Ross Hauser, MD.

Rheumatoid arthritis is an autoimmune disease that attacks the synovial tissue. Synovial tissue lines the joints. Its function is to provide lubrication to the joint and its tendons. This lubrication helps prevent joint breakdown through joint instability and wear and tear, and provides nutrients to the articular cartilage to keep it thick and healthy. Because the craniocervical junction is held together by synovial joints and cervical ligaments, rheumatoid arthritis and its chronic inflammation can lead to a loss of ligamentous strength (the bones begin to wander) and erosion of the bony structures (from grinding and banging into each other) and resulting in craniocervical instability.

There are many risk factors for cervical instability in rheumatoid arthritis.

A March 2024 study in the Archives of medical science (1) writes: “There are many risk factors for cervical instability in rheumatoid arthritis. In clinical practice, special attention should be paid to patients who are male, have a longer course of disease, have long-term glucocorticosteroid use, have previous joint surgery, have peripheral joint damage, and develop disability. . . ”

The cervical spine is affected in more than a half of patients with rheumatoid arthritis

In a 2017 study (2) assessing diagnostic techniques for determining rheumatoid arthritis, researchers in Poland wrote: “(the) Cervical spine is affected in more than a half of patients with rheumatoid arthritis. Depending on the degree of damage to the individual joints and ligaments rheumatoid arthritis-related cervical spine instability takes the form of atlanto-axial subluxation, subaxial subluxation, or cranial settling. In advanced cases, cervical spinal stenosis can occur as well as spinal cord injuries with typical neurological symptoms. The identification of patients with cervical spine instability before the occurrence of neurological complications still constitutes a diagnostic challenge.”

Further, they noted:

• Atlanto-axial subluxation occurred in 65% of patients with rheumatoid arthritis. Anterior subluxation occurs most often (about 75% of all atlanto-axial subluxation); posterior and lateral are not that often.

Cervical involvement should be considered even without neck pain, particularly in established diseases

A March 2024 study in the journal Musculoskeletal Care (3) aimed to evaluate the prevalence of anterior atlantoaxial subluxation and its associated risk factors in patients with rheumatoid arthritis.

• Two hundred and forty patients with an average age of about 56 were recruited, and 191 (78%) were female.
• On average the patients suffered from Rheumatoid arthritis for about 10 years.
• Of all 25 cases (10.4%) diagnosed with anterior atlantoaxial subluxation:
  • One in three patients with anterior atlantoaxial subluxation had no neck pain.
  • Patients with anterior atlantoaxial subluxation had longer disease duration, lower age at diagnosis, lower body mass index, higher anti-cyclic citrullinated peptide autoantibodies (anti-CCP (rheumatoid antibodies)), more frequent (joint) erosion, joint restriction, and joint prostheses (replacement).
• However, thirty-three percent of patients with cervical involvement do not experience neck pain. (This may cause the patient to be misdiagnosed or not treated correctly) Cervical involvement should be considered even without neck pain, particularly in established diseases. 

Cervical proprioception

A February 2025 study in the Journal of Orthopaedic Surgery and Research (4) found cervical proprioception (awareness of position in space – balance) is significantly reduced in rheumatoid arthritis patients and strongly influences postural control. Pain serves as a key mediator in this relationship, emphasizing the need for effective pain management to enhance proprioceptive and postural functions in rheumatoid arthritis patients. (In other words – pain can cause issues with maintaining balance).

An 80-year-old woman with head dropping and balance issues

In April 2021, doctors presented a case history of an 80-year-old woman with head dropping and balance issues in the journal AME Case Reports (5). In this case, the woman had been diagnosed with seropositive rheumatoid arthritis two decades prior and presented with head dropping and losing balance while walking for several months. Radiographic images of the cervical spine showed rheumatoid arthritis-related features of instability in the form of atlantoaxial instability, cranial settling, and subaxial subluxation.

Treatments: 

The doctors reported: “Since physical therapy and acupuncture previously failed to provide a substantial, long-lasting outcome, the patient sought chiropractic care for her condition. The chiropractic regimen consisted of upper thoracic spine mobilization/adjustment, electrical muscle stimulation of the cervical extensors, home exercises, and neck bracing. She regained substantial neck muscle strength, gaze angle, and walking balance following a 4-month chiropractic treatment, although cervical kyphosis persisted.” 

Surgery

Researchers writing in the Egyptian Journal of Neurology (6) wrote: “Most rheumatoid arthritis patients with abnormal imaging of the cervical vertebrae remain asymptomatic for years, and a small portion of patients eventually require surgery, which is primarily due to neurological problems.” The researchers also noted: “. . . other conventional therapies in patients with rheumatoid arthritis include corticosteroids which lead to osteoporosis, cervical movement reduction, and subaxial subluxation worsening cervical spine instability.” The researchers added: “Some studies proposed early and aggressive surgical intervention before neurological deficit and myelopathy manifestation to preserve cervical spine function, minimize long-term mortality, and increase neurological recovery in patients with rheumatoid arthritis ”

Prednisolone usage, biological agent usage, and higher rheumatoid arthritis stage were significant risk factors for cervical lesions in patients with rheumatoid arthritis

A May 2021 study in the journal BioMed Central Musculoskeletal Disorders (7) examined the association between rheumatoid arthritis cervical spine lesions and osteoporosis, especially in patients with vertical subluxation (spinal misalignment that can affect the nerves) that could be induced by the collapse of lateral masses (vertebrae) in the upper cervical spine. The researchers targeted the current pharmacological treatments patients may have been treated with.

• One hundred eighty-five consecutive patients with rheumatoid arthritis were followed and diagnosed with atlantoaxial subluxation (AAS), vertical subluxation, and subaxial subluxation.
• The patients were divided into two groups:
• Cervical lesions were confirmed in 57 % of the patients. Prednisolone usage, biological agent usage, and higher rheumatoid arthritis stage were significant risk factors for cervical lesions in patients with rheumatoid arthritis. The general status of osteoporosis might contribute to the development of vertical subluxation. 

References

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