{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:30:10Z","timestamp":1760059810538,"version":"build-2065373602"},"reference-count":64,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2025,7,13]],"date-time":"2025-07-13T00:00:00Z","timestamp":1752364800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Introduction: Synovitis and damage to natural stabilizers of many axial and peripheral joints make patients with rheumatoid arthritis particularly susceptible to sagittal balance disorders of the axial skeleton. This may determine the high individual variability of cervical spine deformities as well as differences in the rate of development of disease symptoms in these patients, such as radiculopathy and myelopathy. Methods: In the scientific literature, in addition to systemic factors, more and more attention is paid to work on biomechanical factors in the development of cervical spine instability. One of the methods for assessing the influence of biomechanical factors, which can also be used in everyday practice, is the analysis of radiological parameters of sagittal balance. Results: Among the selected sagittal balance parameters studied, a statistical relationship between C4 and C5 distance and the OI parameter has been found, indicating a relationship to a parameter that remains constant throughout an individual\u2019s life in the group of patients with disease duration over 20 years. Conclusions: The development of instability and deformity in the subaxial segment of the cervical spine in patients with rheumatoid arthritis may be the result of insufficiently understood components of biomechanical factors; hence, further research in this field is necessary.<\/jats:p>","DOI":"10.3390\/jcm14144954","type":"journal-article","created":{"date-parts":[[2025,7,14]],"date-time":"2025-07-14T10:55:41Z","timestamp":1752490541000},"page":"4954","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Subaxial Subluxation (SAS) and Cervical Deformity in Patients with Rheumatoid Arthritis in Relation to Selected Sagittal Balance Parameters"],"prefix":"10.3390","volume":"14","author":[{"given":"Robert","family":"Wr\u00f3blewski","sequence":"first","affiliation":[{"name":"Department of Neuroorthopedics and Neurology Clinic and Polyclinic, National Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw, 1 Spartanska Street, 02-637 Warsaw, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0736-0389","authenticated-orcid":false,"given":"Ma\u0142gorzata","family":"Ma\u0144czak","sequence":"additional","affiliation":[{"name":"Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw, 1 Spartanska Street, 02-637 Warsaw, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1947-2775","authenticated-orcid":false,"given":"Robert","family":"Gasik","sequence":"additional","affiliation":[{"name":"Department of Neuroorthopedics and Neurology Clinic and Polyclinic, National Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw, 1 Spartanska Street, 02-637 Warsaw, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,7,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"18001","DOI":"10.1038\/nrdp.2018.1","article-title":"Rheumatoid arthritis","volume":"4","author":"Smolen","year":"2018","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_2","unstructured":"Szczeklik, A. (2020). Interna 2020, Medycyna Praktyczna."},{"key":"ref_3","unstructured":"Canale, S.T., and Beaty, J.H. (2016). Campbell\u2019s Operative Orthopedics, MediPage. [12th ed.]."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1179\/2042618614Y.0000000096","article-title":"Upper cervical instability associated with rheumatoid arthritis: A case report","volume":"24","author":"Cunningham","year":"2016","journal-title":"J. Man. Manip. Ther."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"252456","DOI":"10.1155\/2015\/252456","article-title":"Rheumatoid arthritis and the cervical spine: A review on the role of surgery","volume":"2015","author":"Gillick","year":"2015","journal-title":"Int. J. Rheumatol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1093\/rheumatology\/40.2.123","article-title":"Mortality associated with cervical spine disorders: A population\u2014Based study of 1666 patients with rheumatoid arthritis who died in Finland in 1989","volume":"40","author":"Neva","year":"2001","journal-title":"Rheumatology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1016\/j.spinee.2003.10.006","article-title":"Rheumatoid arthritis of the cervical spine","volume":"4","author":"Nguyen","year":"2004","journal-title":"Spine J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.hcl.2010.09.006","article-title":"Historical perspective on the ethiology of rheumathoid arthritis","volume":"27","author":"Entezami","year":"2011","journal-title":"Hand. Clin."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1136\/ard.25.2.120","article-title":"Rheumatoid arthritis of the cervical spine. An analysis of 333 cases","volume":"25","author":"Conlon","year":"1966","journal-title":"Ann. Rheum. Dis."