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The Clinical Implication of Cervical Interspinous Bursitis in The Editorial Ann Rheum Dis: first published as 10.1136/ard.2008.087999 on 12 May 2008. Downloaded from cervical interspinous space was the seat The clinical implication of of crystallopathic disease in 2 of these 14 individuals. Calcified deposits suggestive cervical interspinous bursitis in of calcium pyrophosphate dihydrate (CPPD) and hydroxyapatite crystal deposition in interspinous bursae were the diagnosis of polymyalgia observed in one them, and areas occupied by CPPD crystals along with areas occu- rheumatica pied by hydroxyapatite were found in the other.17 In the same necropsy study, Bywaters also aimed to determine Miguel A Gonzalez-Gay whether cervical bursitis was present in five patients with juvenile chronic arthri- Polymyalgia rheumatica (PMR) is a rela- Population-based studies have con- tis and in nine patients with adult-onset tively common inflammatory condition firmed that isolated PMR is generally a rheumatoid arthritis (RA).17 Interestingly, characterised by pain, aching and morning benign condition and most long-term two of the nine patients with RA showed stiffness involving the shoulder and hip survival studies have shown no increased bursae between the interspinous processes girdles and the neck.12 Patients are gen- mortality in patients with this condi- but without any specific feature of RA 17 erally older than 50 years and the ery- tion.9–11 Although the diagnosis of PMR involvement. However, cervical bursitis throcyte sedimentation rate (ESR) and is relatively straightforward when typical characterised by synovial lining hyperpla- C-reactive protein (CRP) are usually symptoms are present,12 none of the sia and erosions of the spinous processes elevated.1 PMR may occur as an isolated clinical and laboratory findings in PMR was demonstrated in two of the nine disease or it may be observed in the are specific. In this regard, polymyalgia patients with the adult form of RA and setting of giant cell arteritis (GCA).3 manifestation may occur in patients with also in two patients with juvenile chronic 17 Arthroscopic studies have confirmed infections, neoplasms or other rheumatic arthritis. 13 14 the presence of synovitis in proximal diseases. Due to this, the search for The results reported by Bywaters raise a joints of patients with PMR.4 However, findings that may support a diagnosis of couple of questions that we should con- the cause of musculoskeletal symptoms in PMR is of primary importance in some sider in the assessment of patients with these patients is not clearly defined cases. It may be especially true when rheumatic diseases with severe neck symptoms. because joint synovitis may only partially cervical pain is the predominant symp- explain the diffuse discomfort along with tom. With respect to this, patients with First, we wonder whether the clinical evidence of cervical interspinous bursitis involvement of periarticular structures. crowned dens syndrome, condition may be of some help for establishing the Interestingly, MRI and ultrasonography related to microcrystalline deposition diagnosis of inflammatory rheumatic dis- http://ard.bmj.com/ (US) studies disclosed bilateral inflamma- and radiological calcification of the cruci- eases involving the lower cervical spine. tion of subacromial and subdeltoid bursae form ligament around the odontoid pro- cess, may present with acute cervical pain Second, in a further step, it may be of in association with synovitis of the fever, neck stiffness and biological inflam- interest to determine whether the pre- glenohumeral joints and tenosynovitis of matory syndrome.15 Additionally, we have sence of cervical bursitis at the lower the biceps in patients with PMR.56More recently reported seven patients with late cervical interspinous space may help dis- recently, using MRI and US, Cantini et al onset undifferentiated spondyloarthritis criminate specific inflammatory condi- also confirmed the presence of trochan- presenting with PMR features.16 tions with preferential involvement of on September 27, 2021 by guest. Protected copyright. teric bursitis and, less commonly, iliop- Taking these observations together, an the neck. soas and ischiogluteal bursitis in PMR 7 important step forward in our under- To address these issues, using MRI of patients. These studies support the pivo- 20 standing of the aetiology of cervical pain the cervical spine, Salvarani et al (see tal role of the involvement of extraarti- associated to PMR may be to establish the page 758) studied 12 consecutive, cular synovial structures, in particular presence of objective data that may also untreated new patients with PMR along bursae, in PMR. support the presence of neck involvement with a control group that included 13 Shoulder pain is the most common and in patients with PMR. Another important patients with neck complaints (5 patients the presenting feature in patients with point may be to establish some specific with fibromyalgia, 2 patients with cervi- 12 PMR. By contrast, pelvic