Can rheumatoid arthritis (RA) affect the cervical spine?

Rheumatoid Arthritis and Cervical Spine Involvement

Yes, rheumatoid arthritis significantly affects the cervical spine, with up to 86% of RA patients developing cervical spine involvement during the course of their disease. 1

Patterns of Cervical Spine Involvement in RA

Rheumatoid arthritis can affect the cervical spine in three main patterns:

1. Atlantoaxial subluxation (AAS) - Most common manifestation

   • Results from inflammation of the transverse ligament of the atlas
   • Can lead to instability between C1 and C2 vertebrae

2. Cranial settling (CS) - Also called atlantoaxial impaction

   • Occurs when the odontoid process migrates upward into the foramen magnum
   • Results from erosion of the lateral masses of C1

3. Subaxial subluxation (SAS)

   • Involves vertebrae below C2
   • Results from facet joint destruction and ligamentous laxity

Diagnostic Imaging

Different imaging modalities provide complementary information:

• Plain radiographs (X-rays):

  • Initial screening tool
  • Flexion and extension views are essential to detect atlantoaxial subluxation 2
  • Lateral views show more erosions (1.57-fold) than open mouth views 2

• MRI:

  • Superior for detecting odontoid erosions (67.5% detection rate vs. 12.5% for X-rays) 2
  • Best for evaluating neural element compression
  • Can detect pannus formation and spinal cord compression
  • Can reveal abnormalities even when X-rays appear normal 2

• CT:

  • Best for detecting lateral atlantoaxial subluxation 2
  • Superior for evaluating bony anatomy
  • Detection rate for dens erosions: 41% (vs. 12.5% for X-rays) 2

Clinical Implications and Management

Warning Signs

• Neck pain
• Occipital headache
• Neurological deficits (myelopathy)
• Radicular symptoms
• Vertebrobasilar insufficiency

Management Considerations

• Chiropractic manipulation is contraindicated

  • The American College of Rheumatology (ACR) conditionally recommends against chiropractic therapy (spinal manipulation) for RA patients due to potential cervical spine complications 2
  • High risk of spinal cord injury in patients with cervical instability

• Surgical indications:

  • Progressive neurological deficit
  • Chronic neck pain with radiographic instability
  • Atlantoaxial impaction or cord stenosis
  • Posterior atlantodental interval ≤14 mm 3

• Conservative management:

  • NSAIDs/COXIBs at maximum tolerated dosage for at least 6 weeks 4
  • Physical therapy focusing on cervical spine exercises (avoiding manipulation)
  • Heat therapy for symptom relief 4
  • Patient education about avoiding activities that may exacerbate instability

Monitoring and Follow-up

• Regular radiographic follow-up is essential for RA patients, especially those with:

  • Long-standing disease
  • High disease activity
  • Inadequate disease control
  • Existing cervical spine involvement

• MRI is indicated when:

  • Neurologic deficit occurs
  • Plain radiographs show atlantoaxial subluxation with posterior atlantodental interval ≤14 mm
  • Any degree of atlantoaxial impaction is present
  • Subaxial stenosis with canal diameter ≤14 mm is detected 3

Risk Factors for Cervical Spine Involvement

• Uncontrolled RA disease activity
• Long disease duration
• Presence of rheumatoid factor
• Erosive peripheral joint disease
• Early age of disease onset

Clinical Pearls

• Cervical spine involvement can occur early in the disease course
• Many patients with radiographic abnormalities remain asymptomatic
• Disease-modifying antirheumatic drugs (DMARDs) may prevent development of new cervical instabilities but may not prevent progression of existing damage 5
• RA patients undergoing surgery have higher complication rates and more frequent need for revision surgery than the general population 1

Careful monitoring of the cervical spine should be part of routine care for all RA patients to prevent potentially devastating neurological complications.