Asymptomatic Atlantoaxial Subluxation in Rheumatoid Arthritis


This cross-sectional study is conducted to determine the prevalence of asymptomatic cervical spine subluxation in rheumatoid arthritis patients by plain radiographs and its relation to demographic and clinical characteristics, disease activity measures and medications. 100 rheumatoid arthritis patients (18 male and 82 female) were selected randomly, according to the American college of Rheumatology Criteria, who were under follow up in the rheumatology clinic. A complete history was taken, and physical examination has been done with focus on the cervical spine to determine their demographic data, disease duration, age of disease onset, drug history, swollen and tender joint counts, and ESR, Hb, CRP, RF levels. The disease activity of patients with rheumatoid arthritis was measured using the disease activity score 28. Radiographs of the cervical spine included lateral views taken in flexion, extension, neutral position of the neck and anterioposterior and odontoid projection view. Asymptomatic cervical spine subluxation was found in 17 of the 100 patients (17%). The prevalence of, anterior atlantoaxial subluxation, atlantoaxial impaction and subaxial subluxation was 10(10%), 5(5%) and 6(6%), respectively. Posterior subluxation was not detected. The only characteristic that showed meaningful relationship with cervical spine subluxation was CRP (P=0.036). Our results showed that patients with RA, who have cervical spine subluxation cannot be distinguished on the basis of symptoms. Cervical spine involvement is common and may be asymptomatic, indicating routine cervical spine imaging is needed in patients with RA.

Rasch EK, Hirsch R, Paulose-Ram R, et al. Prevalence of rheumatoid arthritis in persons 60 years of age and older in the United States: Effect of different methods of case classification. Arthritis Rheum 2003;48(4):917-26.

Gabriel SE. The epidemiology of rheumatoid arthritis. Rheum Dis Clin North Am 2001;27(2):269-81.

Majithia V, Geraci SA. Rheumatoid Arthritis: Diagnosis and Management. Am J Med 2007;120(11):936-9.

Caglayan O, Sukru Aydog Y. Serum Zinc and Copper levels in Rheumatoid Arthritis. J Islam Acad Sci l997;10(1):19-24.

Hochberg MC, Spector TD. Epidemiology of rheumatoid arthritis: update. Epidemiol Rev 1990;12(1):252-74.

Fombon FN, Thompson JP. Anesthesia for the adult patients with rheumatoid arthritis. Contin Educ Anesth Crit Care Pain 2006;6(6):235-9.

Albestone CD, Benzel ED. Cervical spine complication in rheumatoid arthritis patients: awareness is the key to averting serious consequences. Postgrad Med 2000;107(1):199-200.

Collins DN, Barnes CL, Fitzrandolph RL. Cervical Spine Instability in Rheumatoid Patients Having Total Hip or Knee Arthroplasty. Clin Orthop Relat Res 1991;272(1):127-35.

Neva MH, Hakkinen A, Makinen H, et al. High prevalence of asymptomatic cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopedic surgery. Ann Rheum Dis 2006;65(7):884-8.

Conlon PW, Isdale IC, Rose BS. Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 1966;25(2):120-6.

Mathews JA. Atlanto-axial subluxation in rheumatoid arthritis. A 5-year follow-up study. Ann Rheum dis 1974;33(6):526-31.

Meikle JA, Wilkinson M. Rheumatoid involvement of the cervical spine: radiological assessment. Ann Rheum Dis I971;30(2):154-61.

Arawwawala D, Morgan P. Preoperative cervical spine xrays for patients with rheumatoid arthritis. Br J Hosp Med 2007;68(1):56.

Younes M, Belghali S, Krifta S, et al . Compared imaging of the rheumatoid cervical spine: Prevalence study and associated factors. Joint Bone Spine 2009;76(4):361-8.

Zikou AK, Alamanos Y, Argyropoulou MI, et al. Radiological cervical spine involvement in patients with rheumatoid arthritis: a cross sectional study. J Rheumatol 2005;32(5):801-6

Naranjo A, Carmona L, Gavrila D, et al. Prevalence and associated factors of anterior atlantoaxial luxation in a nationwide sample of rheumatoid arthritis patients. Clin Exp Rheumatol 2004);22(4):427-32.

Kauppi MJ, Neva MH, Laiho K, et al. Rheumatoid atlantoaxial subluxation can be prevented by intensive use of traditional disease modifying antirheumatic drugs. J Rheumatol 2009;36(2):273-8.

1Vesela M, Stetkarova I, Lisy J. Prevalence of Cl/C2 involvement in Czech rheumatoid arthritis patients, correlation of pain intensity, and distance of ventral subluxation. Rheumatol Int 2005;26(1):12-5.

IssueVol 52, No 6 (2014) QRcode
Atlantoaxial impaction Cervical spine subluxation Subaxial subluxation Rheumatoid arthritis

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How to Cite
Nazarinia M, Jalli R, Kamali Sarvestani E, Farahangiz S, Ataollahi M. Asymptomatic Atlantoaxial Subluxation in Rheumatoid Arthritis. Acta Med Iran. 1;52(6):462-466.