Rheumatoid Arthritis of the Cervical Spine

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When you wake up to stiff joints compliments of rheumatoid arthritis (RA), one becomes gallingly aware of each place the body bends—knuckle, knee, wrist and ankle—but when the stiffness affects the atlantoaxial and atlanto-occipital joints in your upper neck, the cervical spine, the disease can turn dangerous. These joints, which pivot your head to look up, down, right and left, share neck space with the spinal cord and lie just below the brain stem. It is important to seek quick treatment to prevent swelling in this area and damage to these joints.

neck, cervical spine, posterior and later viewsRheumatoid arthritis can affect the neck joints causing stiffness and pain when moving your head up, down and/or side to side. Photo Source: 123RF.com. Understanding your rheumatoid arthritis diagnosis and treatment options can help you comprehend your doctor’s game plans. Gaining knowledge about what can be done to manage the disease can also dissolve feelings of depression or isolation.

Patients who fare best make peace with the fact that RA is a lifelong condition that will alternately flare up and go into remission, says Wendy Chi, MD, Assistant Professor of Medicine in the Division of Rheumatology at Mount Sinai in New York City.

“I would say the most important thing to recognize is that this is a chronic condition that can wax and wane. If you were just diagnosed, don’t be discouraged if the first treatment doesn’t work for you. Don’t feel like you are going to be in this amount of pain or discomfort forever. There are options to treat it and more things in development.”

How can rheumatoid arthritis affect the cervical spine?

Rheumatoid arthritis is a chronic, systemic, autoimmune disease in which the immune system, which is designed to attack foreign bodies like bacteria and viruses, mistakenly attacks other healthy areas of the body, including the spine’s facet joints and even organ systems. Untreated, attacked joints can become deformed and lose their mobility.

When it comes to spine pain, a rheumatoid arthritis diagnosis is limited to the cervical spine. People can have problems, such as facet joint arthritis, further down the spine, but this is likely not due to RA. It is possible to have both osteoarthritis and rheumatoid arthritis at the same time.

If you have RA, you are part of a group of 1.3 million other Americans who have the disease.1 The disease causes morning joint stiffness that can last one to two hours or the whole day. It generally improves with movement of the joints. Other signs and symptoms include loss of energy, low fevers, loss of appetite, and lumps in the elbows and hands, called rheumatoid nodules. About 75% of RA patients are women, but cervical spine involvement is more common in male patients and those with a positive rheumatoid factor.

When rheumatoid arthritis loosens ligaments, erodes bone or causes thickened tissue around the atlantoaxial joint, it can compress the spinal cord and brain stem, which can lead to paralysis or even death if the neck is moved in certain positions. Fortunately, there are many treatments to avoid these outcomes.

anatomical illustration of the cervical spineDetailed illustration of the cervical spine's structures including the atlantoaxial and atlanto-occipital levels. Photo Source: Shutterstock. com.

Cervical RA Diagnosis is Complicated

Doctors may test to see if you have rheumatoid arthritis of the cervical spine by first performing a physical exam. Flexion, extension, and right and left lateral neck movements may be limited and painful if the atlantoaxial joint is involved.

When initially diagnosing rheumatoid arthritis, doctors may take blood as well, looking for C-reactive protein, rheumatoid factor, anti-citrullinated protein antibodies, antinuclear antibodies, and an elevated erythrocyte sedimentation rate. However, all this blood work could come back negative and a rheumatoid arthritis diagnosis might still be made. Key questions and a careful exam remain crucial. “It’s a field where we still rely on a good history and physical to help make the diagnosis,” Dr. Chi said. “Up to 20% of patients can have RA and be seronegative.”

To determine joint damage, images may be taken with x-rays, CT scan or MRI. As well, scans will tell if the bones have shifted, as in atlantoaxial subluxation and odontoid migration, or if the neck joints or bones have odd tissue growth projecting from them, as in odontoid pannus. Pannus is Latin for garment and refers to tissue growth that coats a normal body structure. In RA, any kind of rheumatoid pannus tissue damages the joint it cloaks. The pannus releases enzymes that degrade cartilage, discharges acids and proteins that damage bone and produces excess fluid that causes swelling and pain. Pannus in the cervical spine can also destruct the neck’s transverse, apical and alar ligaments.

Rheumatoid Arthritis Medication Treatment Goals

Pinpointing how to subdue an overactive immune system has stumped doctors for decades. Seventy-five years ago, one of the only rheumatoid arthritis treatments for patients was a weekly injection of gold into the gluteal muscle. Today, there are a plethora of treatment options.

