Rheumatoid Arthritis and the Spine

A condition guide by Mr Mohammed Madi, Consultant Orthopaedic & Spinal Surgeon.

Rheumatoid arthritis is a long-term inflammatory disease that most people associate with the hands and feet, but it can also affect the spine — and, importantly, almost always the upper neck rather than the lower back. The encouraging news is that modern medical treatment has made serious spinal involvement far less common than it once was. This page explains how and why rheumatoid arthritis can affect the neck, what symptoms and warning signs to look for, how it is monitored, and when surgery is considered.

Rheumatoid arthritis (RA) is an autoimmune condition in which the body's immune system attacks the lining of the joints, causing inflammation, swelling and, over time, damage to cartilage, bone and the ligaments that hold joints together. In the spine, RA characteristically affects the cervical spine — the neck — and particularly the highly mobile joints at the very top, just below the skull. It rarely affects the lower (lumbar) spine, which is more often troubled by ordinary wear-and-tear conditions.

In plain terms: in the neck, rheumatoid arthritis can loosen and erode the small joints and ligaments that keep the top of the spine stable, which in a minority of people allows the bones to shift more than they should.

The top two vertebrae of the neck are specially shaped. The first (the atlas, or C1) is a ring that carries the skull; the second (the axis, or C2) has a peg of bone — the odontoid, or dens — that points upwards through the ring of the atlas and acts as a pivot, allowing the head to rotate. A strong band called the transverse ligament holds the peg snugly against the front of the ring, keeping the spinal cord safe in the space behind. This elegant arrangement gives the neck much of its movement, but it depends entirely on healthy ligaments and bone. Rheumatoid inflammation targets exactly these structures.

In rheumatoid arthritis, inflamed joint lining (synovium) proliferates into an aggressive tissue called pannus, which erodes bone and stretches or destroys ligaments. In the upper neck this has three main consequences, which can occur alone or together:

Atlantoaxial subluxation — the transverse ligament loosens or fails and the odontoid peg erodes, so the atlas (C1) slips forward on the axis (C2). This is the most common pattern.

Cranial settling (vertical subluxation or basilar invagination) — erosion of the joints between the skull and the upper neck allows the skull to sink down, so the odontoid peg rides up towards the brainstem.

Subaxial subluxation — inflammation lower in the neck causes one or more vertebrae to slip on those below, sometimes at several levels (a "staircase" appearance).

When these shifts become severe, the spinal cord or brainstem can be compressed, producing neurological problems. Crucially, the amount of movement seen on a scan does not always match the symptoms — significant instability can be present with surprisingly few complaints, which is why monitoring matters.

The underlying cause is rheumatoid arthritis itself. Within RA, spinal involvement is more likely with long-standing, severe and poorly controlled disease, a strongly positive blood test (rheumatoid factor), the presence of bony erosions elsewhere, and long-term use of corticosteroids. The single most important protective factor is good control of the underlying inflammation — which is why the widespread use of modern disease-modifying drugs and biologics has substantially reduced the frequency of serious neck involvement compared with previous decades.

Symptoms range from none at all to serious neurological problems. The most common are:

Neck pain, often felt high in the neck and radiating to the back of the head (occipital pain), sometimes with a sense of the head "clunking" or being unstable on the neck.

Reduced movement and stiffness of the neck.

Neurological symptoms if the cord is compressed (myelopathy): clumsy hands and loss of fine dexterity, heaviness or weakness in the limbs, unsteadiness when walking, tingling or electric-shock sensations down the spine, and in advanced cases problems with bladder control.

Symptoms of brainstem involvement in cranial settling, such as dizziness, difficulty swallowing, drop attacks or blackouts — uncommon but important.

A particular difficulty is that people with rheumatoid arthritis may already have joint pain and deformity elsewhere, and may be less active, which can mask the early signs of cord involvement. New or changing neck or neurological symptoms in someone with RA should always be taken seriously.

Features that warrant prompt specialist assessment include rapidly worsening hand function or walking, new limb weakness, electric-shock sensations down the spine, new bladder or bowel disturbance, drop attacks or blackouts, and severe high neck pain with a feeling of instability. These suggest the cord or brainstem may be under pressure.

Assessment combines a careful history with a neurological examination looking for the upper-motor-neuron signs of cord compression (brisk reflexes, altered tone, a positive Hoffmann's sign, an unsteady gait). Because RA can affect peripheral nerves and joints too, the picture can be complex, and examination is interpreted alongside imaging.

Plain X-rays, including flexion and extension views, remain valuable for showing instability. Specific measurements — the gap between the odontoid peg and the atlas at the front (the anterior atlanto-dental interval) and, more importantly, the space left for the cord behind the peg (the posterior atlanto-dental interval) — help judge how much room the spinal cord has.

MRI is the key test for showing the spinal cord and brainstem, any pannus, and whether the cord is being compressed or damaged. It is particularly useful for assessing cranial settling.

CT shows the bone in fine detail and is helpful for surgical planning and for assessing the eroded odontoid.

