Rheumatoid Arthritis Can Involve The Neck And Be More Than Just Neck Pain
Involvement in rheumatoid arthritis is usually located in the neck where erosive or destructive changes are predominantly seen in the upper portion of the neck called the atlanto-axial region of the cervical spine. Inflamed and thickened tissue around the joints called synovium and seen as pannus can cause bone erosion and destruction of surrounding ligaments. Most seriously if the posterior transverse ligament is involved, loosening or laxity and even rupture of the transverse ligament causes clinical instability with a potential risk of spinal cord injury.
As rhematoid arthritis of the neck destroys the joints, the connection between each vertebra becomes unstable. This may cause the upper neck bone to slide forward on top of the one below, which is called a spondylolisthesis. Increases in this instability may cause pressure on the spinal cord in addition to the nerves.
Rheumatoid arthritis involvement is a progressive and serious condition with reduced lifetime expectancy, and its diagnosis is therefore very important.
The most common symptom in patients with rheumatoid arthritis of the neck is neck pain, but with this condition, there is a risk and potential of serious complications, such as neurological deficits, myelopathy, paralysis and even sudden death. Serious progression of the rheumatoid arthritis is a well-known development when cervical spine deformity is left untreated. Long-term follow-up studies have revealed radiological (x-ray) signs of worsening of the cervical spine deformities in up to 40% of patients. In those patients suffering from rheumatoid arthritis with medication, refractory neck pain or neck pain that does not respond to treatment, neurological deficits and myelopathy, surgical decompression and stabilization constitute the most common therapy.
The symptoms of rheumatoid arthritis in the neck can be varied. Pain is may be part of the joint inflammation that occurs with arthritis. As the disease progresses, symptoms may affect the spinal cord. Pain at the base of the skull is common as nerves that exit the skull and the upper part of the neck are being irritated or compressed. Pressure on blood vessels can lead to blackout spells and may coincide with certain movements of the head and neck.
A change in walking ability can indicate pressure on the spinal cord and should be brought to the attention of your health care professional. Tingling, weakness, or a loss of coordination can affect the arms and/or legs. Changes in bowel or bladder control can also occur.
Treatment of neck problems associated with rheumatoid arthritis is normally managed by a specialist in rheumatology medications that can control the destructive effects of the arthritis on the joints in the neck. Once there is evidence that the rheumatoid arthritis has affected the stability of the neck, the doctor can assess the degree of instability and follow the progression of the disease. With a mild level of instability and no evidence of pressure on the nerves or spinal cord, additional treatment may not be necessary. If there are x-ray signs of instability protection of the neck with a neck brace may be needed, especially when riding in a car to prevent damage to the spinal cord should an injury like whiplash occur. This, along with the car seat head support may afford some protection.
Rheumatoid artritis of the neck is a chronic inflammatory disorder of joints. It is characterised by an erosive inflammation of the joints termed synovitis. This synovial inflammation can lead to joint erosions and erosions of ligaments. The neck requires joint and ligament tissue integrity for stability. Damage to these ligaments and joints can cause different types of instability. X-ray involvement of the neck can be present in up to 86% of all rheumatoid arthritis patients. The clinical instability can be associated with neck pain and/or it can be associated with compression of surrounding structures, particularly the brainstem due to involvement of the upper part of the neck, the spinal cord, or spinal nerve roots which lead to a pinched nerve type of symptoms.
Damage to the bone of the first neck bone can lead to bone loss and upward movement through the base of the skull, which is termed basilar invagination and can cause brainstem compression. The most common instability is the forward movement of the first neck bone over the second, called a subluxation of C1 on C2. This can cause nerve pain and/or a myelopathy. The lower part of the neck can be affected and this can cause a cervical radiculopathy or myelopathy. Instability at multiple levels produces what is called stair stepping or a stepladder deformity. Instability is most commonly found in patients who have had rheumatoid arthritis for ten years or longer and many patients do not have any symptoms over an extended period of time.
Neck pain may be a consequence of the primary inflammatory disorder. Neck pain is a potential consequence of the lower neck involvement and resulting instability. It can be difficult to distinguish between upper and lower neck causes of pain. If a rheumatoid arthritis patient has a severe neck pain, if neck pain tends to occur at a time when lower joint disease is severe, and if it waxes and wanes with a similar pattern to lower joint disease, it is usually considered that, probably, neck pain is a consequence of the primary rheumatoid disorder. Where neck pain is severe but the lower joint problems are mild then it is more likely that upper part is the cause of neck pain. The localization of neck pain in patients with rheumatoid arthritis is as difficult as it is in all patients with neck pain.
Myelopathy is common and patients present with the classical symptoms of gait disturbance, loss of fine motor control in the hands, numbness in the hands, and balance disturbance. It is held by some that it can be difficult to differentiate myelopathic problems in the hands from the problems that are a consequence of joint disease. Brainstem compression is less common and this can produce facial sensory disturbance, dysphagia – problems with swallowing, or other abnormalities. Sudden death is reported, but it is rare.
Rheumatoid arthritis of the neck are common, especially the less severe cases of rheumatoid arthritis, that only a small percentage of patients need an operation. These less severe disorders should not be neglected because they may progress and increase the risk of complication; patients should receive conservative neck pain treatment to help them to live with these abnormalities. Surgery is needed in severe and non-responsive cases, and should be carried out before permanent neurological damage has developed.