Cervical spine involvement in patients with juvenile idiopathic arthritis - MRI follow-up study

Abstract

Background: To describe MRI and clinical findings in patients with juvenile idiopathic arthritis with cervical spine involvement at onset and follow-up under therapy.

Methods: 13 patients with signs of cervical spine involvement in juvenile idiopathic arthritis with a median disease duration of 1.7 years were included in the study. Clinical records and MR images were retrospectively analyzed according to symptoms and findings concerning the cervical spine.

Results: At the onset of cervical spine involvement all patients showed limited range of motion, whereas only 5 of them complained of pain. In MR images joint hyperintensity, contrast enhancement, malalignment, ankylosis, erosion and narrowing of the spinal canal at cranio-cervical junction were found at 28, 32, 15, 2, 2 and 3 sites in 12 (93%), 13 (100%), 8 (62%), 2 (15%), 2 and 3 (20%) patients respectively. 3 of the 5 patients with pain (60%) showed ankylosis, erosions or narrowing of the spinal canal at cranio-cervical junction on MRI. At follow-up - after a median disease duration of cervical spine arthritis of 2.1 years and a variable duration of treatment with methotrexate (all patients) and biological agents (12 patients) - joint hyperintensity, enhancement and malalignment decreased to 15, 19 and 6 sites in 10 (77%), 11 (85%) and 3 (20%) patients respectively whereas ankylosis, erosion and narrowing of the spinal canal at cranio-cervical junction increased to 7, 6 and 4 sites in 3 (20%), 4 (31%) and 4 patients respectively. Pain was no longer reported, but 9 of 13 (69%) patients still had a limited range of motion with 6 of them (46%) showing skeletal changes on MRI.

Conclusions: This first MRI based follow-up study shows that cervical spine arthritis can follow a severe disease course in juvenile arthritis. While malalignments and inflammation sites decreased osseous changes with erosions, ankylosis, and narrowing of the spinal canal increased under treatment despite only minor subjective complaints. Therefore close MRI monitoring of these patients appears to be reasonable.

Figure 1

9-year-old girl with JIA at first diagnosis of cervical arthritis (3 mm coronal T1 spinecho sequence with fat saturation). Malalignment of occiput, atlas and axis. Contrast enhancement of atlanto-occipital joints with a small erosion of the right and a large erosion of the left lateral mass of the atlas (long arrows). Contrast enhancement of the bone marrow in the atlas (short arrow). Contrast enhancement of the widened left atlanto-axial joint (two short arrows).

Figure 2

Left: 13-year-old girl with JIA. STIR 3 mm sagittal. Enlarged dens with bulging dorsal contour (arrow) and narrowing of the spinal canal at the cranio-cervical junction (arrowheads). Right: Normal control. 13-year-old boy without JIA and normal size of his dens.

Figure 3

Two patients with ankylosis. Above: 9-year-old boy (3 mm coronal STIR). Ankylosis with partial fusion of the occipital condyle and atlas on the right with a blurring of the osseous contours on the left. Below: 17-year-old girl with bilateral complete fusion of occipital condyle and atlas (1 mm coronal reconstruction from high-resolution 3D T1 gradient echo post-contrast).