Rheumatoid Arthritis of the Spine

Rheumatoid arthritis (RA) is an autoimmune disease: the immune system attacks the synovium, the lining of the joints, causing inflammation, pain and, over time, damage to cartilage, bone and the ligaments that hold joints together. It most often affects the small joints of the hands and feet, but the spine can be affected too.

Which part of the spine does RA affect?

When RA affects the spine, it is the neck (cervical spine) that is usually involved, rather than the lower back. Studies suggest the neck is affected in more than half of people with RA, although many have no symptoms from it. The joint most often affected is between the top two vertebrae, just below the base of the skull.

Unlike osteoarthritis of the spine, which is linked to wear and tear and bone spurs (osteophytes), RA is an inflammatory arthritis. Pain can occur even when the joints are at rest.

Why the neck matters in RA

Long-standing inflammation can erode bone and loosen the ligaments around the top two vertebrae. This can make the joint unstable (called atlantoaxial subluxation), so the vertebrae can slip. In a minority of people, this presses on the spinal cord or nerves. Neck involvement usually develops within 2 to 10 years of RA starting. Because it often causes no symptoms at first, rheumatology teams may arrange neck X-rays to check for instability.

Symptoms

• Neck pain, especially at the base of the skull
• Stiffness, typically worse in the morning
• Headaches at the back of the head
• Swelling and tenderness over the affected area
• A grinding feeling when moving the neck
• Tiredness and feeling generally unwell, which is common with RA

Signs of pressure on nerves or the spinal cord

Get prompt medical advice if you notice:

• tingling, numbness or weakness in the arms or legs
• clumsy hands, or a loss of coordination or balance when walking
• pain spreading into the arms or legs

Any new difficulty controlling your bladder or bowels is an emergency: get medical help straight away.

Diagnosis

A rheumatologist or spinal specialist will examine your neck and check your strength, reflexes and walking. Tests may include X-rays, often taken with the neck bent forwards and backwards to show instability; an MRI scan to look at the spinal cord and nerves; a CT scan to show bone erosion; and blood tests for inflammation.

Treatment

Medicines that control RA

The main treatment for RA is medicine that slows the disease itself, not just the symptoms. These are prescribed and monitored by a rheumatology team:

• Disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate (usually the first choice), leflunomide, hydroxychloroquine and sulfasalazine. They can take a few months to work.
• Biological treatments, such as adalimumab, etanercept and infliximab, usually given with methotrexate if DMARDs alone haven't worked.
• JAK inhibitors, a newer type of tablet for moderate to severe RA.
• Short courses of steroids to control flares.

Good control of RA with these medicines helps protect the joints, including those in the neck.

Relieving symptoms

• painkillers and anti-inflammatory medicines
• physiotherapy to maintain movement and strength (people with RA in the neck should tell their physiotherapist, as some techniques aren't suitable)

Surgery

Surgery is considered for worsening nerve problems, severe pain with an unstable neck, or significant pressure on the spinal cord. It usually involves fusing the affected vertebrae to stabilise them and taking pressure off the cord.

Living with RA of the spine

Keep taking your RA medicines as prescribed, attend regular reviews, and tell your rheumatology team about any new neck pain or nerve symptoms. Staying active within your limits helps maintain movement and strength.

For bone spurs in the spine, see osteophytic spurring.