1 RA presentation

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Vanessa Gutierrez and Ashley Best


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Rheumatoid Arthritis in Cervical Spine:

Rheumatoid Arthritis in Cervical Spine Ashley Best Vanessa Gutierrez 2/12/12

General Description:

General Description Rheumatoid Arthritis is a chronic, systemic inflammatory disease that can affect organs and tissues throughout the body, most commonly affecting synovial joints 1 It is characterized by periods of exacerbations and remissions of joint pain and swelling that often lead to joint deformities and even disability

General Description:

General Description Up to 60-70% of people with RA develop cervical spine symptoms and up to a quarter of them develop atlantoaxial instability 3 Could be fatal by damaging the vertebral artery, spinal cord or medulla 3

Signs & Symptoms:

Signs & Symptoms Pain Swelling Decreased ROM Bony deformity Crepitus

Signs & Symptoms2:

Signs & Symptoms 2 Morning stiffness Lasting > 3 minutes is hallmark sign 1 Severity and duration are related to the degree of the disease Bilateral and symmetrical pattern of joint involvement Decreased ROM Cardinal signs of inflammation (pain, redness, swelling, warmth)

Signs & Symptoms2:

Signs & Symptoms 2 In cervical spine: Decreased ROM, particularly in ROT because the atlantoaxial joint which allows for 50% of ROT in the cervical spine is a common site of inflammation Inflammation at the AA joint leading to AA subluxation is the most serious complication of RA. It can rupture the transverse ligament or fracture the odontoid causing a life threatening situation MRI very useful to determine spinal cord damage


Incidence In the U.S, approximately 1 case in 100 people Females 2-4x > Males Increase prevalence with increasing age


Diagnosis Combination of the following help confirm a diagnosis Signs and symptoms Radiographic Imaging (details next slide) Lab tests Elevated erythrocyte sedimentation rate (ESR) Elevated C reactive protein (CRP) Presence of Rheumatoid factor (RF) Exclusion of other possible diagnosis

Diagnosis :

Diagnosis Role of Imaging Can detect Changes in soft tissue Joint space narrowing Deformities Erosions Laxity (stress radiographs) Periarticular swelling is one of the 1st signs (therefore MRI is more sensitive for early detection) 3


Prognosis Varies from patient to patient May depend on location, joint involvement, severity, management While RA in the cervical spine can potentially be fatal, it may be avoided with early detection and proper management

Impact on Function:

Impact on Function Pain and inflammation of joints in hands makes it difficult to write and perform fine motor activities. Repetitive flare up’s cause degradation of cartilage and bone, and lead to ligamentous and muscle weakness, making activities difficult and painful. May lead to feelings of worthlessness, low-self esteem, and depression. One study showed more than 25% of women stop working within 4 years after diagnosed with RA. May interfere with family life and decisions to have children.


Treatment Innovations in treatment make it easier for many people with RA to live more normal lives. Common interventions include pain-relieving drugs, medications to slow joint damage, and balancing rest and exercise.


Treatment Common medications for RA include analgesics for pain, corticosteroids and NSAIDs for inflammation. Newest type of medication is biologic response modifiers: 1. Blocks tumor necrosis factor (TNF), a protein that triggers inflammation during normal immune function ( Expl : Humira ). 2.Blocks interleukin-1 (IL-1), a protein seen in excess in pt’s with RA ( Expl:Kineret ). 3. Stops the activation of Bcells ( Expl:Rituxan ). 4. Blocks chemical that stimulates overproduction of T cells seen with RA ( Expl:Orencia )


Imaging X rays: help to determine the degree of joint destruction. First choice in imaging for RA. Not useful until later stages when bone damage is evident. Used to monitor disease progress. May be used to rule out other causes of joint pain. MRI: Better used for early detection, showing swelling during the early stages of RA cause tenosynovitis of the extensor tendons.


Imaging A: Malalignment obvious especially at the PIP joints and MCP joints. B: Decreased bone density at the proximal phalanx and ends of the middle phalanx. C: Fusion of the PIP joints. DIP appears normal cartilage. Decreased space at the PIP joints due to fusion


Imaging A: Altered alignment seen with loss of lordotic curve. C4 appears slid forward on C5. B: Decreased bone density throughout cervical spine, especially in vertebral bodies. Decreased height of vertebral bodies with anterior osteophyte formation. Narrowing of spinal canal. Degradation of odontoid process. C: Decreased disc height. Narrowing of space between vertebral bodies, and appearance of fusion between lamina.

Imaging: MRI:

Imaging: MRI This T2 image of the ring finger shows areas of high intensity over the flexor tendons, indicating a pocket of fluid. This would be caused by tenosynovitis, seen with inflammation in RA. This T1 image shows pannus and degradation of the carpal bones of the wrist, seen with active RA.


References 1. Salter, RB. Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd Ed. Philadelphia, Lippincott W&W; 1999. 231-240. 2. O’Sullivan SB, Schmitz TJ. Physical Rehabilitation, 5th Ed. Philadelphia, FA Davis Company; 2007. 1057-1083. 3. Agustsson H. Imaging for Physical and Occupational Therapists. Course notes, Unit 1 & 2 . 4.Rheumatoid Arthritis Hand Imaging. Website Available at:http://emedicine.medscape.com/article/401271-overview. Accessed February 10, 2012. 5. National institute of Arthritis of Musculoskeletal and Skin Diseases. Website Available at: http://www.niams.nih.gov/health_info/rheumatic_disease/ . Accessed February 10, 2012.

PowerPoint Presentation:

6. Rheumatoid Arthritis Spine Imaging. Website Available at: http://emedicine.medscape.com/article/398955-overview . Accessed February 10, 2012.


Questions 1. If a patient presented with RA that affected the spinal cord, what might you see in a T2 MRI? What would be some precautions that you would want to make your patient aware of, and why? (Think of the on and off inflammatory nature of RA) 2. What would be some signs within the patient history that might clue you in that the patient is developing RA, and what advice would you give them to take home? What would they expect to see in their radiograph if it was RA in their hands?

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