By Carol Eustice 

 Medically reviewed by Anita C. Chandrasekaran, MD

When rheumatoid arthritis (RA) affects your spine, it can cause neck pain, back pain, and radiculopathy (pain that radiates to the legs or arms) due to compression of your nerve roots or nerves within the spinal cord.1 RA is more common in the cervical and lumbar areas of the spine.

Some complications of RA in the spine include compression and spondylolisthesis, both of which can cause pain, as well as difficulty walking, balance issues, and problems controlling your bowels and bladder.

In this article, learn about how RA affects the spine, the symptoms of complications, and how RA of the spine is diagnosed and treated.

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Common Symptoms

The most common symptoms of RA in the spine (as with other joints) include:

• Pain and stiffness

• Joint inflammation

• Warm joints

• Loss of flexibility and mobility

It's more common for RA to impact the cervical spine (neck region) than the lumbar spine or sacroiliac joints in the lower back.2

RA in the Cervical Spine

The cervical spine is the segment of the spinal cord in your neck and consists of seven vertebrae (C1-C7). In addition to impacting your joints, RA can cause your ligaments, which connect bones to other bones, to become lax. When that happens to the ligaments supporting the first and second cervical vertebrae (C1 and C2), it can lead to instability, subluxations (partial dislocations), and possibly spinal cord compression.

Symptoms of cervical RA involvement include:

• Headaches at the base of the skull

• Pain that radiates down your arms (cervical radiculopathy)

• Weakness and tingling in the arms, hands, and fingers

• Popping and cracking when you move your neck (crepitus)

Your healthcare provider will likely evaluate your cervical region often to look for early signs of instability.

RA in the Lumbar Spine

The lumbar spine, the area of your lower back that curves inward, can be affected by RA, although it is less common. It can result in impingement or inflammation of the nerves coming from your spinal cord. Facet joints, which limit the twisting movement of the spine, may be involved as well.3

Symptoms can impact the lower back, buttocks, hips, and legs, including:3

• Pain

• Stiffness

• Abnormal nerve sensations (e.g., tingling)

• Muscle cramping

• Feelings of weakness and heaviness

• Pain that radiates down your legs (lumbar radiculopathy)

• Stiffness in the lower back

• Symptoms that are more severe when standing or walking and relieved by sitting or leaning forward

Because fewer than half of people with RA have lower back involvement, your healthcare provider will likely check for other possible causes of these symptoms, such as vertebral compression fractures.3

Complications

Some of the more common complications of RA in the spine include compression and spondylolisthesis. While the causes of each are different, the symptoms are similar and include problems with balance, difficulty controlling your bowels and bladder, and changes to your reflexes.

Compression

In progressive forms of the disease, joint deterioration can lead to compression (pinching) of the spinal cord or spinal nerve roots.

Common symptoms of compression include:4

• Difficulty walking, a sign of increased pressure on the spinal cord

• Changes to balance and coordination, which may be signs of spinal cord involvement

• Bowel or bladder control problems (e.g., incontinence, inability to urinate, or inability to control the bowels), which may indicate spinal cord involvement

• Hyperreflexia (over-responsive reflexes)2

If you lose control of your bowels or bladder, get immediate medical attention.

Spondylolisthesis

In some cases, rheumatoid arthritis damages the facet joints in the spine that keep the spine from twisting too far. When that happens, a condition known as spondylolisthesis may develop.5

With spondylolisthesis, an upper vertebra slides forward onto the top of the one beneath it, where it can put extra pressure on the spinal cord or the nerve roots where they exit the spine. This may cause the same symptoms related to compression.

Diagnosis of Rheumatoid Arthritis in the Spine

A careful history of symptoms and overall health is a vital first step in the diagnostic process for spinal RA. If your healthcare provider suspects RA, they will likely order blood tests and imaging.

Physical Exam

One of the most important parts of diagnosing RA is doing a physical exam. A healthcare provider will check reflexes, ask about pain, and watch you perform regular activities such as walking, bending over, sitting, and standing to assess your range of movement. Depending on the physical exam results, a healthcare provider might order lab tests and/or imaging studies.

Lab Tests

Several different blood tests can help your healthcare provider understand if you have signs of inflammation that might suggest RA. However, there is no single, definitive test for RA, so the results of this blood work must be considered in addition to your medical history, physical exam, and imaging results. Some tests that might be run include:6

• Rheumatoid Factor: Some people with RA will have elevated levels of a rheumatoid factor antibody. However, not everyone will, and some people will have elevated levels even if they don't have RA.

• Anti-cyclic citrullinated peptide antibody (anti-CCP): This antibody can be elevated in RA patients. Some people show elevated anti-CCP levels before other symptoms of RA, so it can be helpful in early diagnosis.

• C-reactive protein: This test is a marker of increased inflammation, common in RA. Other autoimmune conditions can also cause raised levels of C-reactive protein.

• Erythrocyte sedimentation rate: You might hear this called the "sed rate." It measures inflammation and can be a helpful tool in measuring a person's response to treatment and initial diagnosis.

