The Craniovertebral Region in Chronic Inflammatory Rheumatic Diseases

Radiology, the youngest of the major medical sciences, has undergone an extraordinary technical evolution since the discovery of X-rays. It began with the development of the different types of tomography and the adoption of many contrast agents, then proceeded rapidly to serioscopy, subtraction of images, direct enlargement, echography, thermography, and xerography. Today, even before all these innovations have come into common use, another branch of radiologic technology has evolved: computerized (axial) tomography. More than just an innovation, its true dimensions are unfore­ seeable. Radiology has become in less than a century an indispensable adjunct to the practice of medicine. The development of radiology as a speciality followed its technical advances, which varied greatly from country to country. This rapid development led quickly to subspecialization, even the very early development of radiotherapy and radiodiagnostics as separate entities. However, the entry of radiology into the university has preserved it a single branch of medicine, avoiding the frequent tendency toward auto­ nomy of the branches of a speciality. Today the fourth generation of radiologists is faced with another deci­ sion: whether to become technologists subjugated to their machinery, to become sub specialists with a single skill, or to remain doctors. The vast majority of this fourth generation has rejected becoming an accessory to a master technique and rather has specialized according to the hippocratic concept of medicine.

Material and Patients Studied.- 1 Historical Review.- 2 Anatomy and Physiology of the Craniovertebral Region.- 1 Osteology and Arthrology.- I. Joint Between Occipital Bone and Atlas.- A. Atlanto-Occipital Joint(s).- B. Atlanto-Occipital Ligaments.- II. Connection Between Occipital Bone and Axis.- A Median Occipitoaxoid Ligament (Membrana Tectoria).- B. Occipitodental Ligaments.- III. Connection Between Atlas and Axis.- A. Anterior Atlantodental Joint.- B. Syndesmo-Odontoid Joint.- C Atlantoaxial Joint(s).- D. Atlantoaxial Ligaments.- 2 Normal Radiographic Anatomy.- I. Normal Radiographic Anatomy of the Joint Spaces.- A. Atlanto-Occipital Joints.- B. Anterior Atlanto-Odontoid Joint.- C. Lateral Atlantoaxial Joints.- II. Normal Radiographic Anatomy of the Bones.- A. Occiput.- B. Atlas.- C. Axis.- III. Angles, Lines and Bony Landmarks.- A. Lateral Projection.- B. Frontal Projection.- 3 Positive Arthrography of the Craniocervical Joints.- I. Material and Method.- II. Results.- A. Atlanto-Occipital Joints.- B. Atlantoaxoid Joints.- C. Atlantodental Joints.- 4 Mechanics of the Joints.- I. Flexion-Extension Movement in the Atlantoaxial and Atlanto-Odontoid Joints.- II. Rotation in the Atlantoaxial and Atlanto-Odontoid Joints.- III. Rotation in the Atlanto-Occipital Joints.- IV. Lateroflexion and Anteretroflexion in the Atlanto-Occipital Joints.- V. Sliding Movement.- 5 Radiological Studies of the Mobility of the Joints.- I. Flexion-Extension.- A. Penning’s Method.- B. Wackenheim’s Method.- C. Author’s Method.- II. Forward and Backward Sliding.- III. Rotation.- IV. Lateroflexion.- 3 Pathological Anatomy.- I. Articular Lesions.- A. Rheumatoid Synovitis.- B. Capsular and Ligamentous Lesions.- C. Lesions of Cartilage and Bone.- II. Lesions of the Meninges.- III. Medullary Compression.- IV. Lesions of the Vertebral Artery.- V. Lesions of the Nervous Structures.- 4 Clinical Examination.- 1 Rheumatologic Examination.- 2 Neurologic Manifestations.- 5 Radiology in Rheumatoid Arthritis.- 1 Rarefaction of Bone.- I. Osteoporosis.- II. Osteomalacia.- 2 Articular Changes: Arthritis.- 3 Destructive Bone Lesions.- 4 Constructive Bone Lesions.- I. Osteophytes.- II. Bone Ankylosis.- III. Hyperostosis.- A. Morphology.- B. Signification of Ossifications.- 5 Subluxations-Ligamentous Lesions.- I. Transverse Subluxation.- A. Radiographic Technique.- B. The Different Types of Transverse Subluxation.- C. Provoked Transverse Subluxation.- D. Irreducible Transverse Subluxation.- II. Subluxation and Rotation.- III. Anterior Atlantoaxial Subluxation.- A. Radiological Technique.- B. Normal Values of the Anterior Atlantodental Articular Inter-space.- C. Measurements of Atlantoaxial Subluxation.- D. Results of Our Study.- E. Radiodynamic Examination in Atlantoaxial Subluxation.- F. Frequency of Atlantoaxial Subluxation.- G. Etiology of Atlantoaxial Subluxation.- H. Follow-up Studies in Atlantoaxial Subluxations.- IV. Upward Atlantoaxial Subluxation.- A. Morphologic Changes.- B. Modifications With Regard to the Usual Radiological Land-marks.- C. Correlations Between Basilar Invagination and Rheumatoid Arthritis.- V. Backward Subluxation of the Atlas.- VI. Backward Subluxation of the Occiput.- 6 Other Radiological Investigations.- I. Angiography.- A. Arteries.- B. Veins.- II. Myelography.- III. Bone Scintigraphy.- IV. Computerized Axial Tomography.- 6 Radiology in Other Chronic Inflammatory Rheumatic Diseases.- 1 Juvenile Chronic Polyarthritis.- 2 Ankylosing Spondylarthritis.- I. Materials.- II. Rarefaction of Bone.- III. Articular Changes: Arthritis.- IV. Destructive Bone Lesions.- V. Constructive Bone Lesions.- A. Ossification of the Ligaments.- B. Ossification of the Meninges.- C. Articular Fusion.- D. Syndesmophytes and Hyperostosis.- E. Shining Odontoid.- F. Hypertrophy of the Anterior Arch of the Atlas.- VI. Subluxations.- A. Anterior Atlantoaxial Subluxation.- B. Upward Atlantoaxial Subluxation.- C. Atlantoaxial Rotation and Transverse Subluxation.- D. Anterosuperior Subluxation of the Atlas.- E. Backward Subluxation of the Occiput.- VII.Radiofunctional Study of the Cervico-Occipital Joint.- 3 Psoriatic Arthropathy.- 4 Miscellaneous.- I. Reiter’s Syndrome.- II. Connective Tissue Diseases.- A. Systemic Lupus Erythematosus.- B. Progressive Systemic Sclerosis.- I. Behcet’s Syndrome.- II. Intestinal Arthropathies.- III. Sarcoidosis.- 7 The Principles of Treatment in Lesions of the Cervico-Occipital Joint in Chronic Inflammatory Rheumatisms.- I. Methods.- A. Conservative Treatment.- B. Surgical Techniques.- II. Results.- A. Evolution in Case of Abstention from Specific Therapy.- B. Results of Treatment with External Supports.- C. Results of Fixation Surgery.- III. Therapeutic Indications.- A. Indications for Conservative Treatment.- B. Indications for Surgical Treatment.- References.