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Comparaison between imaging modalities of rheumatoid cervical spine: Study of prevalence and associated factors Poster No.: C-1087 Congress: ECR 2013 Type: Scientific Exhibit Authors: M. Limeme, N. Mallat,
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Comparaison between imaging modalities of rheumatoid cervical spine: Study of prevalence and associated factors Poster No.: C-1087 Congress: ECR 2013 Type: Scientific Exhibit Authors: M. Limeme, N. Mallat, H. Zaghouani Ben Alaya, H. Amara, D. Bakir, C. Kraeim; Sousse/TN Keywords: Bones, CT, MR, Contrast agent-intravenous, Imaging sequences, Inflammation DOI: /ecr2013/C-1087 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 46 Purpose The cervical spine is a common target of rheumatoid arthritis (RA), ranking only third after the hands and feet [1, 2]. The proportion of RA patients who experience cervical spine involvement at some point of their disease has ranged from 14% to 88% [1, 4]. The large number of synovial joints in the cervical spine explains the susceptibility of this site to damage caused by RA [2]. Cervical spine involvement can cause severe neurological complications. Rheumatoid lesions to the bones and ligaments lead to marked alterations in the relationships between cervical spine structures. Thus, the main abnormality at the upper cervical spine is atlantoaxial subluxation (AAS), whose main causes are development of a C1-C2 pannus and rupture of the transverse ligament. At the lower cervical spine, the main lesion is subaxial subluxation. There is a broad spectrum of clinical manifestations ranging from isolated neck pain to compression of the medulla oblongata and spinal cord. The symptoms do not correlate with the imaging study #ndings. Symptoms are absent in 10-50% of cases [4], indicating a need for routine evaluations during follow-up. Standard radiography remains the #rst-line investigation of choice for detecting cervical spine involvement in patients with RA. The sensitivity of standard radiography for detecting anterior AAS can be improved by obtaining #exion and extension views [3]. Helical computed tomography (CT) with reformations in the coronal and sagittal planes provides an accurate assessment of the C1-C2 complex, thereby ensuring the detection of rotatory and lateral AAS [2]. Magnetic resonance imaging (MRI) with a range of sections offers the most comprehensive evaluation of rheumatoid lesions. Furthermore, MRI is the only method capable of visualizing a clinically silent C1-C2 pannus and of providing a detailed assessment of effects on neurological structures [2, 4, 5]. Here, we determined the prevalences of cervical spine involvement by standard radiography, CT, and MRI in patients with RA and we compared the diagnostic contributions of these three imaging modalities. In addition, we looked for factors associated with cervical spine involvement. Methods and Materials 1. Patients: We conducted a retrospective cross-sectional study in 80 RA patients seen at the rheumatology department, and investigated at the radiology department, between 2004 and Females and males, who met American College of Rheumatology (ACR) 1987 criteria for RA [6], were eligible if their disease duration was at least 2 years. We included consecutive patients irrespective of whether they had or not cervical symptoms. Page 2 of 46 We recorded the following data for each patient: age, sex, and disease duration; Disease Activity Score 28 (DAS 28) and Health Assessment Questionnaire (HAQ) score; extra-articular manifestations; erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; rheumatoid factors (RFs) and antibodies to cyclic citrullinated peptides (anti-ccp); radiographic Sharp score as modi#ed by Van Der Heidje [7]; and treatments (nonsteroidal antiin#ammatory drugs, glucocorticoids, and disease-modifying antirheumatic drugs). 