A steroid injection into the atlantoaxial joint (AAJ) was found to decrease cervical neck pain and improve neck mobility and rate of recovery in patients with an acutely inflamed AAJ related to rheumatoid arthritis, according to a study published in Pain Physician.
Patients with rheumatoid arthritis who had upper neck pain and/or headache as a result of an inflamed AAJ, as assessed by magnetic resonance imaging (MRI), were enrolled and randomly assigned to receive an AAJ injection with 0.5 mL bupivacaine 0.5% and 0.5 mL of 20 mg of triamcinolone plus 2 oral placebo tablets every 8 hours for 1 week (n=30; AAJI group) or systemic steroids plus oral prednisolone tablets of 5 mg (2 tablets every 8 hours for 1 week) and an AAJ injection with 0.5 mL bupivacaine 0.5% and 0.5 mL normal saline solution (n=30; SS group).
Outcomes of interest included the percentage of patients with a reduction in visual analog scale (VAS) pain score ≥50% at 1, 2, and 3 months after treatment; VAS pain score and neck disability index at 2, 4, 6, 8, and 12 weeks postoperatively; and MRI changes at the AAJ at 4 weeks postoperatively.
A greater percentage of patients who received an AAJI vs SS reported a reduction in VAS pain score ≥50%, 1 month (75% vs 46.45%, respectively; P =.033), 2 months (60.7% vs 25%, respectively; P =.009), and 3 months (53.6% vs 17.9%, respectively; P =.007) after treatment. The overall reduction in VAS (41.5±2.6 vs 52.1±2.6, respectively; P =.005) and neck disability index (43.7±3.1 vs 52.4±3.1, respectively; P =.040) scores was greater in participants in the AAJI vs SS group.
A greater percentage of patients who received AAJI vs systemic steroids no longer had synovial enhancement (72.7% vs 43.5%, respectively; P =.026) and had improvements in bone marrow edema (71.4% vs 42.9%, respectively; P =.033). AAJI was also associated with a greater reduction in pannus size compared with SS (60% vs 11%, respectively; P =.041).
Reliance on MRI findings to determine acute inflammation of the AAJ, rather than using a diagnostic AAJ injection to validate the source of the patients’ upper neck pain, represents a potential limitation of the study.
“Ultimately, the rheumatologist and pain interventionist should weigh the risk of AAJ destruction and subsequent neurologic damage and the complications related to injections, which are very rare when the technique is done by experienced pain interventionist under real-time fluoroscopy and possibly ultrasound guidance,” noted the study authors.
Hetta DF, Elawamy AM, Hassanein MM, et al. Efficacy of atlantoaxial joint glucocorticoid injection in patients with rheumatoid arthritis: a randomized trial. Pain Physician. 2019;22(4):E295-E302.