Disclosures: John A. Donovan, Jr., MD, MSENG, MS: No financial relationships or conflicts of interest

Case Diagnosis: Rheumatoid arthritis presenting with cervical axial pain w/ radiculopathy

Case Description or Program Description: The patient presented with subacute cervical axial pain radiating into the left upper extremity that was described as moderate to severe in intensity. Pain worsened with activity and associated symptoms included paresthesia of the left hand. She had minimal improvement with NSAIDs, acetaminophen, methocarbamol and gabapentin. She had transient relief with a methylprednisolone dose pack with symptoms returning on cessation. Her exam was notable for bilateral proximal shoulder girdle weakness and diminished sensation in the left C6-7 distribution. MRI C-Spine was ordered to evaluate for nerve root compression. Given proximal muscle weakness on exam and transient response to steroids, inflammatory markers were also ordered including ESR, CRP and CK.

Setting: Academic Outpatient Clinic

Assessment/Results: MRI C-Spine was notable for disc protrusions at C4-5 and C5-6 with moderate foraminal narrowing on the left at these levels. Inflammatory workup revealed an elevated ESR (106) and CRP (148). Urgent rheumatology referral was placed and further testing confirmed seropositive rheumatoid arthritis. Patient was started on prednisone, methotrexate and adalimumab. Within three weeks, the patient had resolution of her cervical and radiating pain symptoms and was able to avoid any interventional spine procedures.

Discussion (relevance): Rheumatological conditions are one of many potential spine masqueraders. Despite classic symptoms of cervical radiculitis on the surface with supporting pathology on MRI C-Spine, the primary pain generator in this case was a more systemic inflammatory arthropathy. Pursuing interventional spine procedures as the primary treatment option may have resulted in delayed care or unnecessary surgical intervention.

Conclusions: Physiatrists should keep a broad differential when evaluating spine patients due to the presence of potential spine masqueraders. Cost effective tests such as inflammatory markers, when appropriate, can be a useful tool in evaluating for any underlying or contributing pathology.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/rheumatoid-arthritis-as-a-spine-masquerader-a-case-report/