2. Methods: A thorough physical examination including a neurological evaluation and examination of the cervical spine was conducted in each patient. We used the classi#cation scheme developed by Pellici and Ranawat [8] to evaluate the severity of cervical pain and neurological involvement. Three imaging modalities were used in each patient to evaluate the cervical spine: standard radiography (anteroposterior, lateral, open-mouth, #exion, and extension views), MRI (with #exion and extension views if not contraindicated), and CT. All imaging studies were performed during the study period and interpreted by a single radiologist who was blinded to patient identity. The following abnormalities were looked for: AAS (anterior, vertical, lateral, rotatory, and posterior), subaxial subluxation, dens erosions, C1-C2 arthritis, and in#ammatory discitis. Degenerative lesions were disregarded. a. Standard radiography: Anterior AAS was assessed on lateral radiographs taken in neutral position, #exion, and extension. The diagnosis was based on an anterior atlantodental interval (AADI) greater than 3 mm (Fig.1). A posterior atlantodental interval (PADI) smaller than 14 mm was used as a sensitive marker for spinal cord compression (Fig.2). Vertical AAS (Fig.2) was diagnosed based on McGregor's line [9], the Ranawat method [10], and the Sakaguchie Kauppi method [11]. Lateral AAS was de#ned as a greater than 2-mm offset of C1 on C2 on the open-mouth radiograph (Fig.3). Asymmetry of the lateral masses relative to the dens on the open-mouth radiograph de#ned rotatory AAS (Fig.4). Posterior AAS was diagnosed when the posterior aspect of the anterior arch of C1 was behind the anterior aspect of the C2 vertebral body on the lateral radiograph in the neutral position and in extension (Fig.5). Subaxial subluxation was de#ned as at least 3 mm of forward slippage of a vertebra relative to the underlying vertebra (Fig.6). C1-C2 arthritis (Fig.8) and in#ammatory discitis (Fig.9) were de#ned as disk space narrowing and endplate erosions without osteophytes. b. Computed tomography: Axial sections through C1-C2 can be used to detect and to measure lateral AAS (greater than 2-mm offset of C1 relative to C2) (Fig.10) and rotatory AAS (asymmetry of the lateral masses or of the space between the dens and lateral masses without offset of C1 relative to C2) (Fig.11). Sagittal two-dimensional reformations serve to measure the AADI and Page 3 of 46 PADI and to detect anterior AAS (Fig.12) and posterior AAS (Fig.13). Erosions of the dens are best detected on axial sections and on coronal and sagittal reformations (Fig.14, 15). c. Magnetic resonance imaging: The following sequences were used: sagittal spin-echo T1-weighted sequence; sagittal fast-spin-echo (FSE) T2- weighted sequence with dynamic acquisition; sagittal spin-echo T1-weighted sequence after gadolinium injection and fat saturation; and axial spin-echo T1-weighted sequence through C1-C2 with gadolinium injection. Anterior AAS was detected by measuring the AADI and PADI in the neutral position and in #exion and extension (Fig.16). The cutoffs used to de#ne abnormal values were those described in the section on standard radiography. For the PADI, the space available for the spinal cord and cerebrospinal #uid, but not the meninges, was taken into account and the value was considered abnormal if smaller than 12 mm. On MRI scans, the anatomic landmarks used to determine the Ranawat criterion, Sakaguchie Kauppi criterion and McGregor's line are difficult to identify. We therefore de#ned vertical AAS as protrusion of the dens above Mac Rae's line (Fig.17) [12, 13]. Posterior AAS was detected in the neutral position and in extension (Fig.18). Whether subaxial subluxation (Fig.19) was present and whether the displacement was spontaneous or occurred only with #exion were noted. Coronal MRI sections were not obtained, and therefore lateral AAS and rotatory AAS were not evaluated by MRI. A C1-C2 pannus was looked for and its type was speci#ed as follows: hypervascular (high T2 signal and low T1 signal with postgadolinium enhancement) (Fig.20); #brous (low T2 signal and low or heterogeneous T1 signal without postgadolinium enhancement) (Fig.21); and acute synovitis (high T2 #ash signal and low T1 signal with postgadolinium enhancement) (Fig.22). The following abnormalities were recorded: erosions of the dens (low T1 signal and high T2 signal with postgadolinium enhancement) (Fig.23), C1-C2 arthritis (abnormal postgadolinium enhancement of the lateral masses on axial sections) (Fig.24) and in#ammatory discitis (narrowing, endplate erosions, and postgadolinium enhancement) (Fig.25). The images were carefully assessed for evidence of neural involvement seen as impingement or spinal cord compression (Fig.17). Spinal cord compression was evaluated by measuring the cervico-medullary angle, which was considered abnormal if smaller than 135 [13] (Fig.17). 3. Statistical analysis: The data were entered into a computer and analyzed using SPSS version 15.0 in English. Descriptive statistics consisted of numbers (percentages) for qualitative variables and means (SD) or medians for quantitative variables. Qualitative variables were compared using the chi-square test, or Fisher's exact test, as appropriate. To compare quantitative variables, we used Student's t test or analysis of variance (Anova). p values smaller than 0.05 were considered signi#cant. Page 4 of 46 Images for this section: Fig. 1: Lateral Radiographs of the cervical spine in neutral position (A), in flexion (B) and in extension (C): Anterior atlantoaxial subluxation detected in flexion (AADI = 10 mm) and reduced in extension. Page 5 of 46 Fig. 2: Lateral radiography of the cervical spine in neutral position : Vertical atlantoaxial subluxation : Ranawat = 13 mm, Mac Gregor Line line = 4.5 mm, Kauppi grade II, AADI = 13 mm and PADI = 6 mm, posterior erosion of the dens. Page 6 of 46 Fig. 3: Open-mouth radiograph : Lateral atlantoaxial subluxation : offset of C1 on C2 of 4 mm to the right with a total narrowing C1-C2 to the left. Page 7 of 46 Fig. 4: Open-mouth radiograph : Rotatory atlantoaxial subluxation : asymmetry of the lateral masses relative to the dens, with lateralization of the dontoid, total narrowing C1C2. Page 8 of 46 Fig. 5: Lateral radiography of the cervical spine in extension : Posterior atlantoaxial subluxation : the posterior aspect of the anterior arch of C1 is behind the anterior aspect of the C2 vertebral body. Page 9 of 46 Fig. 6: Lateral radiography of the cervical spine in flexion : Subaxial subluxation at multiple levels, producing a stepladder deformity. Page 10 of 46 Fig. 7: Lateral radiography of the cervical spine : posterior erosions of the dens. Page 11 of 46 Fig. 8: Open-mouth radiograph : C1-C2 arthritis at the right with lateral atlantoaxial subluxation. Page 12 of 46 Page 13 of 46 Fig. 9: Lateral radiography of the cervical spine in extension : In#ammatory discitis : disk space narrowing and endplate erosions in C5-C6. Page 14 of 46 Page 15 of 46 Fig. 10: CT of the cervical spine in coronal (A) and axial (B) : Lateral atlantoaxial subluxation : 2,5 mm offset left of C1 relative to C2 Page 16 of 46 Page 17 of 46 Fig. 11: CT of the cervical spine in axial (a) and coronal (b) : Rotatory atlantoaxial subluxation : deviation of the axis of the dens (a) and asymmetry of the space between the dens and lateral masses without offset of C1 relative to C2. Fig. 12: CT of the cervical spine in sagittal: Anterior atlantoaxial subluxation (AADI = 6 mm). Page 18 