Imaging

• X-ray: Standard X-rays are a very useful tool for clinicians diagnosing RA. It can show bone degradation from RA. It is less helpful in providing information about inflammation.7

• Magnetic Resonance Imaging (MRI): MRI can show more soft tissue damage and inflammation and potentially help make an earlier diagnosis.7

• Ultrasound: Ultrasound can diagnose many forms of RA, although it is usually more effective in diagnosing RA in the extremities.7

Treatment of Rheumatoid Arthritis of the Spine

Medication

Medications can help treat the pain caused by spinal RA and also help reduce inflammation. Options include:

• Pain relievers: Over-the-counter medications like Tylenol and NSAIDs like ibuprofen and naproxen can help relieve the pain associated with spinal RA. Other NSAIDs require a prescription, such as Celebrex (celecoxib).

• Steroids: Steroids can be given to reduce the inflammation caused by RA. They can be either oral steroids or corticosteroidal injections.

• Disease-modifying antirheumatic drugs (DMARDs): There are different categories of DMARDs, including conventional DMARDs (most notably methotrexate), biologics (such as Humira or Remicade), and Janus kinase (JAK) inhibitors (such as Xeljanz and Rinvoq).

Therapies

Various therapies can help manage the symptoms of spinal RA and help you continue to perform your daily living tasks, including:

• Physical Therapy (PT): Physical therapy helps build muscle strength that can help support areas affected by RA.8

• Occupational Therapy (OT): OT focuses on maintaining the ability to perform everyday tasks optimally.

• Cold/Heat Therapy: Heating pads or hot packs can help ease stiffness and enhance overall mobility. Conversely, ice packs or cold plunges can help with inflammation and pain.9

Other alternative therapies like acupuncture, massage, supplements, meditation, and others have less data to back their use but might offer some benefit. Speak to a healthcare professional before starting supplements or other alternative therapies to make sure it is safe for you.

Surgery

Less invasive therapies are almost always tried before surgery is recommended. If other therapies fail, however, surgery might be an option. The surgical approaches for RA in the spine include:10

• Vertebral Fusion: Spinal fusion surgery involves connecting two or more vertebrae, preventing movement between them. Bone grafts are placed between vertebrae and plates, and screws might hold it all together while it heals. This is more common in cervical spine RA.

• Laminectomy: In a laminectomy, all or part of the vertebrae is removed. This is more common in lumbar spine RA and can help when compression occurs.

Summary

Common symptoms of rheumatoid arthritis affecting the spine include pain, stiffness, inflammation, warm joints, and loss of flexibility. RA often impacts the cervical spine more than the lumbar region. Diagnosis involves a careful history, physical examination, blood tests, and imaging. Treatment options include medications, therapies, and surgery. If you have pain that you think could be related to rheumatoid arthritis, see a healthcare provider for evaluation.

Sources

Gillick JL, Wainwright J, Das K. Rheumatoid arthritis and the cervical spine: a review on the role of surgery. Int J Rheumatol. 2015;2015:252456. doi:10.1155/2015/252456

Gillick J, Wainwright J, Das K. Rheumatoid arthritis and the cervical spine: A review on the role of surgery. Int J Rheumatol. 2015;2015:1-12. doi:10.1155/2015/252456

Joo P, Ge L, Mesfin A. Surgical management of the lumbar spine in rheumatoid arthritis. Global Spine J. 2019:219256821988626. doi:10.1177/2192568219886267

The Spine Hospital at The Neurological Institute of New York. Rheumatoid arthritis.

Hagege B, Tubach F, Alfaiate T, Forien M, Dieudé P, Ottaviani S. Increased rate of lumbar spondylolisthesis in rheumatoid arthritis: A case-control study. Eur J Clin Invest. 2018;48(9):e12991. doi:10.1111/eci.12991

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Rheumatoid Arthritis: Diagnosis, Treatment, and Steps to Take.

Sudoł-Szopińska I, Jans L, Teh J. Rheumatoid arthritis: what do MRI and ultrasound show. J Ultrason. 2017;17(68):5-16. doi:10.15557/JoU.2017.0001

Johns Hopkins Arthritis Center. Rehabilitation management for rheumatoid arthritis patients.

Johns Hopkins Arthritis Center. Rheumatoid arthritis: complementary and alternative medicine options.

Joo P, Ge L, Mesfin A. Surgical management of the lumbar spine in rheumatoid arthritis. Global Spine J. 2020;10(6):767-774. doi:10.1177/2192568219886267

Additional Reading

Arthritis Foundation. When back pain may mean arthritis.

UpToDate. Cervical subluxation in rheumatoid arthritis. Updated March 2020.

UpToDate. Clinical manifestations of rheumatoid arthritis. Updated March 2020.

By Carol Eustice
Carol Eustice is a writer covering arthritis and chronic illness, who herself has been diagnosed with both rheumatoid arthritis and osteoarthritis.