Craniocervical instability associated with rheumatoid arthritis: a case report and brief review

Abstract

Rheumatoid arthritis (RA) is an autoimmune disease that affects the synovial tissue which lines joints and tendons. The craniocervical junction is made up exclusively of synovial joints and ligaments and especially vulnerable to the inflammatory process of RA. The chronic inflammation of RA leads to loss of ligamentous restriction and erosion of the bony structures and results in craniocervical instability (CCI). This is a case report of an 80-year-old woman who had been diagnosed with seropositive RA two decades ago presented with head dropping and losing balance while walking for several months. Radiographic images of the cervical spine showed RA-related features of instability in the form of atlantoaxial instability, cranial settling and subaxial subluxation. Since physical therapy and acupuncture previously failed to provide a substantial, long-lasting outcome, the patient sought chiropractic care for her condition. The chiropractic regimen consisted of upper thoracic spine mobilization/adjustment, electrical muscle stimulation of the cervical extensors, home exercises and neck bracing. She regained substantial neck muscle strength, gaze angle and walking balance following a 4-month chiropractic treatment, although cervical kyphosis persisted. The current study aims to provide basic knowledge of CCI associated with RA and ability to modify a treatment program to accommodate the needs of patients with coexisting red flags.

Keywords: Cervical spine; chiropractic; craniocervical instability (CCI); head dropping; rheumatoid arthritis (RA).

Figure 1

Pre-treatment extension (A) and oblique (B) cervical EOS^® images demonstrated vertebral instability consisting of reversed cervical lordosis, superimposition of landmarks of the occipital base upon the C1 vertebra, anterior subluxation of the C1 (dashed white arrow) on C2 (white arrow), broken spinolaminar line (red curved line) at C2–C3, multi-level disc narrowing, and multi-level vertebral wedging with osteophytosis. It was difficult to identify the tip of the dens. If the dens extends >4.5 mm above the McGregor line (from posterior hard palate to base of occiput) basilar invagination is present. Red hollow arrow stands for the force of the gravity of the head. McGregor line (dashed red line) is used in the assessment of basilar invagination. EXT, extension view; OLB, oblique view.

Figure 2

Postural assessment. (A) At initial assessment, the patient could not stand unaided. She supported herself with the right hand holding door handle and the back leaning against the cabin interior. Sagittal EOS^® radiograph showed severe cervical kyphosis, degenerative spondylosis and s/p internal fixation of the sacrum. (B) At 4-month follow-up, sagittal EOS^® imaging demonstrated cervical imbalance with respect to offset of the center of gravity of the head [COG-C7 sagittal vertical axis (SVA) offset, yellow arrow]. With straightening of the lumbar spine, the C7 plumb line (dashed white line) was tangential to the posterior-superior corner of the upper sacral endplate (white circle), suggestive of a compensated global sagittal balance. In the sagittal plane, the gravity line (dashed red line) passes slightly posterior to the hip joint.

Figure 3

Comparison of the patient’s posture. (A) Upon examination, the patient was in a head dropped posture and ambulated with a cane to maintain balance. (B) At the 4-month follow-up, she regained substantial gaze angle along with walking balance, although cervical kyphosis and some weakness of neck extensors persisted.