of disease progression. RESULTS: Baseline radiographical evaluation showed no pre-existing cervical lesion in 44 patients, AAS in 29, and VS in 18. Radiological progression occurred in 7% patients without baseline lesions, 79% in the AAS group, and 72% in the VS group. The incidence of progression was significantly lower in patients without lesions at baseline. Multivariate regression analysis demonstrated pre-existing cervical lesions, disease activity score-C-reactive protein levels at baseline and metalloproteinase-3 levels at final visit as good predictors of RA progression. CONCLUSION: BAs prevented de novo cervical lesions in patients with RA but failed to control progression in patients with pre-existing cervical lesions. Disease activity score-C-reactive protein levels at baseline were related to pre-existing joint destruction, and metalloproteinase-3 levels accurately predicted ongoing bone destruction during BA treatment. LEVEL OF EVIDENCE: 3.

Upper cervical facet joint and spinal rami blocks for the treatment of cervicogenic headache.

OBJECTIVE: To evaluate the efficacy of upper cervical facet joint injections and spinal rami blocks in the treatment of cervicogenic headache. BACKGROUND: Cervicogenic headache has been recognized as a common and often disabling disorder. The treatment of this headache type remains challenging. METHODS: We conducted a retrospective chart review of 31 patients with refractory cervicogenic headache who underwent fluoroscopically guided C(1/2), C(2/3) facet joint injections and C(2), C(3) spinal rami blocks using a mixture of 0.25% bupivacaine and 3 mg betamehtasone. The outcome measures were the change in headache severity, assessed using an 11-point numerical pain scale, after treatment, and the duration of head pain relief. RESULTS: Twenty-eight (90.3%) patients experienced >50% headache relief after treatment, with an average duration of 21.7 (1-90) days. Mean (+/-SD) head pain intensity decreased from 7.5 +/- 1.3 before treatment to 2.7 +/- 1.9 immediately after it (P < .0001). The procedures were well tolerated. CONCLUSIONS: C(1/2), C(2/3) facet joint injections and C(2), C(3) spinal rami blocks were effective and well tolerated for the treatment of cervicogenic headache in this study. The procedures provided significant and prolonged pain relief in the majority of patients. Larger controlled studies are needed to further evaluate the efficacy of this treatment modality in cervicogenic headache.

Rheumatoid atlantoaxial subluxation can be prevented by intensive use of traditional disease modifying antirheumatic drugs.

OBJECTIVE: To evaluate the 5-year incidence of cervical spine disorders in patients with early rheumatoid arthritis (RA) treated by 2 different disease modifying antirheumatic drug (DMARD) strategies. METHODS: In a national, multicenter, prospective FIN-RACo-trial, a cohort of 199 patients with early, clinically active RA was randomly assigned to treatment with a combination of 3 DMARD and prednisolone (Combi group) or with a single DMARD (Single group) with or without prednisolone, aiming to induce remission. After 2 years, the DMARD therapy was unrestricted. Lateral view cervical spine radiographs during full flexion and extension were taken at the 5-year followup visits. The presence of anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI), and subaxial subluxation (SAS) was assessed in the 149 patients with radiographs available (80 Single and 69 Combi). RESULTS: At the 5-year visits, aAAS, AAI, and SAS were found in 13 (9%), 6 (4%), and 9 (6%) patients, respectively. The corresponding Single/Combi group ratios were 11/2, 5/1, and 5/4. Of the baseline data, only poor physical function [Health Assessment Questionnaire (HAQ); p = 0.024] and Single treatment strategy (p = 0.019) were significantly associated with aAAS. Worse HAQ scores and Disease Activity Score 28 values were found in patients who developed aAAS during the 5-year followup. CONCLUSION: RA patients with sustained clinical disease activity and poor HAQ are at increased risk of developing aAAS. The development of aAAS during the first 5 years of RA was rare among the patients treated with a combination of DMARD for at least 2 years from the diagnosis. Intensive treatment with traditional DMARD prevents or retards the development of aAAS in patients with recent-onset RA.

Management of recalcitrant osteoarthritis of the atlanto-axial joint.