Several grading systems (such as the Ranawat classification of neurological status) are used to describe severity and track change over time.

In someone with well-controlled rheumatoid arthritis, the upper neck may remain stable for many years and never cause trouble. Where instability does develop, it can progress, and the concern is that established cord compression (myelopathy) tends to worsen and recovers less well the longer it is left. Cranial settling in particular can progress and is potentially serious. This combination — that instability can advance quietly and that outcomes are better when treated early — is the reason people with significant RA are monitored for neck involvement, especially before any planned operation requiring a general anaesthetic, where neck positioning matters.

The foundation of treatment is good control of the rheumatoid arthritis itself, managed by the rheumatology team with disease-modifying drugs and biologic therapies. Effective suppression of inflammation reduces the risk of spinal damage developing or progressing, and is the main reason serious neck involvement is now much less common.

For people with instability but no neurological problems and manageable pain, a careful watching approach is reasonable — with monitoring of symptoms and imaging, pain management, and attention to safety (for example, awareness during anaesthesia and physiotherapy, and sometimes a collar in specific circumstances). Non-surgical care does not correct instability but allows the situation to be observed safely.

Surgery is considered when there is instability with neurological compromise (myelopathy), progressive instability, intractable pain, or signs that the cord or brainstem is at risk. The aim is to stabilise the affected segments — and, where needed, take pressure off the cord — to prevent further neurological decline. The specific operation depends on the pattern:

Atlantoaxial subluxation is usually treated with a C1–C2 fusion.

Cranial settling generally requires a fusion from the skull to the upper neck (occipito-cervical fusion), sometimes with reduction of the settled bones.

Subaxial subluxation is treated with decompression and fusion of the affected levels.

A consistent and important message from the evidence is that operating before advanced myelopathy develops gives better results than waiting until neurological damage is established. Against this, people with rheumatoid arthritis tend to have higher surgical complication rates and a greater need for further surgery than other patients, partly because of fragile bone, the disease itself and its medications — so the decision is carefully individualised and made jointly between the patient, the spinal surgeon and the rheumatology team.

Where surgery is performed for instability before the cord is badly damaged, it can reliably halt progression, relieve pain and protect neurological function, and many people stabilise or improve. Once severe myelopathy is established, surgery aims chiefly to prevent further decline, and recovery of lost function is less certain. Recovery after fusion involves a period of healing while the bone unites, and rehabilitation is tailored to the individual and to their general health and other joint problems.

For most people with rheumatoid arthritis today, the neck never becomes a serious problem, particularly when the disease is well controlled. The long-term priorities are good disease control, awareness of the warning symptoms, and appropriate monitoring of the neck where there is significant or long-standing disease — especially before any operation under general anaesthetic. Treated appropriately and in good time, even significant instability can be managed effectively.

"Rheumatoid arthritis affects the lower back." In the spine, RA characteristically affects the upper neck, not the lumbar spine.

"If my neck doesn't hurt, it must be fine." Symptoms do not always reflect the degree of instability; significant changes can be present with little pain, which is why monitoring matters.

"Nothing can be done." Good disease control prevents most problems, and timely surgery can stabilise the neck and protect the spinal cord.

"Surgery should be a last resort." For neck instability with cord involvement, earlier surgery generally gives better results than waiting.

Rheumatoid arthritis can affect the spine, almost always at the top of the neck, by loosening and eroding the joints and ligaments that keep it stable. Modern disease-modifying treatment has made serious involvement much less common. Symptoms range from none to neck pain and, in a minority, spinal cord problems — and because symptoms do not always match the degree of instability, monitoring matters in significant disease. The mainstay is good control of the arthritis; surgery is reserved for instability with neurological risk or progression, and is most effective when carried out before serious cord damage develops.

This page is for general education and does not replace advice from your own clinical team. If you have rheumatoid arthritis and develop new neck pain radiating to the head, clumsy hands, unsteadiness, limb weakness, electric-shock sensations down the spine, blackouts, or any bladder disturbance, seek prompt medical review.

• —Gillick JL, Wainwright J, Das K. Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery. International Journal of Rheumatology. 2015;2015:252456.
• —Joaquim AF, Ghizoni E, Tedeschi H, et al. Radiological evaluation of cervical spine involvement in rheumatoid arthritis. Neurosurgical Focus. 2015;38(4):E4.
• —Wasserman BR, Moskovich R, Razi AE. Rheumatoid arthritis of the cervical spine — clinical considerations. Bulletin of the NYU Hospital for Joint Diseases. 2011;69(2):136–148.
• —Mallory GW, Halasz SR, Clarke MJ. Advances in the treatment of cervical rheumatoid: Less surgery and less morbidity. World Journal of Orthopedics. 2014;5(3):292–303.
• —Krauss WE, Bledsoe JM, Clarke MJ, et al. Rheumatoid arthritis of the craniovertebral junction. Neurosurgery. 2010;66(3 Suppl):83–95.

This information is for general patient education and is not a substitute for an individual consultation. Always seek personalised advice from a qualified spinal specialist.