Rheumatoid arthritis (RA) is a disease that affects all of the synovial joints in the body, including the spine. The destruction caused by RA can affect different regions of your spine. For the patient with RA, the effects of arthritis on the spine can vary from minimal symptoms to life threatening pressure on the spinal cord that requires complex surgery to stabilize the spine and reduce the pressure on the spinal cord.
RA is a disease that causes destruction of synovial joints. The problems that arise in the spine are primarily due to this destruction of the synovial joints. As the joints are destroyed, the connection between each vertebra becomes unstable. The upper vertebra is able to slide forward on top of the one below. This slippage is called spondylolisthesis. This sliding can lead to pressure on the nerve roots and the spinal cord. This problem of instability is most dramatic between the C1 and C2 vertebrae in the cervical spine.
RA in the spine causes a wide range of symptoms. Pain is the earliest symptom and may be part of the overall joint inflammation that occurs with the arthritis. As the disease progresses, the symptoms that are most worrisome are those that suggest your spinal cord is being affected.
Pain at the base of the skullis common when the cervical spine is affected by RA, and can indicate that the nerves that exit the skull and the upper spine are being irritated or compressed. Pressure on the vertebral arteries can lead to blackout spells when the blood flow through these arteries is reduced when you move your head and neck a certain way.
A change in the ability to walk can signal increasing pressure on your spinal cord. Your gait (the way you walk) may become irregular, and may be accompanied by weakness and problems keeping your balance. This is an indication that your spinal cord is being compressed. Any change in the ability to walk should be brought to the attention of your doctor. Feelings of tingling, weakness, or a loss of coordination can affect your arms or legs. Changes in bowel or bladder control, such as incontinence or inability to urinate, can also occur.
The diagnosis of RA in the spine begins with a thorough history and physical examination. You doctor will want to know about changes in your ability to walk and get around, especially if this has gotten worse rapidly. Changes in your bowel or bladder function are also important. Any neurological symptoms that have changed such as weakness, numbness, or loss of fine motor skills are important.
An important part of evaluating your spine includes X-ray. This may include special X-rays where you are asked to bend your spine in different directions. These are called flexion and extension X-rays and can show how much instability is present between the vertebrae of the spine.
The MRI scan is the most important test for showing the nerves and soft tissues of your spine. This test uses magnetic waves to create slices through your spine. Using this test, the degree of compression on your spinal cord can be assessed more accurately than with X-rays alone.
Finally, special electrical tests may be ordered by your doctor and performed by a neurologist. These tests are useful to determine how your spinal cord is functioning.
The primary conservative treatment for RA in the spine begins with good medical control of the rheumatoid arthritis. This treatment is normally managed by a specialist in rheumatology. Within the past several years, there have been significant advances in the development of new medications that can control the destructive effects of RA on the joints. Your rheumatologist will manage these medications.
Once there is evidence that RA has affected the stability of your spine, the most important part of spine care is close follow up. X-rays may be needed from time to time to assess the degree of instability and follow the progression of the disease. Mild instability with no evidence that the instability is causing any pressure on your nerves or spinal cord may not require any additional treatment. Patients with X-ray signs of instability may need to protect their spine with a special brace. This is mainly to prevent damage to the spinal cord should a spine injury occur.
When signs of pressure on your spinal cord become apparent, many doctors feel that surgical stabilization should be considered. The goal of surgery is to stabilize the unstable portion of your spine, to remove pressure from your spinal cord, and to relieve the pain caused by the underlying instability.
The process by which two or more vertebrae are stabilized is called spinal fusion. When a spinal fusion is performed, the movement in your spine is reduced. For example, surgery that joins C1 and C2 together in your cervical spine reduces neck rotation up to 50 percent. Some spinal fusion approaches stop all forward and backward motion between the fused vertebrae.
The decision when to operate should be made based on your symptoms, your expectations, and your overall medical condition. These operations are extremely complex and carry significant risks that need to be taken into consideration.