Case report | Volume 36, Article 217, 27 Jul 2020 | 10.11604/pamj.2020.36.217.24850

C1-C2 instability in psoriatic arthritis

Teka Maher, Zaier Akram Yassine, Ben Hnia Majdi, Naouar Nader

Corresponding author: Teka Maher, Department of Orthopaedics and Trauma, Taher Sfar Hospital of Sousse, Sousse, Tunisia

Received: 06 Jul 2020 - Accepted: 15 Jul 2020 - Published: 27 Jul 2020

Domain: Orthopedic surgery

Keywords: Arthritis psoriatic, spondyloarthropathies, arthrodesis

©Teka Maher et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Teka Maher et al. C1-C2 instability in psoriatic arthritis. Pan African Medical Journal. 2020;36:217. [doi: 10.11604/pamj.2020.36.217.24850]

Available online at: https://www.panafrican-med-journal.com/content/article/36/217/full

Home | Volume 36 | Article number 217

Case report

C1-C2 instability in psoriatic arthritis

C1-C2 instability in psoriatic arthritis

Teka Maher1,&, Zaier Akram Yassine1, Ben Hnia Majdi1, Naouar Nader2

 

1Department of Orthopaedics and Trauma, Taher Sfar Hospital of Sousse, Sousse, Tunisia, 2Department of Orthopaedics and Trauma, Sahloul Hospital of Sousse, Sousse, Tunisia

 

 

&Corresponding author
Teka Maher, Department of Orthopaedics and Trauma, Taher Sfar Hospital of Sousse, Sousse, Tunisia

 

 

Abstract

Cervical spine damage is common in psoriatic arthritis especially in older forms and it is rarely initiated by symptomatic atloid-axoid instability. Spinal involvement is frequently associated with sacroiliac dysfunction, the cervical spine involvement is observed in 35%-75% of cases with two types of radiological lesion. Upper cervical spine localization often manifests as C1-C2 arthritis, lower cervical spine involvement is manifested by syndesmophytes, ossification of the anterior longitudinal ligament and posterior inter apophyseal osteoarthritis. our case is about a late onset upper cervical spine instability in a 45 year old patient who has been treated for 20 years for rheumatism and has checked for paraesthesia's of the four limbs and gait difficulty that have been evolving over the last 3 months and the outcome of this case is that a C1-C2 instability must be systematically checked for in view of the appearance of deficient signs.

 

 

Introduction    Down

Cervical spine damage is common in psoriatic arthritis. It is most often seen in older forms of the disease and may or may not be associated with peripheral joint damage. Symptomatic atloid-axoid instability rarely initiates the disease. We report a case of late-onset upper cervical spine instability in psoriatic arthritis.

 

 

Patient and observation Up    Down

A 45-year-old patient, treated for 20 years for psoriatic rheumatism using immunosuppressant drugs, who has checked for paraesthesia´s of the four-limb and gait difficulty that have been evolving over the last 3 months. Clinical examination revealed extensive skin lesions on the trunk and on all four limbs in the form of rounded or polycyclic red patches (Figure 1) and a pyramidal tract syndrome with predominantly left-sided muscle weakness. Standard X-rays of the cervical spine showed subtotal pinching of the C3-C4 intervertebral space with C3 posterior wall recoil. Dynamic X-rays showed obvious C1-C2 instability (Figure 2). MRI showed damage to the transverse ligament resulting in C1-C2 dislocation (increased space between the odontoid and posterior arch of C1) and the presence of retrolisthesis of C3 relative to C4 with signs of spinal cord compression at this level (Figure 3). The patient had an instrumented posterior arthrodesis C1, C2, C3, C4 and C5 associated with laminectomy C3, C4 and C5 (Figure 4, Figure 5). At 6 months follow-up, the evolution was satisfactory with a complete neurological recovery and a good stability of the upper cervical spine.

