Background/Purpose It is believed that 40% to 80% of patients with rheumatoid arthritis (RA) have cervical spine lesions. In particular, atlantoaxial subluxation (AAS) and vertical subluxation (VS) are clinically important. However, little is known about how disease activity and other factors are involved in their development.  The aim of this study is to identify risk factors for upper cervical lesions in RA patients.

Methods IORRA is a prospective observational cohort study of Japanese patients with RA established in 2000 at the Institute of Rheumatology, Tokyo Women’s Medical University. Approximately 5,000 patients with RA are involved in each phase of the biannual survey. In our department, when RA patients schedule surgery, dynamic X-rays of the cervical spine are conventionally taken to assess instabilities in case tracheal intubation for general anesthesia is required. In this study, we evaluated these X-rays and investigated their relevance to the integrated data in the IORRA cohort study. Inclusion criteria were: (1) scheduled surgery in our department from 1 April 2010 to 31 March 2013, and (2) registration into the IORRA cohort study within 2 years from onset of RA. Fifty-seven patients were selected, with the following characteristics: women, 49 (85.9%); median onset age, 56 years; disease duration, 8.5 years; and DAS28, 4.3. Cervical X-rays were measured two times by one board-certified orthopedic surgeon and mean values were generally used. To assess AAS, the atlantodental interval (ADI) was measured, and for VS, the Redlund-Johnell method (R-J) was adopted. AAS was defined as ADI≧3mm; VS was defined as 34mm≦R-J in males, 29mm≦R-J in females. For statistical analysis, regression analysis was used for ADI and R-J, and logistic regression analysis was used for AAS and VS.

Results Median ADI was 2.8mm, and R-J was 34mm. Twenty-seven patients had AAS (48.2%) and twelve had VS (21.4%). No significant correlation between ADI and R-J was observed (ρ=-0.025, p=0.8). By univariate regression analysis, gender (p=0.004), height (p<0.0001), body weight (p=0.03), total methotrexate dose (p=0.002), and DAS28 maximum value (p=0.001) and integrated value (p=0.003) during the IORRA enrollment period were significantly relevant to R-J. Multivariate regression analysis revealed height (β=0.59, 95%CI: 0.011-0.25, p<0.0001) and maximum DAS28 (β=-0.27, 95%CI: -2.4- to -0.33, p=0.011) to be significantly associated with R-J. No factors were significantly associated with ADI. By univariate logistic regression analysis, maximum DAS28 (OR=2.4, 95%CI: 1.3-5.2, p=0.01) was significantly associated with VS. Total duration of biological drug use (OR=1.2, 95%CI: 1.0-1.6, p=0.04) was also significantly associated with AAS, but this involved development and was not thought to be causal.

Conclusion Higher RA disease activity appears to be a significant risk factor for VS development and severity, regardless of integrated value of disease activities. We suggest that RA disease activity should be tightly controlled to prevent development of upper cervical lesions, particularly VS.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/how-does-rheumatoid-arthritis-disease-activity-affect-development-of-upper-cervical-lesions-a-retrospective-study-of-cervical-spine-x-rays-combined-with-a-cohort-study-in-rheumatoid-arthritis-patient/