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Cervical spine manifestations in patients with inflammatory arthritides

Nature Reviews Rheumatology volume 9, pages 423–432 (2013)Cite this article

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Abstract

The cervical spine can frequently become involved in patients with rheumatologic disorders, as a result of either the rheumatologic disease itself or age-associated degenerative processes that can also occur in the rest of the population. Awareness of the increased risk of cervical spine manifestations in patients with rheumatologic disorders enables early recognition and initiation of the appropriate treatment regimen. For example, patients with rheumatoid arthritis (RA) often have spinal instability which, if left untreated, can lead to neurological deficits. Biologic agents are effective in slowing the progression of the skeletal abnormality as well as for treating the RA, and this approach is often sufficient. However, early surgical intervention is recommended for patients with RA who develop neurologic deficits, as conservative approaches have limited effectiveness in this group. Spinal stability should be the primary surgical objective. For patients with ankylosing spondylitis, cervical spine surgery might be required either for fracture repair or to correct severe kyphosis. Understanding each condition's specific cervical spine manifestation and its natural history can help to clarify the appropriate indications for and timing of surgery to maximize patients' outcomes and limit complications.

Key Points

  • The three most common cervical spine manifestations of rheumatoid arthritis (RA) are atlantoaxial instability, subaxial instability and basilar invagination

  • Cervical spine conditions can clinically manifest as any combination of axial neck pain, radiculopathy and/or myelopathy

  • In carefully selected patients with RA with clear indications for surgery, surgical treatment is safe and can preserve, and in some cases improve, neurologic status

  • The possibility of an unstable spine injury should be considered for patients with ankylosing spondylitis who have any trauma to their cervical spine

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Figure 1: Anatomy of the cervical spine.
Figure 2: Important radiographic measurements for assessment of basilar invagination measuring the relative position of the skull and C1.
Figure 3: Sagittal MRI of the cervical spine showing basilar invagination.
Figure 4: Radiographic images of surgically treated cervical spine manifestations of inflammatory arthritides.
Figure 5: Surgical correction of severe cervical kyphosis in a patient with ankylosing spondylitis.

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Author information

Authors and Affiliations

  1. Spine Division, Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 3800, Boston, 02114, MA, USA

    Thomas D. Cha

  2. Spine Division, Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, MOR Building Suite 100, Chicago, 60612, IL, USA

    Howard S. An

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Contributions

T. Cha researched the data for the article. T. Cha and H. An contributed equally to discussions of its content, writing the article, reviewing and editing the manuscript before submission.

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Correspondence to Thomas D. Cha.

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Competing interests

T. Cha declares that he has received institutional fellowship support from AOSpine, Globus Medical, Orthopedic Medical Grants Association and Orthopedic Research Education Foundation. H. S. An declares that he has received institutional fellowship support from the Orthopedic Research Education Foundation and Synthes, holds stock in U&I, Articular Engineering and Annulex, and has acted as a paid consultant to Advanced Biologics, Life Spine, Pioneer Surgical Technology, Smith & Nephew and Zimmer Spine.

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Cha, T., An, H. Cervical spine manifestations in patients with inflammatory arthritides. Nat Rev Rheumatol 9, 423–432 (2013). https://doi.org/10.1038/nrrheum.2013.40

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