 

 

Discussion Up    Down

Psoriatic arthritis belongs to the group of spondyloarthropathies. The prevalence of psoriasis in the general Caucasian population is 1-3% [1, 2]. It is rarer among Africans, Black Americans, Latin American Indians and the Chinese population. The distribution is identical in men and women [2], with an average age of 27 years. The familial nature of psoriasis has been demonstrated by several studies [3]. Spinal involvement is frequently associated with sacroiliac dysfunction. It is characterized by the existence of syndesmophytes [4]. Cervical spine involvement in psoriatic arthritis is well known; it is observed in 35-75% of cases [5]. It occurs most often during severe psoriatic arthritis with a long evolutionary period [6, 7]. Two types of radiological lesions of the cervical spine are described in the literature: upper and lower cervical [8, 9]. Upper cervical spine localization, often manifests as C1-C2 arthritis with erosion of the odontoid in 10% of cases and as atloid-axoid dislocation in 5% of cases, which is classically of late occurrence and may be complicated by a fracture of the odontoid process or spinal cord compression. Lower cervical spine (LCS) involvement is manifested by syndesmophytes, ossification of the anterior longitudinal ligament and posterior inter apophyseal osteoarthritis [5]. It has been considered by many authors to be a non-life-threatening condition and rarely leads to a functional prognosis. This was suggested by the frequency of oligoarticular forms with often satisfactory evolution.

 

 

Conclusion Up    Down

Cervical spine involvement in psoriatic arthritis is frequent (35-75% of the cases) and shows a long evolution of the disease. A C1-C2 instability must be systematically checked for on the dynamic cervical spine X-ray, in view of the appearance of deficient signs.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors' contributions Up    Down

All authors contributed in this work and they all approved to publishing this manuscript in this journal. All authors read and approved the final version of this manuscript and equally contributed to its content.

 

 

Figures Up    Down

Figure 1: photo showing psoriatic skin lesions

Figure 2: dynamic X-rays showing overt C1-C2 instability and C3/C4 retrolisthesis

Figure 3: MRI appearance in T1 and T2 showing instability and signs of spinal cord pain

Figure 4: intraoperative view after laminectomy C3, C4, C5

Figure 5: X-rays (6 months later)

 

 

References Up    Down

  1. Alinaghi F, Calov M, Kristensen LE, Gladman DD, Coates LC, Jullien D et al. Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies. J Am Acad Dermatol. 2019 Jan;80(1):251-265.e19. PubMed | Google Scholar

  2. Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013 Feb;133(2):377-85. PubMed | Google Scholar

  3. Lee EB, Wu KK, Lee MP, Bhutani T, Wu JJ. Psoriasis risk factors and triggers. Cutis. 2018 Nov;102(5S):18-20. PubMed | Google Scholar

  4. Baraliakos X, Coates LC, Braun J. The involvement of the spine in psoriatic arthritis. Clin Exp Rheumatol. Sep-Oct 2015;33(5 Suppl 93):S31-5. PubMed | Google Scholar

  5. Sallés M, Clavaguera T, Mínguez S, Valencoso O, de Recalde Lopez M, Tuneu R. Atlantoaxial rotatory dislocation in a patient with psoriatic spondyloarthritis. Joint Bone Spine. 2019 Jul;86(4):519-521. PubMed | Google Scholar

  6. Queiro R, Sarasqueta C, Torre JC, Tinture T, López-Lagunas I. Prevalence and predictors of cervical involvement in psoriatic spondyloarthropathy. J Clin Rheumatol. 2002 Feb;8(1):23-9. PubMed | Google Scholar

  7. Ouédraogo D-D, Palazzo E, Nlomé-Nzé M, Somogyi N, Ballard M, Hayem G et al. Predominant cervical involvement in patients with psoriatic arthritis: report of two cases. Joint Bone Spine. 2007 Mar;74(2):175-8. PubMed | Google Scholar

  8. Blau R, Kaufman R. Erosive and subluxing cervical spine disease in patients with psoriatic arthritis. J Rheumatol. 1987 Feb;14(1):111-7. PubMed | Google Scholar

  9. Salvarani C, Macchioni P, Cremonesi T, Mantovani W, Battistel B, Rossi F et al. The cervical spine in patients with psoriatic arthritis: a clinical, radiological and immunogenetic study. Ann Rheum Dis. 1992 Jan;51(1):73-7. PubMed | Google Scholar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case report

C1-C2 instability in psoriatic arthritis

Case report

C1-C2 instability in psoriatic arthritis

Case report

C1-C2 instability in psoriatic arthritis