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Cervical Rheumatoid Arthritis

What is Rheumatoid Arthritis?

The disease of (RA) is a disease process where the body believes that joints which have a joint lining (synovium) are foreign material. The body then tells the immune system to attack these joints (autoimmune disease).

Which joints are usually affected by Rheumatoid Arthritis?

RA typically affects all the synovial joints in the body. These are all the true joints in the body such as knees, hips, shoulders, elbows, ankles, etc. RA can also involve other organs such as the lung, the sac around the heart () and the skin.

Which part of the spine is usually affected by Rheumatoid Arthritis?

The spine has synovial joints in the form of the on the back of the spine. RA targets these facet joints and the ligaments surrounding them and begins a process of inflammation and wear and tear on these joints. The joints become inflamed, swollen and progressively stiffer.

Where in the neck does Rheumatoid Arthritis cause damage?

The cervical spine (neck) is most affected by this process, specifically at the first and second vertebrae (C-1, C-2). The joint destruction at these levels often makes the joints unstable and causes abnormal motion between the vertebrae.

The joint between the skull and C-1 () can also be affected which allows the skull to begin to “settle” (slide down) on the C-1 vertebrae. This can allow the odontoid process of C-2 ()(part of C-2 which points upward into the ring of C-1) to be pushed upward towards the base of the brain. The result can be compression of the spinal cord or brain stem (part of the brain which connects to the spinal cord).

In general, RA creates breakdown and instability of the most vulnerable part of the cervical spine where it meets the skull.

How many people are affected by Rheumatoid Arthritis?

1% of the world’s population is affected by RA. Women are diagnosed with RA 3 times more often than men.

85% of patients with RA will have disease of the cervical spine. This often begins to happen within the first few years after the disease is present.

What are the symptoms of Rheumatoid Arthritis?

The symptoms from joint destruction of the cervical spine in RA can vary.

Here are some examples:

  1. A feeling of instability of the head or neck
  2. A “crunching” sensation in the neck
  3. Headaches at the back of the skull
  4. Feeling unstable when walking
  5. Pain radiating to the shoulders or arms
  6. Pain, numbness or weakness in the arms and legs
  7. Changes in bowel or bladder control

How do Spine Specialists diagnose Rheumatoid Arthritis?

Spine specialists use information from the patient history, physical examination, and special tests to diagnose Rheumatoid Arthritis of the Spine:

  1. History

Patients with known RA are presumed to have spine involvement. It is helpful to know how long the disease has been present, what complications it has caused and how it has been treated.

      2. Physical Examination

The examination often focuses on signs of spinal cord dysfunction ( to rule out advanced forms of spinal involvement. The following may be evaluated:

  1. Gait
  2. Reflexes
  3. Tenderness in the neck
  4. Range of motion of the neck
  5. Muscle strength in the arms and legs
  6. Sensation in the arms and legs
  7. Babinski sign
  8. Lhermitt’s sign
  9. Ankle Clonus test
  10. Hoffman’s Sign

      3. Imaging

a. X-Rays

X-Rays of the cervical spine are very important in evaluating a patient with RA. They can show the wear and tear as well as any instability between the vertebrae. Often, these X-Rays are taken with the patient bending the head forward (flexion) and backwards (extension). This allows the spine specialist to see if there is any abnormal motion or instability.

b. MRI Scans                                                            

MRI scans can show the degeneration of the joints in the neck and if there is any compression of the spinal cord or spinal nerves. In very severe cases, the MRI can also show if there is any danger to the brain itself. Since RA often produces fluid and swelling the MRI can determine if this swelling is having an impact on the spinal cord.

c. CT Scans

CT Scans can show the bones of the spine in detail. They are typically not quite as useful as X-Rays and MRI Scans and expose the patient to significant radiation. However in certain instances they are needed to plan surgery or see more bone detail if needed.

What are the treatments for Rheumatoid Arthritis of the Spine?

Here are some Non-Surgical and Surgical treatments of the spine:

  1. Non-Surgical Care

The most important non-surgical treatment is to maximize any medical treatment of the disease in hopes of slowing down the effects on the spine and the other organs affected. A group of medications called “Disease-Modifying Anti Rheumatic Drugs” (DMARD) are used by Rheumatologists to control the disease.

Here are some other treatments to help control the symptoms of Rheumatoid Arthritis:

A. Alternative Health Care

There are some alternative health options which can complement medical options for this condition.

Meditation Exercises, and Herbal Remedies are some examples of Alternative Health Care Options.

B. Chiropractic Care

Chiropractic care may be beneficial for milder cases of this disease. Advanced cases with unstable spine conditions may not be suitable for chiropractic manipulation. However, other non-manipulation treatments can be offered.

C. Spine Exercises

Gentle spine exercises can help maintain the muscle tone and mobility for patients with RA. More aggressive, high impact exercises are typically not recommended.

D. Physical Therapy (PT)

Strengthening the support structures of the neck is an important part of providing as much stability to the neck as possible. Certain exercises can help. Muscle spasms can be treated with soft tissue techniques and electrical stimulation.

E. Self Help Devices

A for severe instability of the neck can be used to prevent further damage and to provide some added stability. Sometimes hard braces have to be used to accomplish this.

F. Medications

Here are some examples of available medication to treat the discomfort from RA:

1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

2. Muscle Relaxants

3. Pain Killers

4. Spinal Injections

Spinal injections can help with the pain from RA. Since RA can affect different parts of the neck, various injections can be offered. However, these are typically reserved for patients without severe compression of the spinal cord. A spine surgeon can determine when an injection is advisable.

Here are some potential options:

  1. Cervical Interlaminar Epidural Steroid Injection
  2. Cervical Transforaminal Epidural Steroid Injection
  3. Cervical Nerve Root Block
  4. Cervical Facet Joint Injection
  5. Cervical Radiofrequency Facet Joint Rhizotomy
  6. Cervical Spinal Cord Stimulation


      2. Surgical Care

The surgical treatment for RA is typically reserved for patients with advanced stages of the disease and those with significant instability of the neck. Sometimes surgery has to be done in the very advanced cases due to severe pressure on the spinal cord which could lead to paralysis and even death.

Here are some surgical treatment options:


  1. Cervical Laminectomy and Fusion
  2. Occipito-Cervical Fixation
  3. Posterior Cervical Fusion