of 46 Fig. 13: CT of the cervical spine in sagittal : Posterior atlantoaxial subluxation : disappearance of the distance between the anterior arch of the atlas and the dens. Page 19 of 46 Fig. 14: CT of the cervical spine in sagittal : anterior and posterior erosions of the dens. Page 20 of 46 Fig. 15: CT of the cervical spine in axial : lateral C1-C2 arthritis, erosions of the dens and lateral atlantoaxial subluxation. Page 21 of 46 Fig. 16: Sagittal T2 MRI of the cervical spine centered on C1-C2 in neutral position (A), in flexion (B) and in extension (C) : Anterior atlantoaxial subluxation occurred upon #exion of the neck and reduced in extension. Page 22 of 46 Fig. 17: Sagittal T2 MRI of the cervical spine centered on C1-C2 : Vertical atlantoaxial subluxation : Mac Rae + 3 mm, cervico-medullary angle = 125, AADI = 10 mm, PADI = 4 mm, large anterior pannus and spinal cord compression. Page 23 of 46 Fig. 18: Sagittal T2 MRI of the cervical spine centered on C1-C2 : Posterior atlantoaxial subluxation : the posterior aspect of the anterior arch of C1 is behind the anterior aspect of the C2 vertebral body Page 24 of 46 Page 25 of 46 Fig. 19: Sagittal T2 MRI of the cervical spine in flexion : Subaxial subluxation with irregular and eroded aspect in C5-C6. Fig. 20: Sagittal T2 (A), T1 (B) and T1 contrast (C) MRI of the cervical spine, centered on C1-C2 : Anterior hypervascular pannus : intermediate T2 signal (A), low T1 signal (B) with post-gadolinium enhancement (C), anterior diastasis (AADI= 6 mm). Page 26 of 46 Fig. 21: Sagittal T1 contrast MRI of the cervical spine, centered on C1-C2 : Posterosuperior fibrous pannus : discrete post-gadolinium enhancement. Page 27 of 46 Fig. 24: agittal T2 MRI of the cervical spine, centered on C1-C2 : Anterior acute synovitis : post-gadolinium enhancement with #ash signal, without anterior diastasis (AADI= 2 mm), posterior erosions of the dens. Page 28 of 46 Fig. 22: Sagittal T1 contrast MRI of the cervical spine, centered on C1-C2 : Posterior erosions of the dens (juxta-cortical low signal). Page 29 of 46 Fig. 23: Axial T1 contrast MRI of the cervical spine, centered on C1-C2 : lateral C1-C2 arthritis. Page 30 of 46 Fig. 25: Sagittal T1 (A) and T1 contrast (B) MRI of the cervical spine : In#ammatory discitis C5-C6 : narrowing with endplate erosions and discrete post-gadolinium enhancement. Page 31 of 46 Results 1. Study population : We studied 80 patients, and the cervical spine involvement was objectified in 50 patients, 36 females and 14 males, with a mean age of 55.2 ±11.9 years (range, 32-86). Table 1 shows the main characteristics of the study population. Of the 50 patients, 37 (92.5%) used glucocorticoids, in a mean daily dosage of 7.5 mg prednisone-equivalent. In addition, 34 (85%) patients were on methotrexate, in a mean weekly dosage of 9.6 mg, and 3 (7.5%) patients were on sulfasalazine. None of the patients was taking TNF# antagonists. Two patients had history of surgery related to their joint disease (total hip replacement in 1 patient and fusion of a wrist and ankle in the other). Table 1. Main characteristics of the 80 study patients with rheumatoid arthritis. Age, years (mean ± SD) 55.2 ± 11.9 Females/Males 3.44 Disease duration, years (mean ± SD) 10 ± 7.9 Joint deformities (%) 62.5 Extra-articular rheumatoid manifestations 62.5 (%) DAS 28 (mean ± SD) 4.79 ± 1.62 HAQ (mean ± SD) 1.44 ± 0.84 ESR 20 mm/h (%) 82.5 CRP 6 mg/l (%) 45 Rheumatoid factors (%) 80 Anti-CCP (%) 72 Modified Sharp score (median, range) 87.5 (9-386) Narrowing score 58 (8-163) Erosions score 30 (1-243) 2. Clinical manifestations at the neck : Symptoms at the neck or neurological manifestations were present in 30 (75%) patients. The most common symptom was neck pain, which was reported by 52 (65%) patients, compared to 15 (37.5%) patients with range-of-motion limitation and 5 (12.5%) with occipital neuralgia. Among neurological manifestation, the most common was Page 32 of 46 paresthesia, with 16 (40%) patients. Pyramidal tract symptoms, often re#ex in nature, were noted in 9 (22.5%) patients. Histogram.1 shows the distribution of the patients among Ranawat classes for pain and neural involvement. Histogram.1. Distribution of the study patients according to the Ranawat pain class (a) and neural involvement class (b). 