What is the pathophysiology of rheumatoid arthritis (RA) of the cervical spine?

Updated: Aug 13, 2019
  • Author: Steven R Garfin, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
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Answer

Answer

Although the pathogenesis of rheumatoid arthritis remains incompletely understood, current theories suggest that the synovial cells of these patients chronically express an antigen that triggers the production of rheumatoid factor (RF), an immunoglobulin molecule directed against other autologous immunoglobulins. An inflammatory response is initiated, involving immune complex formation, activation of the complement cascade, and infiltration of polymorphonuclear leukocytes.

The proliferating fibroblasts and inflammatory cells produce granulation tissue, known as rheumatoid pannus, within the synovium. The pannus produces proteolytic enzymes capable of destroying adjacent cartilage, ligaments, tendons, and bone. The destructive synovitis results in ligamentous laxity and bony erosion with resultant cervical instability and subluxation. [3, 4, 5]

Atlantoaxial subluxation results from erosive synovitis in the atlantoaxial, atlanto-odontoid, and atlanto-occipital joints and the bursa between the odontoid and the transverse ligament (see the image below). Damage to the transverse ligament alone leads to approximately 3-4 mm of subluxation. [6]

Rheumatoid spondylitis. Depiction of anterior subl Rheumatoid spondylitis. Depiction of anterior subluxation of C1 on C2, retrodental pannus, and osseous erosions; the spinal cord is compressed between the pannus anteriorly and the posterior arch of the atlas.

The superior migration of the odontoid is attributed to erosion and bone loss in the occipitoatlantal and atlantoaxial joints (see the following images).

Rheumatoid spondylitis. Depiction of superior migr Rheumatoid spondylitis. Depiction of superior migration of the odontoid into the foramen magnum with compression of the spinal cord.
Rheumatoid spondylitis. Pertinent measurements of Rheumatoid spondylitis. Pertinent measurements of superior migration of the odontoid; cranial migration distance (CMD).

Subaxial subluxation results from destruction of the facets, intervertebral discs, and interspinous ligaments. In contrast to degenerative disik disease, involvement of C2-C3 and C3-C4 is common, and osteophytes are seldom seen.


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