Rheumatoid nodules of the spine: case report and review of the literature

Abstract

We present the case of a patient who had rheumatoid nodules of the vertebrae, which had resulted in bony destruction of the spine at 3 levels. Although there have been only 3 previous reports of such findings with confirmation by histologic analysis, we believe the condition is more common than has been thought. From a review of the literature, we found that similar clinical and radiographic features, as well as descriptions of rheumatoid granulation tissue invading the disc spaces, have been described in several subjects, Rheumatoid nodules are found in approximately 20% of patients with rheumatoid arthritis (RA). These nodules occur most commonly on the extensor surface of the forearm, on the Achilles tendon, and in the olecranon bursa (1). Less commonly, they have been found in the lungs, heart, spinal cord, meninges, and on the vocal cords. Standard rheumatology texts, however, make no mention of rheumatoid nodule involvement on body structures (2,3). Autopsy studies have demonstrated that rheumatoid nodules were the cause of vertebral body destruction in 3 subjects with RA (4-6). We report another case of vertebral destruc- tion at multiple levels of the spine. This case is unique in that, during spinal surgery, rheumatoid nodules were found to have caused the vertebral destruction.Case report. The patient, a 65-year-old American Indian woman, had a 17-year history of seropositive nodular RA and a 9-year history of insulindependent diabetes mellitus. The arthritis had been treated with prednisone for most of the 17 years, and D-penicillamine had recently been added to the regimen. Her arthritis was well controlled with these medications until November 1984, when she noted the onset of dull, nonradiating pain in her lower back.The pain progressed, and in April 1985, roentgenograms were made of the patient's spine; these showed destruction of the L3-L4 disc space. A bane scan was also performed, and it showed diffuse uptake in this same area. Needle aspiration of the disc space was performed. Cytologic results and acid-fast bacilli (AFB) staining were negative, as were bacterial and tuberculosis (TB) cultures. It was believed, however, that the radiographic results were most compatible with a diagnosis of TB of the spine, and she was started on a regimen of isoniazid and rifampin.The pain worsened, and by June 1985, the patient became unable to walk. Roentgenograms of her spine (July 1985) showed progressive destruction of the L3-L4 disc space, with right sacroiliac (SI) joint destruction. A computed tomography scan demonstrated marked destruction of the L4 vertebral body. Needle aspiration of the right SI joint gave negative results on cytologic study, AFB staining, and bacterial and TB cultures. At that time, the patient was referred to the University of Colorado Health Sciences Center for further evaluation.At the time of admission, she was taking the

Thoracic spinal cord compression by a rheumatoid nodule

“…Literature revue reveals only three previously documented cases of spinal cord compression at the thoracic level, secondary to rheumatoid nodule formation extradurally. [4][5][6] It is unclear whether these patients had been taking methotrexate. In those with severe nodular disease who have experienced significant complications such as spinal cord compression, it seems particularly relevant to reassess the benefits of methotrexate therapy to the joints and compare that to the potential harm caused by acceleration of nodular disease.…”