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"141","DOI":"10.3171\/2013.4.SPINE12838","article-title":"Cervical spine alignment, sagittal deformity, and clinical implications: A review","volume":"19","author":"Scheer","year":"2013","journal-title":"J. Neurosurg. Spine"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1097\/00007632-197803000-00003","article-title":"The basic kinematics of the human spine. A review of past and current knowledge","volume":"3","author":"White","year":"1978","journal-title":"Spine"},{"key":"ref_12","first-page":"136","article-title":"Rheumatoid arthritis of the cervical spine\u2014Clinical considerations","volume":"69","author":"Wasserman","year":"2011","journal-title":"Bull. NYU Hosp. Jt. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1227\/01.NEU.0000365854.13997.B0","article-title":"Rheumatoid arthritis of the craniovertebral junction","volume":"66","author":"Krauss","year":"2010","journal-title":"Neurosurgery"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"201","DOI":"10.5114\/reum.2017.69782","article-title":"Cervical spine instability in the course of rheumatoid arthritis\u2014Imaging methods","volume":"55","author":"Gasik","year":"2017","journal-title":"Reumatologia"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1007\/s00586-009-0945-5","article-title":"Subaxial subluxation after atlantoaxial transarticular screw fixation in rheumatoid patients","volume":"18","author":"Ito","year":"2009","journal-title":"Eur. Spine J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1551","DOI":"10.1097\/BRS.0b013e3181af0d85","article-title":"Risk factors for development of subaxial subluxations following atlantoaxial arthrodesis for atlantoaxial subluxations in rheumatoid arthritis","volume":"35","author":"Ishii","year":"2010","journal-title":"Spine"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1097\/01.BRS.0000107225.97653.CA","article-title":"A retrospective radiographic analysis of subaxial sagittal alignment after posterior C1-C2 fusion","volume":"29","author":"Yoshimoto","year":"2004","journal-title":"Spine"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1111\/1756-185X.13096","article-title":"Cervical spine involvement risk factors in rheumatoid arthritis: A meta-analysis","volume":"20","author":"Zhu","year":"2017","journal-title":"Int. J. Rheum. Dis."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Yurube, T., Sumi, M., Nishida, K., Miyamoto, H., Kohyama, K., Matsubara, T., Miura, Y., Hirata, H., Sugiyama, D., and Doita, M. (2014). Accelerated development of cervical spine instabilities in rheumatoid arthritis: A prospective minimum 5-year cohort study. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0088970"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1097\/BRS.0000000000001853","article-title":"Predictive Risk Factors of Cervical Spine Instabilities in Rheumatoid Arthritis: A Prospective Multicenter Over 10-Year Cohort Study","volume":"42","author":"Terashima","year":"2017","journal-title":"Spine"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1007\/s10067-020-05243-9","article-title":"Risk factors for cervical spine instability in patients with rheumatoid arthritis","volume":"40","author":"Baek","year":"2021","journal-title":"Clin. Rheumatol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"24","DOI":"10.3171\/2024.1.SPINE231199","article-title":"Effect of high disease activity on spinal sagittal malalignment in patients with rheumatoid arthritis","volume":"41","author":"Honda","year":"2024","journal-title":"J. Neurosurg. Spine"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Wu, J., Kuai, J., Shi, M., Xu, Z., Chen, F., Ding, Y., Ni, B., Wu, Y., and Guo, Q. (2025). The Influence of Cervical Ossification of the Posterior Longitudinal Ligament on Retro-odontoid Soft Tissue Thickness and Cervical Sagittal Balance. Clin. Spine Surg., ahead of print.","DOI":"10.1097\/BSD.0000000000001851"},{"key":"ref_24","first-page":"19","article-title":"Spinal Alignment, Balance and Harmony through the Ages","volume":"2","author":"Dubousset","year":"2019","journal-title":"Int. J. Orth."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1097\/00007632-198501000-00013","article-title":"Toward standards for posture. Postural characteristics of the lower back system in normal and pathologic conditions","volume":"10","author":"During","year":"1985","journal-title":"Spine"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1097\/00007632-198207000-00003","article-title":"Reciprocal angulation of vertebral bodies in a sagittal plane: Approach to references for the evaluation of kyphosis and lordosis","volume":"7","author":"Stagnara","year":"1982","journal-title":"Spine"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1007\/s005860050038","article-title":"Pelvic incidence: A fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves","volume":"7","author":"Legaye","year":"1998","journal-title":"Eur. Spine J."