What is the next step in management for a patient with pannus encircling the dens on cervical spine MRI?

Management of Pannus Encircling the Dens on Cervical Spine MRI

The next step in management is urgent rheumatology referral for initiation of disease-modifying antirheumatic therapy (DMARTs) combined with assessment for surgical intervention if neurologic deficits or significant spinal cord compression are present. 1, 2

Immediate Clinical Assessment

Perform a focused neurological examination to stratify urgency and guide treatment decisions:

• Assess for myelopathy signs: Test for upper motor neuron findings including hyperreflexia, Babinski sign, clonus, and spasticity 3, 2
• Evaluate motor function: Document weakness patterns in all extremities, as quadriparesis can develop rapidly with subaxial pannus 1
• Check sensory deficits: Map dermatomal sensory changes that correspond to the level of compression 3
• Measure subarachnoid space encroachment: This correlates significantly with neurologic deterioration, even when clinical signs are absent 4

Critical pitfall: Severe radiographic abnormalities often exist without corresponding neurologic signs—absence of symptoms does not indicate absence of risk 2, 4

Risk Stratification Based on Imaging and Clinical Findings

High-Risk Features Requiring Urgent Surgical Evaluation:

• Circumferential pannus causing severe spinal cord compression 5
• Any neurologic deficits (motor weakness, sensory changes, or myelopathy) 1, 2
• Brain stem compression or cervicomedullary angle abnormalities 4
• Progressive symptoms despite medical management 1

Moderate-Risk Features:

• Pannus without current neurologic deficits but with significant cord compression on MRI 6, 4
• Atlantoaxial subluxation in combination with pannus 2
• Erosion of dens and atlas 4

Treatment Algorithm

For Patients WITH Neurologic Deficits or Severe Compression:

1. Immediate neurosurgical consultation for decompression 1, 2

   • Surgical options include C1-C2 laminectomy with occipitocervical fusion for circumferential compression 5
   • Transoral resection of dens or dorsal stabilization for retro-odontoid pannus 6
   • Surgery prevents fatal complications from cervical myelopathy 2

2. Concurrent rheumatology referral to initiate aggressive DMARD therapy post-operatively 2

For Patients WITHOUT Neurologic Deficits:

1. Urgent rheumatology referral (within 1-2 weeks) for DMARD optimization 7, 2

   • Early rheumatologic intervention is advantageous for preventing progression 7
   • Rheumatologists have specialized expertise in managing inflammatory pannus 7

2. Consider rigid cervical collar immobilization as a temporizing measure or alternative when surgery is not feasible 6

   • Rigid collar for 8 weeks followed by soft collar for 4 weeks can reduce pannus size 6
   • This is a satisfying option when surgery is technically demanding or contraindicated 6

3. Serial MRI monitoring every 3-6 months to assess for progression 2

   • MRI is the only reliable method to detect early changes and determine surgical timing 2

Laboratory Evaluation to Obtain

• Rheumatoid factor and anti-CCP antibodies: Most patients with cervical pannus are RF-positive 2
• Inflammatory markers (CRP, ESR): Elevated in active disease 3
• Complete blood count: Check for leukocytosis 3

Common Pitfalls to Avoid

Do not rely on clinical examination alone: There is no correlation between MRI findings and symptoms/examination findings in many cases 2, 4

Do not delay imaging: Plain radiographs have low sensitivity for pannus—MRI is essential for diagnosis 3, 2

Do not assume pannus is limited to C1-C2: Subaxial cervical spine involvement can occur and cause rapid neurologic deterioration 1

Do not underestimate mortality risk: Three out of ten patients with cervical myelopathy from pannus died from neural compression in one series 2

Multidisciplinary Coordination

Rheumatology should lead the diagnostic and medical management process while coordinating with neurosurgery for structural intervention when needed 7. The combination of aggressive immunosuppression and timely surgical decompression offers the best outcomes for preventing fatal complications 1, 2.