The medical records and radiographs of 17 patients with recalcitrant pain secondary to C1-C2 osteoarthritis were independently reviewed. All patients were treated by the senior author (K.D.R.). Initial treatment included physical therapy, nonsteroidal anti-inflammatory drugs, and soft collar immobilization. If non-responsive, patients were referred to a single radiologist for injection of the involved C1-C2 joint(s). If symptoms persisted, then transarticular screw fixation and Magerl wire fixation with structural iliac crest bone graft was performed. Postoperatively, all patients were placed in a soft collar. Postoperative anteroposterior (AP), lateral, flexion/extension, and open-mouthed odontoid radiographs were taken at 6 weeks, 3 months, and 1 year. Three independent observers assessed all radiographs for fusion. Fusion was noted by radiographic evidence of bridging bony trabeculae across the C1-C2 joint and/or bridging bone from the posterior arch of C1 to the C2 spinous process. Patient satisfaction improved significantly whether they were treated by corticosteroid injection or surgically.

Infection-related atlantoaxial subluxation in two adults: Grisel syndrome or not?

Grisel's syndrome involves the subluxation of the atlanto-axial joint from inflammatory ligamantous laxity following an infectious process in the head or neck. It is a rare disease usually affecting children, but infrequent adult cases do occur. Today, due to the widened use of antibiotics and availability of MR imaging, some cases presenting with neck pain, resulting from the infectious inflammation of C1 and C2 but without pronounced subluxation, can be a challenging problem for most neurosurgeons. Several theories have been proposed to explain the pathogenesis of inflammatory subluxation. The primary treatment of Grisel's syndrome is medical. The underlying infectious organism must be isolated and appropriate antibiotics must be prescribed. The subluxation is reduced in holter or skeletal traction. This paper reports two cases of infection-related atlanto-axial subluxation in two adults. The literature on this subject is briefly reviewed.

Intraarticular glucocorticosteroid injection into the lateral atlantoaxial joint under fluoroscopic control. A retrospective comparative study in patients with mechanical and inflammatory disorders.

OBJECTIVES: To evaluate the overall efficacy in various disorders of glucocorticoid injection into the lateral atlantoaxial joints, performed via the posterior route under fluoroscopic control. METHODS: Retrospective study of 26 patients including 16 (19 injections) with mechanical disorders and ten (16 injections) with inflammatory disorders. RESULTS: The response rate was 69.3%, the mean pain scale score decrease was 52.3 +/- 40.1%, and the mean duration of pain relief was 8.1 +/- 11.8 months. All three parameters were significantly (P < 0.005) better in the subgroup with inflammatory disorders than in the subgroup with mechanical disorders (response rate, 100% vs 50%; pain scale score decrease, 80 +/- 27% vs 34.2 +/- 40%, and pain relief duration, 16.9 +/- 14.9 months vs 24.5 months). A single patient developed a side effect (moderately severe hypertension). CONCLUSION: Glucocorticoid injection into the lateral atlantoaxial joints is a valid treatment alternative in patients who fail to respond to conventional noninvasive therapy.

Conservative therapy of atlantoaxial osteomyelitis. A case report.

STUDY DESIGN: A rare case of C1-C2 vertebral osteomyelitis treated conservatively is described. The radiologic findings as well as the follow-up evaluation are reported. OBJECTIVE: To increase knowledge about the pathogenesis and treatment of vertebral osteomyelitis in the high cervical region. SUMMARY OF BACKGROUND DATA: This is one of the first cases reported of successful conservative treatment of osteomyelitis at this level. METHODS: In a 58-year-old man with lumbar staphylococcal infection, a subsequent cervical infection developed. Because the lumbar spondylitis was treated promptly, the cervical osteomyelitis was treated at a very early stage of development. RESULTS: Operative decompression is the treatment most often used in osteomyelitis at the C1-C2 level. This is an extremely unusual circumstance in which early treatment of the infection negated the need for surgery. CONCLUSION: Conservative treatment of osteomyelitis at the C1-C2 level can be efficacious in the correct setting.