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Roussouly, P., Pinheiro-Franco, J., Labelle, H., and Gechren, M. (2019). From the head to the feet: Anatomy of upright position. Sagittal Balance of the Spine: From Normal to Pathology: A Key for Treatment Strategy, Normative Values Following Age and Populations. Thieme. [1st ed.].","DOI":"10.1055\/b-0039-171399"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1889","DOI":"10.1007\/s00586-019-06083-1","article-title":"Sagittal balance of the spine","volume":"28","author":"Thompson","year":"2019","journal-title":"Eur. Spine J."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1097\/00002517-200104000-00008","article-title":"Computer-assisted assessment of spinal sagittal plane radiographs","volume":"14","author":"Rajnics","year":"2001","journal-title":"J. Spinal Disord."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"804","DOI":"10.1136\/annrheumdis-2012-203158","article-title":"EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis","volume":"72","author":"Colebatch","year":"2013","journal-title":"Ann. Rheum. Dis."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1007\/s00296-022-05239-5","article-title":"Radiological assessment and surgical management of cervical spine involvement in patients with rheumatoid arthritis","volume":"43","author":"Siempis","year":"2023","journal-title":"Rheumatol. Int."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1580","DOI":"10.1136\/ard.2010.138461","article-title":"2010 rheumatoid arthritis classification criteria: An American College of Rheumatology\/European League Against Rheumatism collaborative initiative","volume":"69","author":"Aletaha","year":"2010","journal-title":"Ann. Rheum. Dis."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"E4","DOI":"10.3171\/2015.1.FOCUS14664","article-title":"Radiological evaluation of cervical spine involvement in rheumatoid arthritis","volume":"38","author":"Joaquim","year":"2015","journal-title":"Neurosurg. Focus."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2136","DOI":"10.1097\/BRS.0b013e31826def1c","article-title":"Incidence and aggravation of cervical spine instabilities in rheumatoid arthritis: A prospective minimum 5-year follow-up study of patients initially without cervical involvement","volume":"37","author":"Yurube","year":"2012","journal-title":"Spine"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1097\/00007632-199501150-00015","article-title":"Subaxial lesions in rheumatoid arthritis. Radiographic factors suggestive of lower cervical myelopathy","volume":"20","author":"Yonezawa","year":"1995","journal-title":"Spine"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1097\/00003086-197506000-00011","article-title":"Biomechanical analysis of clinical stability in the cervical spine","volume":"109","author":"White","year":"1975","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1003","DOI":"10.2106\/00004623-197961070-00006","article-title":"Cervical fusion in rheumatoid arthritis","volume":"61","author":"Ranawat","year":"1979","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"194","DOI":"10.2106\/00004623-200102000-00006","article-title":"Diagnosing basilar invagination in the rheumatoid patient. The reliability of radiographic criteria","volume":"83","author":"Riew","year":"2001","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2284","DOI":"10.1097\/01.brs.0000142224.46796.a7","article-title":"Evaluation of a functional position for lateral radiograph acquisition in adolescent idiopathic scoliosis","volume":"29","author":"Faro","year":"2004","journal-title":"Spine"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Zhu, W., Sha, S., Liu, Z., Li, Y., Xu, L., Zhang, W., Qiu, Y., and Zhu, Z. (2018). Influence of the Occipital Orientation on Cervical Sagittal Alignment: A Prospective Radiographic Study on 335 Normal Subjects. Sci. Rep., 8.","DOI":"10.1038\/s41598-018-33287-0"},{"key":"ref_42","first-page":"102","article-title":"Occipital incidence\u2013a novel morphometric parameter for understanding occipitocervical spinal alignment","volume":"13","author":"Kim","year":"2013","journal-title":"J. Spinal Disord. Tech."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1512","DOI":"10.1016\/j.spinee.2019.04.021","article-title":"McGregor\u2019s slope and slope of line of sight: Two surrogate markers for Chin-Brow vertical angle in the setting of cervical spine pathology","volume":"19","author":"Moses","year":"2019","journal-title":"Spine J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"269","DOI":"10.3171\/2013.5.SPINE121067","article-title":"A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction: Clinical article","volume":"19","author":"Ames","year":"2013","journal-title":"J. Neurosurg. Spine"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"673","DOI":"10.3171\/2014.12.SPINE14780","article-title":"Reliability assessment of a novel cervical spine deformity classification system","volume":"23","author":"Ames","year":"2015","journal-title":"J. Neurosurg. Spine"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1007\/s00586-018-5835-2","article-title":"Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): Results of the CSRS-Europe multi-centre study project","volume":"28","author":"Koller","year":"2019","journal-title":"Eur. Spine J."