Progressive Occipitocervical Subluxation Despite Biologic Agent Therapy in a Patient with Advanced Rheumatoid Arthritis

Yoon-Jeong Oh; Jee Won Chai; Kichul Shin

doi:10.4078/jrd.2017.24.3.169

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Oh, Chai, and Shin: Progressive Occipitocervical Subluxation Despite Biologic Agent Therapy in a Patient with Advanced Rheumatoid Arthritis

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J Rheum Dis 2017;24(3):169-170.

Published online: 31 October 2017

DOI: https://doi.org/10.4078/jrd.2017.24.3.169

Progressive Occipitocervical Subluxation Despite Biologic Agent Therapy in a Patient with Advanced Rheumatoid Arthritis

Yoon-Jeong Oh¹, Jee Won Chai², Kichul Shin¹

¹Division of Rheumatology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea

²Department of Radiology, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea

Corresponding to: Kichul Shin, Division of Rheumatology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea. E-mail: kideb1@gmail.com

Received 1 April 201722 May 2017 Accepted 23 May 2017

This is a Open Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

REFERENCES

1. Joaquim AF, Appenzeller S. Cervical spine involvement in rheumatoid arthritis–a systematic review. Autoimmun Rev. 2014; 13:1195–202.

2. Ahn JK, Hwang JW, Oh JM, Lee J, Lee YS, Jeon CH, et al. Risk factors for development and progression of atlantoaxial subluxation in Korean patients with rheumatoid arthritis. Rheumatol Int. 2011; 31:1363–8.

3. Imagama S, Oishi Y, Miura Y, Kanayama Y, Ito Z, Wakao N, et al. Predictors of aggravation of cervical spine instability in rheumatoid arthritis patients: the large joint index. J Orthop Sci. 2010; 15:540–6.

4. Joaquim AF, Ghizoni E, Tedeschi H, Appenzeller S, Riew KD. Radiological evaluation of cervical spine involvement in rheumatoid arthritis. Neurosurg Focus. 2015; 38:E4.

5. Han MH, Ryu JI, Kim CH, Kim JM, Cheong JH, Bak KH, et al. Factors that predict risk of cervical instability in rheumatoid arthritis patients. Spine (Phila Pa. 1976; 2016 Oct 25 [Epub].DOI: DOI: 10.1097/BRS.0000000000001942.

Figure 1.

(A) There are multiple erosions (arrowheads) at the base and neck of the odontoid process of axis (open mouth view). Note the symmetrical joint space narrowing (arrows) of lateral atlantoaxial joints, which is a typical finding in rheumatoid arthritis.(B) Anterior subluxation of the atlantoaxial joint is evident at flexion. The atlantodental interval is 7 mm (double-headed arrow). (C) The Ranawat C1∼ C2 index (double-headed arrow) is 12 mm, just below the normal range.

Figure 2.

(A) Three years later, the Ranawat C1∼ C2 index (double-headed arrow) is markedly decreased, suggesting basilar impression. Note the odontoid process (asterisk) is protruded beyond the horizontal axis of atlas (dashed line). (B) The reformatted sagittal computed tomography (CT) scan shows that the odontoid process is protruded above the level of foramen magnum (McRae line; dashed line). There are multiple erosions (arrows) in the C4, C5 discovertebral area. (C) A reformatted sagittal CT scan of a 25-year-old healthy female. The odontoid process is under the McRae line (dashed line).

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