3. Imaging studies of the cervical spine : a. Standard radiographs : Different cervical lesions detected by standard radiographies are: - Anterior atlantoaxial subluxation : Of the 50 patients, 9 (22.5%) had anterior AAS (Fig.1), including 6 in whom the displacement occurred only upon #exion of the neck. The mean AADI value on radiographs was 4 (1.5-13) in the neutral position, 5.9 (4-13) in #exion, and 2.7 (1.5-5) in extension. Only 1 of the 9 patients had a PADI of less than 14 mm (6 mm) on the standard radiographs (Fig.2). Mean PADI in the 9 patients was 23.5 mm (6-32)in the neutral position, 22.6 mm (6-31) in #exion, and 23.7 mm (17-32) in extension. - Vertical atlantoaxial subluxation : The method based on McGregor's line showed poor reproducibility owing to difficulties identifying the dens and/or bony palate. The distance between the tip of the dens and McGregor's line was abnormal in 5 patients. The mean value was 2.3 mm (0-8.5). Ranawat's criterion was abnormal in 4 patients ( 13 mm). The mean value of the Ranawat criterion was 16.5 mm (12-22). The Sakaguchie Kauppi grade was I in 34 patients, II in 6 patients, and III in 1 patient. Vertical AAS was diagnosed when at least two of the three criteria were abnormal. With this de#nition, 4 (10%) patients had vertical AAS (Fig.2). - Lateral, rotatory, and posterior atlantoaxial subluxation : were found in 5 (12.5%), 4 (10%), and 1 (2.5%) patients, respectively (Fig.3,4,5). - Subaxial subluxation : was noted in 4 (10%) patients (Fig.6), including 3 in whom the displacement occurred only upon #exion of the neck. - Other lesions : Erosions of the dens were visible in 5 (12.5%) patients (Fig.7). A single patient had C1-C2 arthritis (Fig.8) and 3 patients had in#ammatory discitis (Fig.9); the levels involved were C5-C6 in 2 patients, C2-C3 in 1 patient, and C6-C7 in 1 patient. b. Computed tomography : Page 33 of 46 CT was performed in 39 patients, of whom 6 (15.4%) had lateral AAS (Fig.10) and 4 (10.3%) had rotatory AAS (Fig.11). The CT #ndings agreed with the standard radiography #ndings in 4 patients with rotatory AAS and 4 with lateral AAS. One patient with lateral AAS by standard radiography had no evidence of lateral AAS by CT, whereas the opposite occurred in 2 patients. Anterior AAS was noted in 3 patients (Fig.12). The mean AADI was 2.06 mm (0-13). A single patient had a PADI value of less than 14 mm (6 mm). The mean PADI was mm (6-27). Erosions of the dens were seen in 16 (41%) patients (Fig.14,15), C1-C2 arthritis in 3 (7.7%) patients (Fig.15), and posterior AAS in 1 (2.56%) patient (Fig.13). c. Magnetic resonance imaging : MRI was performed in all 50 patients, although dynamic sequences were obtained in only 34 patients. Anterior AAS was noted in 7 (17.5%) patients, including 3 in whom the displacement occurred only upon #exion of the neck (Fig.16). The mean AADI value was 3.7 mm (0.5-10) in the neutral position, 13.6 mm (0.5-6) in #exion, and 2.4 mm (0.5-4) in extension. A comparison of AADI values on standard radiographs and MRI scans in 10 patients with anterior AAS showed greater distances on the radiographs, most notably in #exion. However, dynamic MRI sequences were not available for 3 of the patients with anterior AAS. The mean PADI value was 13.3 mm (4-18) in the neutral po
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