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Kim, H.J., Virk, S., Elysee, J., Ames, C., Passias, P., Shaffrey, C., Mundis, G., Protopsaltis, T., Gupta, M., and Klineberg, E. (2021). Surgical strategy for the management of cervical deformity is based on type of cervical deformity. J. Clin. Med., 10.","DOI":"10.3390\/jcm10214826"},{"key":"ref_48","unstructured":"B\u0142aszczyk, J. (2004). Biomechanika Kliniczna, Podr\u0119cznik dla Student\u00f3w Medycyny i Fizjoterapii, WydawnictwoLekarskie PZWL."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"994","DOI":"10.1016\/j.spinee.2010.08.031","article-title":"The use of the T1 sagittal angle in predicting overall sagittal balance of the spine","volume":"10","author":"Knott","year":"2010","journal-title":"Spine J."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"E41","DOI":"10.1097\/BSD.0b013e3182396301","article-title":"The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults","volume":"25","author":"Lee","year":"2012","journal-title":"J. Spinal Disord. Tech."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"S149","DOI":"10.1097\/BRS.0b013e3182a7f449","article-title":"Cervical radiographical alignment: Comprehensive assessment techniques and potential importance in cervical myelopathy","volume":"38","author":"Ames","year":"2013","journal-title":"Spine"},{"key":"ref_52","first-page":"3","article-title":"Studia nad zmienno\u015bci\u0105 wybranych w\u0142a\u015bciwo\u015bci taksonomiczno-antropometrycznych w kategoriach wieku dojrza\u0142ego","volume":"1","author":"Kapica","year":"1981","journal-title":"Acta Univ. Lodz. Folia Zool. Anthropol."},{"key":"ref_53","unstructured":"Roy, I.B. (2016). Anthropology. The Study of Man, S Chand & Co Ltd."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1016\/S0268-0033(00)00034-6","article-title":"Biomechanics of the cervical spine. I: Normal kinematics","volume":"15","author":"Bogduk","year":"2000","journal-title":"Clin. Biomech."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"153628","DOI":"10.1155\/2011\/153628","article-title":"Cervical myelopathy in rheumatoid arthritis","volume":"2011","author":"Mukerji","year":"2011","journal-title":"Neurol. Res. Int."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1007\/s12178-016-9349-4","article-title":"Cervical radiculopathy","volume":"9","author":"Iyer","year":"2016","journal-title":"Curr. Rev. Musculoskelet. Med."},{"key":"ref_57","unstructured":"Van Mameren, H. (1988). Motion Patterns in the Cervical Spine. [Ph.D. Thesis, Maastricht University]."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1471","DOI":"10.1016\/j.jbiomech.2013.03.004","article-title":"Cervical spine intervertebral kinematics with respect to the head are different during flexion and extension motions","volume":"46","author":"Anderst","year":"2013","journal-title":"J. Biomech."},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Wr\u00f3blewski, R., Koszela, K., Ma\u0144czak, M., Sudo\u0142-Szopi\u0144ska, I., and Gasik, R. (2023). Relationship between Cervical Instability in the Course of Rheumatoid Arthritis and Pelvic Parameters of Sagittal Balance. J. Clin. Med., 12.","DOI":"10.3390\/jcm12206507"},{"key":"ref_60","doi-asserted-by":"crossref","unstructured":"Wr\u00f3blewski, R., Ma\u0144czak, M., and Gasik, R. (2024). Atlantoaxial Instability in the Course of Rheumatoid Arthritis in Relation to Selected Parameters of Sagittal Balance. J. Clin. Med., 13.","DOI":"10.3390\/jcm13154441"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"1393","DOI":"10.1111\/1756-185X.14601","article-title":"Finite element analysis of joints involved in rheumatoid arthritis","volume":"26","author":"Chen","year":"2023","journal-title":"Int. J. Rheum. Dis."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1055\/s-0043-1768930","article-title":"Finite Element Modeling of the Human Wrist: A Review","volume":"12","author":"Mena","year":"2023","journal-title":"J. Wrist Surg."},{"key":"ref_63","doi-asserted-by":"crossref","unstructured":"Naoum, S., Vasiliadis, A.V., Koutserimpas, C., Mylonakis, N., Kotsapas, M., and Katakalos, K. (2021). Finite Element Method for the Evaluation of the Human Spine: A Literature Overview. J. Funct. Biomater., 12.","DOI":"10.3390\/jfb12030043"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"949","DOI":"10.31616\/asj.2022.0295","article-title":"A Review of Finite Element Modeling for Anterior Cervical Discectomy and Fusion","volume":"17","author":"Lin","year":"2023","journal-title":"Asian Spine J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/14\/4954\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:09:12Z","timestamp":1760033352000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/14\/4954"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,13]]},"references-count":64,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["jcm14144954"],"URL":"https:\/\/doi.org\/10.3390\/jcm14144954","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2025,7,13]]}}}