European Journal of Cardiovascular Medicine

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that may affect many tissues and organs, but principally attacks the joints producing an inflammatory synovitis that often progresses to destruction of the articular cartilage and ankylosis of the joints¹. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue under the skin. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in its chronicity and progression².

The incidence of RA is 3 cases per 10,000 population per annum. Onset is uncommon under the age of 15 and from then the incidence rises with age until the age of 80. The prevalence rate is 1% with women affected three to five times as often as men³. It is 4 times more common in smokers than non-smokers. Some native American groups have higher prevalence rates (5-6%) and people from the Caribbean region have lower prevalence rates. First degree relatives prevalence rate is 2-3% and disease genetic concordance in monozygotic twins is about 15-20%⁴.

It is strongly associated with the inherited tissue type Major histo-compatibility complex (MHC) antigen HLA-DR4 (most specifically DR0401 and 0404)- hence family history is an important risk factor⁵.

Rheumatoid arthritis affects women three times more often than men, and it can first develop at any age. The risk of first developing the diseases (the diseases incidence) appears to be greatest for women between 30 to 50 years of age, and for men somewhat later⁶. RA is a chronic disease and although rarely, a spontaneous remission may occur, the natural course is almost invariably one of persistent symptoms, waxing and waning in intensity, and a progressive deterioration of joint structures leading to deformities and disability⁷.

RA typically manifests with signs of inflammation, and the affected joints are swollen, warm, painful and stiff early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the inflammation disease which the person may experience and may last for more than an hour. Gentle movements may relieve symptoms in early stages of the disease⁸.

Spinal involvement of the cervical spine in rheumatoid arthritis (RA) has been well studied. It has been reported that 43-88% of patients with RA have cervical subluxation. Upper cervical lesions, identified as atlantoaxial subluxation and vertical subluxation, and lower cervical lesions in patients with RA produce neck pain and myelopathy because of the destructive changes in the cervical spine⁹.

This cross-sectional study was planned to include 50 consecutive RA patients attending the outpatient clinic of our Rheumatology Department at S.P. Medical College attached to P.B.M Associated Group of Hospitals, Bikaner.

INCLUSION CRITERIA:

All patients of rheumatoid arthritis above 16 years of age diagnosed as per 2010, American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) revised the 1987 ACR classification criteria for RA were included in the study.

DIAGNOSTIC CRITERIA:

The 2010 American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) revised the 1987 ACR classification criteria for RA.

The radiological evaluation consisted of x-rays of hand and wrist (anteroposterior, view). CS x-rays was evaluated atlantoaxial subluxation (AAS) of 3 mm or more, atlantoaxial impaction, disc space narrowing affecting upper cervical discs without osteophytosis, multiple subluxation of 1 mm or more, vertebral plate erosions and sclerosis, apophyseal joint erosions and sclerosis, osteoporosis).

MAGNETIC RESONANCE IMAGING:

The following sequences were used: sagittal spin-echo TI- weighted sequence; sagittal fast-spin-echo (FSE) T2-weighted sequence with dynamic acquisition; sagittal spin echo T1-weighted sequence after gadolinium injection and fat saturation; and axial spin-echo T1-weighted sequence through C1-C2 with gadolinium injection

Table 1 Distribution of cases according to Age group in relation to MRI Findings

Pannus was present in 9 patients and out of them 4 and 5 had their age <40 and >40 years respectively. Dense erosion was present in total 3 patients and out of them 2 and 1 belonged to <40 and >40 years age group respectively, AAS was present in 13 patients and out of them 4 and 9 belonged to <40 and >40 years of age group, SAS was present in 5 patients and out of them 1 and 4 belonged to <40 and >40 years of age group, Anterior subarachnoid space narrowing was present in 8 patients and out of them 3 and 5 belonged to <40 and >40 years of age group, Vertebral plate erosion was present in only 3 patients and out of them 2 and 1 belonged to age group <40 and >40 years and Inflammatory discitis was present in only 4 patients and out of them 1 and 3 belonged to age group <40 and >40 years.

