Rheumatoid Arthritis – C-Spine

Rheumatoid Arthritis – Cervical Spine: Modern Study Review

High-Yield Summary

Rheumatoid arthritis (RA) frequently involves the cervical spine, leading to potentially severe instability and neurologic compromise. The most critical pathologies include atlantoaxial instability (AAI), vertical migration (basilar invagination), and subaxial subluxation. Early recognition and timely surgical intervention are essential to prevent irreversible spinal cord injury and optimize pain relief and function.

Key Diagnostic Findings

Anatomy

• Atlantoaxial joint (C1-C2): Primary site of instability due to transverse and alar ligament involvement.
• Basilar invagination: Upward migration of the odontoid into the foramen magnum causing brainstem compression.
• Subaxial cervical spine (C3-C7): Can develop subluxation and canal stenosis secondary to pannus formation and ligamentous laxity.

Clinical Presentation

• Myelopathy symptoms: Progressive limb weakness, gait disturbance, bowel/bladder dysfunction, incoordination.
• Cranial nerve involvement: Dysphagia, dysphonia, occipital pain, and upper cervical root symptoms.
• Physical exam challenges: Joint deformities complicate motor testing; sensory exam (light touch, pinprick, proprioception, vibration) and cranial nerve assessment (especially CN IX, X, VII, V) are critical.
• Lhermitte’s sign: May indicate cervical cord involvement.

Imaging

– MRI: Essential for assessing spinal cord compression, pannus formation, and soft tissue involvement.

• CT: Useful for detailed bony anatomy, especially preoperative planning for screw placement.

Classification Systems

• No universally accepted RA-specific cervical spine classification; however, instability is often described by the degree of AADI and presence of vertical migration or subaxial subluxation.
• Modern imaging-based criteria guide surgical indications rather than rigid classification schemes.

Current Gold Standard Treatment

Non-operative

• Indications: Mild or asymptomatic instability without neurologic deficits or cord compression.
• Management:
• Optimize RA medical therapy with rheumatology collaboration.
• Close clinical and radiographic monitoring.
• Cervical immobilization may be considered but has limited efficacy in preventing progression.

Operative

• Indications:
• Neurologic deficits or myelopathy.
• PADI ?13 mm with cord compression on MRI.
• Basilar invagination with cord compression.
• Atlantoaxial instability with AADI >7 mm and symptoms.
• Subaxial subluxation causing stenosis and neurologic symptoms.

• Surgical options:
• Posterior cervical fusion (C1-C2 or occipitocervical fusion) for atlantoaxial instability and basilar invagination.
• Decompression with fusion for subaxial stenosis.
• Preoperative CT and MRI essential for planning screw trajectories and assessing anatomy.

• Perioperative considerations:
• Multidisciplinary approach with rheumatology and anesthesia.
• Immunosuppressants (methotrexate, biologics): No consensus on stopping; individualized risk-benefit analysis.
• Steroid supplementation perioperatively to prevent adrenal insufficiency.
• NSAIDs stopped 5-7 days pre-op to reduce bleeding risk.

Modern Complications & Outcomes

Complications

Outcomes

• Surgical stabilization improves pain, neurologic function, and quality of life when performed timely.
• Delay in treatment correlates with worse neurologic outcomes.
• Long-term follow-up is essential due to progressive nature of RA and risk of adjacent segment disease.

Classic Clinical Notes

Approach to the Rheumatoid C-Spine

In Summary – Need to think of three things: vertical migration, atlantoaxial, and subaxial instability

• AADI on X-ray of greater than 3 mm is abnormal. 7 mm signifies complete transverse ligament rupture. 10 mm signifies complete transverse ligament and alar ligament insufficiency.
• PADI on X-ray of 14 mm or less warrants MRI investigation. PADI on MRI of 13 mm, cervicomedullary angle of 135 or less, and cord diameter of less than 6 warrants fusion.
• Basilar invagination is bad in general, and should be fused and/or decompressed if you can demonstrate cord compression.
• Subaxial canal diameter on X-ray of 14 mm or less warrants MRI. PADI on MRI of 13 mm warrants decompression and fusion if cord is being compressed.

The History:

• Look for symptoms of myelopathy: bowel/bladder, progressive weakness of L/E or U/E, incoordination, gait changes, unsteadiness
• Look for cranial nerve and upper root problems: dysphagia, dysphonia, trouble swallowing, pain in occiput

The Physical:

• Often very difficult to sort out motor function because of disease in joints
• Lhermitte’s, range of motion, pain, numbness in occiput
• Neurologic assessment is often based primarily on the sensory exam because everything else is difficult to assess.
• Light touch, pinprick, proprioception and vibration
• Cranial nerve exam – particularly IX, X, VII, V

X-rays: measure the PADI, assess for VMO and subaxial instability
Get an MRI and CT particularly in upper C-spine if contemplating transarticular screws

Then, the pre-op assessment:

• Needs bloodwork: CBC, lytes, BUN, Crt, glucose, type and screen, INR, PTT, CXR, ECG
• Needs to have rheumatologist maximize medical therapy
• Needs to have preop anesthesia consult for awake intubation
• Need to be prepared for particular medications
• Methotrexate and other immunosuppressants: stop at least a few weeks in advance? Controversial. No good studies indicate that these should be stopped. Depending on your philosophy, the risk of an acute flare probably outweighs the risk of wound infection or healing.
• Steroids: need to cover her perioperatively; 100 mg hydrocortisone before surgery, second 100 mg intraoperatively, followed by 100 mg IV q8h for 24 hours, 50 mg q8h the next day, and a single dose of 100 mg IV on the third day. For minor surgical procedures, can give them a single preoperative dose of 100 mg hydrocortisone.
• NSAIDs: need to make sure that they’re off for 5-7 days.

Last Updated on January 25, 2026 by orthonet