الفهرس 
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Abstract
Rheumatoid arthritis (RA) is an autoimmune disease characterized primarily by a chronic symmetrical polyarthritis of large and small joints, the characteristic feature is persistent inflammatory synovitis usually involving peripheral joints in a symmetrical distribution. The axial skeleton, with the exception of the cervical spine, is affected later and less frequently.
After the small joints of the hands, the most common region to be involved in rheumatoid arthritis is the cervical spine. This can lead to pain and disability, as well as a variety of neurologic signs and symptoms although some patients with significant radiographic evidence of disease may be asymptomatic.
The most common cervical symptom among our cases was neck pain, seen in 82% of cases, followed by numbness (64%), then tinnitus (50%) and lastly vertigo, seen in only 38% of cases
The main alterations occur in the spine’s most mobile region: its upper portion. Typical alterations include anterior atlanto-axial subluxation, atlanto-axial impaction or basilar invagination (also known as vertical atlanto-axial subluxation), and subaxial disease. All of these alterations are due to chronic local inflammation.
The results of cervical X -ray in our study showed that atlantoaxial sublaxation was found in 28% of cases, basilar invagination was found in 12% of cases and subaxial sublaxation was found in 8% of cases. The overall cervical X -ray was normal in 30 cases (60%) and abnormal in 40% of cases.
The aim of this study was to investigate the association between structural cervical spine involvement in patients with RA and both of age at disease onset and degree of radiological severity of RA detected by Larsen score.
This was a cross-sectional study which included 50adult RA patients (age of onset above 16 years old) ,patients recruited from rheumatology outpatient clinic in Sohag University hospital diagnosed according to the revised ACR (American college of Rheumatology ) criteria 1989 or 2010 for RA.
All of the patients that selected randomly underwent a complete history taking and physical examination to determine their demographic data: Disease duration, age of disease onset, the disease activity of patients with RA measured using disease activity score 28 DAS28 score, extra-articular manifestations of RA , type of drugs used in treatment of RA during course of the disease, questionnaires about possible symptoms related to cervical spine disease were completed (NDI), laboratory tests included (CBC, CRP, ESR, RF, ACPA, ALT, Serum creatinine ,urine analysis ), radiological investigations done for them (cervical, hand and feet x-ray), severity of RA determined for each patient according to Larsen score.
Comparison between age at disease onset and cervical symptoms revealed that age at disease onset affected only the incidence of numbness while comparison between disease severity (measured by Larsen score) and neck symptoms among our study population showed that disease severity affected only the incidence of tinnitus.
Our results revealed that patients with cervical involvement tend to be younger at their disease onset than those with no cervical involvement as detected by cervical X-ray. The relation was significant regarding all cervical involvements with the exception of basilar invagination. On other hand, disease severity significantly increases the risk for subaxial sublaxation while all other cervical X -ray findings of RA tends to have non significant relation with the disease severity.
Using univariate binary regression analysis for risk factors for cervical involvement in RA patients we found that the only probable risk factor for cervical involvement (detected by X-ray) in RA patients is the age at disease onset.
Therefore the age at disease onset affects cervical spine involvement in patients with rheumatoid arthritis more than the disease severity measured by Larsen score.
Conclusions from our study
• Cervical spine misalignment is a common radiographic finding and occurs more frequently in participants with earlier age at disease onset and longer length of RA.
• Disease severity significantly increases the risk for subaxial sublaxation while all other cervical X -ray findings of RA tends to have non significant relation with the disease severity
• Therefore, the age at disease onset affects cervical spine involvement in patients with rheumatoid arthritis more than the disease severity measured by Larsen score.
• Radiography remains the mainstay for imaging in RA (Spinal, hand and feet); it is inexpensive, readily available, easily reproducible, and it allows easy serial comparison for assessment of disease progression. While the major role for CT and MRI is in preoperative assessment.
Recommendations
• Cervical spine involvement is common and may be asymptomatic, indicating that routine cervical spine imaging should be done as a screening test, especially in patients with erosive seropositive RA.
• Early diagnosis and early treatment in RA patients with cervical spine manifestations is advised because the longer the duration and the more severity of the disease the more affection of cervical spine.
• It is important for a clinical rheumatologist to understand the scoring of plain radiographs especially Larsen score to determine severity of any case of RA.