and cervical features that may be useful in discrimi- cal osteoarthritis and 6 patients with 2 involvement is less commonly observed. nating neck involvement in the setting of spondyloarthritis). In this regard, in a population-based study PMR from those observed in other condi- Interestingly, in all 12 patients with from Northwest Spain, the frequency of tions that may also yield cervical pain. PMR, MRI disclosed the presence of fluid shoulder girdle involvement was almost In the early and middle 1980s, Bywaters in the cervical interspinous bursae at the 100% in patients with isolated PMR and and colleagues reported three elegant C5–C7 level, suggesting bursitis.20 Fluid 8 PMR associated with GCA. However, studies addressing important information accumulation in the cervical interspinous neck involvement was observed in 74% of on spinal anatomy.17–19 In one of them, bursae at the same level was also found individuals with isolated PMR and 67% of Bywaters described the presence of bursal in 6 of the 13 control patients (3 patients 8 those with PMR associated with GCA. spaces between the cervical interspinous with fibromyalgia, 2 with psoriatic spon- processes at necropsy in 14 of 27 ‘‘nor- dylitis and 1 with cervical osteoarthritis). 17 Correspondence to: Miguel A Gonzalez-Gay, mal’’ adult necks. The presence of bursae Of note, from four patients with primary Rheumatology Division, Hospital Xeral-Calde, c) Dr Ochoa was most frequently located at the C6–C7 ankylosing spondylitis, none showed s/n, 27004 Lugo, Spain; [email protected] interspinous space.17 Interestingly, the cervical bursitis.20 More importantly, Ann Rheum Dis June 2008 Vol 67 No 6 733 Editorial Ann Rheum Dis: first published as 10.1136/ard.2008.087999 on 12 May 2008. Downloaded from moderate accumulation of fluid (moder- 7 days (in most cases within the first 24– 8. Gonza´lez-GayMA, Garcı´a-Porru´a C, Va´zquez- Caruncho M. Polymyalgia rheumatica in biopsy proven ate bursitis) and/or sufficient quantity to 72 h) in the majority of patients with giant cell arteritis does not constitute a different stretch the walls of structures (marked isolated PMR.1912However, based on the subset but differs from isolated polymyalgia bursitis) was more commonly observed in results shown by Salvarani et al, clinicians rheumatica. J Rheumatol 1998;25:1750–5. patients with PMR (10 of 12) than in the might consider the possibility of perform- 9. Gonza´lez-GayMA, Garcı´a-Porru´a C, Va´zquez- 20 Caruncho M, Dababneh A, Hajeer A, Ollier WE. The control group (4 of 13). ing a cervical MRI in patients with spectrum of polymyalgia rheumatica in northwestern Although these promising data need to atypical PMR, in those with predominant Spain: incidence and analysis of variables associated be confirmed in a larger study, they cervical manifestations, or in individuals with relapse in a 10 year study. J Rheumatol provide evidence of the presence of lower 1999;26:1326–32. presenting with PMR and poor response 10. Gran JT, Myklebust G, Wilsgaard T, Jacobsen BK. interspinous cervical bursitis as the under- to glucocorticoids. Survival in polymyalgia rheumatica and temporal lying cause of neck pain in patients with A further step to be considered as a arteritis: a study of 398 cases and matched PMR. result of Salvarani et al’s study may be to population controls. Rheumatology (Oxford) A quick look at Salvarani et al’s data 2001;40:1238–42. establish whether glucocorticoid therapy 11. Doran MF, Crowson CS, O’Fallon WM, Hunder GG, raises additional considerations. Namely, is able to decrease the severity of inter- Gabriel SE. Trends in the incidence of polymyalgia the presence of bursitis by itself deter- spinous bursitis in PMR treated patients. rheumatica over a 30 year period in Olmsted County, Minnesota, USA. J Rheumatol 2002;29:1694–7. mined by cervical MRI may not be In conclusion, cervical MRI seems to be specific for PMR, as other conditions 12. Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, another additional tool to improve the Hunder GG. Diagnostic approach in a patient may also be associated with cervical diagnosis of PMR. However, further presenting with polymyalgia. Clin Exp Rheumatol bursitis. It may be the case that some studies encompassing a larger number of 1999;17:276–8. 13. Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, patients have CPPD disease mimicking patients are still needed. 21 Olivieri I, Hunder GG. The spectrum of conditions PMR. However, in the study by mimicking polymyalgia rheumatica in Northwestern Salvarani et al, none of four patients with Competing interests: None declared. Spain. J Rheumatol 2000;27:2179–84. primary ankylosing spondylitis showed Accepted 25 February 2008 14. Gonza´lez-GayMA, Garcı´a-Porru´a C, Salvarani C, cervical bursitis. Taking into account this Olivieri I, Hunder GG. Polymyalgia manifestations in Ann Rheum Dis 2008;67:733–734. different conditions mimicking polymyalgia observation, evidence of bursitis in a doi:10.1136/ard.2008.087999 rheumatica. Clin Exp Rheumatol 2000;18:755–9.
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