Can Rheumatoid Arthritis Affect the Cervical Spine?

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune condition. In autoimmune diseases, the immune system, which is supposed to fight infections and other harmful agents, mistakenly targets and attacks the body’s tissues. This results in chronic inflammation that causes damage to various tissues in the body, such as the joints, skin, eyes, heart, lungs, and kidneys.

The autoimmune attack in RA can target the bones of the spine, typically those in the neck or cervical region. This may cause three main types of abnormalities in the cervical spine:

1. Atlantoaxial instability: Most common abnormality seen in RA that affects the cervical spine. The atlantoaxial joint is the joint between the atlas and axis (first two cervical bones or vertebrae). This abnormality results in the misalignment of the two cervical vertebrae.
2. Superior migration of the odontoid: The odontoid process is a projecting bony part of the second cervical vertebra on which the first cervical vertebra rotates. This deformity can result in pressure on the lower part of the brain that may cause neurological dysfunction and even death in severe cases. 
3. Subaxial subluxation: Least common type of cervical spine deformity. It can result in compression of the spinal cord.

The symptoms of rheumatoid arthritis (RA) of the cervical spine may vary depending on the type and severity of the abnormality caused.

Symptoms may include:

• Neck pain
• Neck stiffness
• Pain in the skull’s base or back of the head (occipital region)
• Vertigo or dizziness
• Facial pain (due to compression of certain nerves passing through the cervical vertebrae)
• Weakness or numbness
• Difficulty walking
• Dysphagia (difficulty swallowing)
• Tinnitus (ringing in the ears)
• Grating sensations or crepitations in neck movement
• A feeling that the head is “falling forward” while bending the neck
• Shock-like sensations through the body or limbs on neck movement (the Lhermitte’s sign).

Other classical symptoms of RA, such as pain and swelling in small joints (those of the hands or feet) and morning stiffness, may also be seen.

Doctors usually diagnose rheumatoid spondylitis based on:

• The detailed medical history of patients, including the symptoms, history of injury, any family history of rheumatoid arthritis, any ongoing medications, and any underlying health issues
• Physical examination to look for reflexes, stiffness any bony abnormalities, etc.
• Investigations including:
  • Blood tests, such as rheumatoid factor and anti-CCP antibodies in the blood
  • Imaging studies, such as X-rays, CT scans, and MRI
  • Other tests to look for other organ involvement, such as ECG, echocardiography, and pulmonary, kidney, and liver function tests

Treatment mainly focuses on preventing any serious complications. As the cervical vertebrae are close to the lower part of the brain, several nerves, and the spinal cord, untreated spondylitis can result in permanent neurological damage and even death. Most patients may be managed with conservative treatment; however, others may require surgery. 

Surgery may help relieve pressure on the nerves, brain, or spinal cord. It may also reduce the symptoms while improving the stability of the cervical spine.

The non-surgical treatments generally include:

• Cervical collars
• Regular follow-up
• Physical therapy 
• Medications
  • The nonsteroidal anti-inflammatory drug, such as ibuprofen and naproxen
  • Corticosteroids, such as prednisone
  • Disease-modifying antirheumatic drugs, such as sulfasalazine, methotrexate, and leflunomide
  • Biological response modifiers or biologicals, such as abatacept, adalimumab, and tocilizumab
  • Janus kinase inhibitors, such as baricitinib, tofacitinib, and upadacitinib