ARTICLE - Careful when adjusting patients with RA

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Careful When Adjusting Patients with Rheumatoid Arthritis

By Deborah Pate, DC, DACBR

02 Nov 1998

Rheumatoid arthritis (RA) is a highly inflammatory disease that

frequently involves the cervical spine, particularly the

occipital-atlanto-axial region. With patients that have RA, careful

attention to the upper cervical region should be noted. This region

can be subluxated due to ligamentous laxity or rupture of ligaments

from the inflammatory process of the disease. Adjusting this region

can cause serious complications and injury.

You may recall RA causes inflammation of the synovial of the synovial

joints and pannus formation which causes osseous erosions, destruction

of cartilage and laxity of ligaments or even ligamentous rupture.

There are six synovial joints in the occipito-atlanto-axial region:

occipito-atlantal joint; atlanto-axial joint; joint between the

odontoid process and the anterior arch of the atlas; and the joint

between the odontoid process and the transverse ligament. Any or all

of these joints can be affected by the inflammatory process of RA.

The most common radiographic change in the cervical spine is widening

of the atlanto-odontal interspace, which should not exceed 3mm in

measurement in the adult. About 35 percent of patients with RA of the

cervical spine will demonstrate an increase in this measurement

resulting in an anterior atlanto-axial subluxation due to laxity or

rupture of the transverse ligament. When severe, it may be associated

with cervical myelopathy and compression of the vertebral artery.

Erosions of the odontoid process can, however, give the appearance of

a subluxation, which may not indicate abnormalities of the transverse

ligament. It is also possible to observe a decrease in the

atlanto-odontal interspace, due again to erosions of the odontoid

process resulting in " a loose fit " in the confines of the anterior

atlas and transverse ligament, accounting for atlanto-odontoid

instability. Lateral subluxation of C1 on C2 is associated with marked

atlanto-odontoid instability.

Occipitocervical abnormalities can occur in about 20 percent of cases

with longstanding RA of the cervical spine. Probably the most serious

complication of RA involving the cervical spine is cranial settling.

This occurs when pannus from the inflamed synovial joints leads to

erosion and collapse of the lateral masses of C1 and to a lesser

extent erosion of the occipital condyles and superior articular facets

of C2, allowing the skull to literally settle at a lower level on the

cervical spine. The diagnosis of cranial settling can generally be

established with conventional radiography by simply measuring

McGregor's line. If this measurement is positive (less than 30mm) and

if the patient demonstrates signs of cord compression, a CT scan of

the occipitocervical region is recommended to evaluate the extent of

collapse and articulations involved.

The most common symptom of cranial settling is occipital pain with

radiation toward the skull vertex. Neurologic symptoms such as

paresthesias, paresis or micturition disturbances occur in 30 percent

of patients with cranial settling due to RA.

Cranial settling occurs in only five percent of patients with RA, but

some form of C1-C2 subluxation occurs in 45-85 percent of patients

with RA of the cervical spine. We chiropractors should be acutely

aware of the specific complications of patients with RA.

Deborah Pate, DC, DACBR

San Diego, California

patedacbr-cox.net

http://www.chiroweb.com/mpacms/dc/article.php?id=37534

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