“Current treatments give most patients good or excellent relief of symptoms and let them keep functioning at or near normal levels,” reports the website of the American College of Rheumatology.2

Since there is no cure for the disease, the aim of treatment is to reduce pain and halt joint breakdown. “The goal is to not only control symptoms, but to prevent further damage and deformities,” Dr. Chi said.

Many rheumatoid arthritis treatment drugs fall into a bucket labeled disease modifying antirheumatic drugs (DMARDs). While most patients receive some form of a DMARD, no single drug is a guaranteed solution as patients react to the drugs differently. Scientists designed some of the drugs to fight against certain immune cells, while other drugs reduce immune mediators or block immune cell functions. Patients may be treated with a DMARD in combination with nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose corticosteroids, which reduce swelling and pain.

Common first line DMARDs include methotrexate, leflunomide, hydroxychloroquine and sulfasalazine.

Rarely still prescribed are certain antibiotics (minocycline), other immunosuppressive medications sometimes used as anti-rejection medications for transplants (azathioprine and cyclosporine), and the aforementioned metal gold. Of note, new research is considering gold implants as gold ions have been shown to reduce production of pro-inflammatory cytokines in cell culture.

If first line medications don’t work, rheumatologists can pull out a list of second line medications called biologic response modifiers or “biologics.”

“These are the ones advertised on TV all the time,” Dr. Chi stated. While the brand names are used in the commercials, the generic names for 10 common biologics are: Abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, sarilumab and tocilizumab. Two Janus kinase inhibitors (JAKs)—tofacitnib or barcitinib may also be used. Often, the above drugs are taken in combination with methotrexate.

Your doctor may pick a less potent drug first because medically suppressing the immune system too drastically can cause it to stop fighting off actual infections. When on any immunosuppressant, it is important to practice good hand hygiene and avoid contagious people, Dr. Chi said.

The good news is that there are drugs in development that target ever more specific parts of the immune system. For example, a Janus kinase inhibitor may nonspecifically inhibit all of the JAK cytokines. “Now in trials are ones that target JAK 1and JAK 2 specifically,” Dr. Chi said.

RA Medicines and Manipulating the Gut Microbiome

One reason that a medicine may work for one patient and not another may have to do with what bacteria make up each individual’s gut microbiome, according to researchers at New York University’s Microbiome Center for Rheumatology and Autoimmunity. For example, certain bacteria help patients with RA to convert dietary fibers into short-chain fatty acids that team with regulatory T-cells to suppress the inflammatory response. However, other bacteria hinder drug absorption. For example, a recent study found that certain bacteria metabolize methotrexate so quickly that the body can’t absorb the drug for itself. Figuring out the commonalities of the gut microbiomes of drug non-responders as well as analyzing the intestinal dysbiosis (eg, stomach upset) of patients experiencing flares helps researchers figure out how they can manipulate the microbiome as a treatment.

What is the role of diet in rheumatoid arthritis treatment?

Patients can also control their own gut microbiome by altering their diets. Because there is not enough hard data and because different individuals react differently to a given food, the American College of Rheumatology doesn’t promote any diet, Dr. Chi said, other than a heart healthy diet, due to the damage rheumatoid arthritis can wreak on the body’s cardiovascular system. In general, Omega 3 fatty acids that are found in fatty fish like salmon are thought to have anti-inflammatory effects, and there is plenty of anecdotal evidence for turmeric, vegan diets, and eliminating fast food, processed food, dairy or gluten.

Dr. Chi stated that while she doesn’t recommend any diet, she doesn’t deter her patients from experimenting with diets and supplements as long as patients get the nutrients they need. “I don’t discourage patients from trying different kinds of diets. And people ask me about supplements all the time. As long as it’s from a reputable source and not potentially tainted with something, it’s fine to try,” she said. However, it should be noted that supplements are not regulated by the FDA or any other governing body, so safety cannot be guaranteed.

Other Rheumatoid Arthritis Treatment Options

Patients can also relieve joint stiffness with low impact exercises like swimming, walking or cycling, Dr. Chi said. “I generally prefer low impact,” Dr. Chi stated. “The more force you apply to the joints, the more damage you could do to the cartilage.”

Spinal surgery may be a treatment as well. The most important indications for cervical spine surgery when rheumatoid arthritis is involved are resistant pain, neurologic deficits and/or a need to stabilize the upper cervical spine (eg, atlantoaxial joint) to prevent spinal cord damage.

Updated on: 10/23/19
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Acquired Upper Cervical Disorders and Your Spine
Wei Wei (Wendy) Chi, MD
Assistant Professor of Medicine
Division of Rheumatology
Icahn School of Medicine at Mount Sinai
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