Table 2 Demographic clinical and imaging finding of patients with established rheumatoid arthritis

Cervical spine involvement was found in significant proportion of patients. Cervical spine involvement was found in 16(32%) of cases among which 11 were females and 5 were males in our study.

Table 3 Overall positivity of MRI findings

Most common abnormality was atlantoaxial subluxation in 13(26%) patients followed by pannus in 9(18%), anterior sub arachnoid space narrowing in 8(16%), subaxial subluxation in 5(10%), inflammatory discitis in 4(8%) and vertebral plate erosion and dens erosion in 3(6%) patients each.

Table 4 Distribution of cases according to duration of disease (years) in relation to MRI Findings

MRI findings were significantly correlated with disease duration, severity of disease assessed by DAS28 Score, deformities of other joints (hands) and neurological sign and symptoms

Each dawn brings new knowledge, new thoughts and new theories to the medical sciences that help man to explore deeper into the complexities of the human body. Many diseases, since long, have troubled the medical fraternity because of their uncertain aetiologies. Each new day is helping us to have better insight into the causes of a few of these diseases and their spectrum of involvement of organs and structures. Rheumatoid arthritis is also such kind of disease which involved many structures with varied frequencies and severities. According to COPCORD (Community Oriented Program for Control of Rheumatic Disease) study conducted in Bikaner by Ranwa et al⁷⁵ in 2008 the prevalence of RA was 1.18 in Bikaner district. In our study most of the patients belong to this population.

The prevalence of rheumatoid cervical spine involvement 32 % (16 patients out of 50) by MRI conducted in 50 patients (37 females and 13 males) with mean age 42.72+13.70 years and mean duration of disease 9.12+5.56 years. These values are within the previously reported range of 14-88%^20,21,63,76. The variability in reported prevalence is ascribable to differences in clinical and radiological inclusion criteria and to differences in the imaging modalities used for lesion detection.

According to MRI findings, Pannus was present in 18% of cases, dense erosion was present in 6% of cases, AAS was present in 26% of cases, SAS was present in 10% of cases, Anterior subarachnoid space narrowing was present in 16% of cases, vertebral platelet erosion was present in 6% of cases and inflammatory discitis was present in 8% of cases.

The prevalence of AAS was 26% (13 patients out of 50) in our population vs. 52-75% in previous studies^60,71,76,77. AAS was found in 81.25% of all positive cases (16 patients), AAS was present in 13 patients.

Only parameters that were significantly associated with rheumatoid involvement of the cervical spine in study conducted by Younes et al⁶⁸ were the a high modified Sharp score (P ¼ 0.002) and a high CRP value (P ¼ 0.004). Anterior AAS develops early, before vertical AAS and subaxial subluxation. A disease duration longer than 10 years was associated with pathological type of the pannus⁴⁸. The parameters that were significantly associated with rheumatoid involvement of the cervical spine in our study were disease severity, longer disease duration and abnormal X-ray finding of hand (deformities). A larger sample size would perhaps have led to the identification of additional factors. In earlier studies, older age and, above all, longer disease duration significantly predicted rheumatoid involvement of the cervical spine^63,71,78. But in our study no any association was found with age. Cervical spine involvement has been shown to begin within the first 2 years of RA onset⁷⁸. Anterior AAS develops early, before vertical AAS and subaxial subluxation.

A disease duration longer than 10 years was associated with subaxial subluxation in several studies^58,63,83. In a longitudinal study, the cervical spine was involved in 43% of patients at baseline and in 70% of patients 5 years later⁸⁵.

No patient was found in DAS-28 group <2.6 in all MRI findings. All the parameters had significant changes when we compared MRI findings with DAS-28 score (p<0.05) except Dense Erosion, SAS and Vertebral Plate Erosion.

The presence of deformities was associated with cervical spine involvement in early studies^60,85,86. All the patients who MRI findings, had a positive X-ray hand findings except 1 each patient who had AAS and Anterior subarachnoid space narrowing had no findings of X-ray hand.

Pannus, AAS, SAS and Anterior subarachnoid space narrowing had statistically significant changes (p<0.05) while Dens Erosion, Vertebral plate erosion and inflammatory discitis had insignificant changes

As the study sample was small, studies involving large size of sample are required to confirm the present study finding

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