Efficacy and safety of intra-articular steroid injection for inflamed atlantoaxial joint in patients with rheumatoid arthritis

(AS) group, received intra-articular steroid injection for atlantoaxial joint following failure of systemic steroids (prednisolone, oral tablet, 5 mg/3 times daily for 2 weeks) administration as part of the trial to resolve inflammation of the atlanto-axial joint assessed by MRI , (adherence to treatment is confirmed by empty drug packet return), in addition to intramuscular methotrexate 12.5 mg per week and hydroxychloroquine, oral tablet 200 mg, 2 tablets per day (regular treatment for patients with rheumatoid arthritis that continues for life).Injection technique: With the patient placed in the prone position and a pillow under the chest to allow for slight neck flexion, the C-arm is brought to the head of the table in an anteroposterior direction. The C-arm is rotated in a cephalad-caudad direction to better visualize the lateral atlantoaxial joint (AAJ). The needle insertion site is marked on the skin overlying the lateral third of the AAJ. The skin is prepped and draped in the usual sterile fashion, and a skin wheel is raised with 3 ml of lidocaine 1 % at the insertion site. Then, a 22 G 3 and 1/2 inches blunt needle is advanced towards the posterolateral aspect of the inferior margin of the inferior articular process of the atlas (C1). Then, a lateral view is obtained. The needle is withdrawn slightly, directed towards the posterolateral aspect of the (AAJ), and advanced for 2 millimetres. Usually a distinctive pop is felt signalling entering the joint cavity. After careful negative aspiration for blood or cerebrospinal fluid, 0.2 ml of omnipaque dye is injected to verify intra-articular placement of the tip of the needle under direct real-time fluoroscopy to check for inadvertent intra-arterial injection. Anteroposterior and lateral views are obtained to insure that the contrast agent remained confined to the joint cavity without escape to the surrounding structures and finally, 1.0 ml of a mixture of bupivacaine 0.5 % and 20 mg of triamcinolone is injected. The injection will be performed once (will not repeated) bilaterally ( both AAJ). The injection will be done by senior staff pain clinician.