Atlantoaxial joint involvement in rheumatoid arthritis: clinical and imaging features

Objective: to study clinical and imaging characteristics in patients with rheumatoid arthritis (RA) with atlantoaxial joint involvement.

Material and methods. A total of 60 patients with RA were examined; mean age was 53.6±12.4 years. Median DAS28-CRP was 5.1 [4.8; 5.3], and median disease duration was 120 [66; 300] months. Extended clinical assessment included evaluation of neurological status, components of neuropathic pain and central sensitization, quality of life, and the degree of functional impairment. Magnetic resonance imaging (MRI) of the craniovertebral junction (CVJ) was performed with assessment of structural changes and measurement of five craniometric parameters to detect displacement of the CII odontoid process.

Results and discussion. Clinical signs of cervical spine (C-spine) involvement were present in 91.7% of patients: neck and head pain, varying degrees of activity limitation due to neck pain, and neurological manifestations. MRI revealed CVJ changes in 90% (n=54) of patients: structural abnormalities in 81.7% and displacement of the CII odontoid process in 68.3%. The strongest correlations of structural changes were found with the presence of neck pain, low quality-of-life scores (EQ-5D), high RA activity, peripheral joint erosions on radiographs, arterial hypertension, high body mass index, and the absence of systemic manifestations of the disease. Craniometric abnormalities were associated (p<0.05) with older age, concomitant osteoporosis, poorer quality of life, neuropathic pain, features of the RA course (duration, positivity for anti-cyclic citrullinated peptide antibodies, small joint involvement at onset, functional limitations, fewer systemic manifestations), elevated CRP, more advanced radiographic stage, and glucocorticoid use. Long-term therapy with nonsteroidal anti-inflammatory drugs and biologic agents was associated with less pronounced MRI changes (p<0.05).

Conclusion. Based on the study, the risk factors for C-spine involvement in RA patients are neck pain, certain features of the RA course, comorbidity, functional limitations (HAQ), and low quality of life (EQ-5D).

1. Nasonov EL, Karateev DE, Balabanova RM. Rheumatoid arthritis. In: Nasonov EL, Nasonova VA, editors. Rheumatology. National Guide. Moscow: GEOTAR-media; 2008. P. 290-331.

2. Hermann KG, Bollow M. Magnetic resonance imaging of the axial skeleton in rheumatoid disease. Best Pract Res Clin Rheumatol. 2004 Dec; 18(6):881-907. doi: 10.1016/j.berh.2004.06.005.

3. Nguyen HV, Ludwig SC, Silber J, et al. Rheumatoid arthritis of the cervical spine. Spine J. 2004 May-Jun;4(3):329-34. doi: 10.1016/j.spinee.2003.10.006.

4. Drosos AA, Pelechas E, Voulgari PV. Radiological findings of the cervical spine in rheumatoid arthritis: what a rheumatologist should know. Curr Rheumatol Rep. 2020 May 13;22(6):19. doi: 10.1007/s11926-020-00894-8.

5. Di Muzio C, Conforti A, Bruno F, et al. The assessment of atlantoaxial joint involvement in patients with rheumatoid arthritis, results from an observational "real-life" study. Sci Rep. 2023 Nov 17;13(1):20146. doi: 10.1038/s41598-023-46069-0.

6. Gillick JL. Rheumatoid arthritis and the cervical spine: a review on the role of surgery. Global Spine J. 2015 Aug;5(4):324-38.

7. Joaquim AF, Appenzeller S. Cervical spine involvement in rheumatoid arthritis – a systematic review. Autoimmun Rev. 2014 Dec;13(12):1195- 202. doi: 10.1016/j.autrev.2014.08.014.

8. Yurube T, Sumi M, Nishida K, et al. Incidence and aggravation of cervical spine instabilities in rheumatoid arthritis: a prospective minimum 5-year follow-up study of patients initially without cervical involvement. Spine (Phila Pa 1976). 2012 Dec 15;37(26):2136-44. doi: 10.1097/BRS.0b013e31826def1c.

9. Kauppi M, Neva MH. Sensitivity of lateral view cervical spine radiographs taken in the neutral position in atlantoaxial subluxation in rheumatic diseases. Clin Rheumatol. 1998;17(6): 511-4. doi: 10.1007/BF01451289.

10. Boden SD. Rheumatoid arthritis of the cervical spine. Spine (Phila Pa 1976). 1994 Oct 15; 19(20):2275-80. doi: 10.1097/00007632-199410150-00005.

11. Garaeva AR, Lapshina SA, Abdulganieva DI. Clinical and instrumental features of atlantoaxial pathology in rheumatic diseases (literature review). Meditsinskiy alfavit. 2023;(9):35-39. (In Russ.).

12. Dreyer SJ, Boden SD. Natural history of rheumatoid arthritis of the cervical spine. Clin Orthop Relat Res. 1999 Sep:(366):98-106. doi: 10.1097/00003086-199909000-00013.

13. Joyce AA, Williams JN, Shi J, et al. Atlantoaxial pannus in patients with and without rheumatoid arthritis. J Rheumatol. 2019 Nov;46(11): 1431-1437. doi: 10.3899/jrheum.181429.

14. Clinical guidelines for the provision of medical care to patients with rheumatoid arthritis. 2025.

15. Rifbjerg-Madsen S, Christensen AW, Christensen R, et al. Pain and pain mechanisms in patients with inflammatory arthritis: a Danish nationwide cross-sectional DANBIO registry survey. PLoS One. 2017 Jul 7;12(7):e0180014. doi: 10.1371/journal.pone.0180014.

16. Mayer TG, Neblett R, Cohen H, et al. The development and psychometric validation of the Central Sensitization Inventory. Pain Pract. 2012 Apr;12(4):276-85. doi: 10.1111/j.1533-2500.2011.00493.x.

17. Bakhtadze MA, Lusnikova IV, Bolotov DA, Kuzminov KO. Neck Disability Index in patients with cervicogenic headache. Rossiyskiy zhurnal boli. 2021;19(1):25-30. (In Russ.).

18. Kotecki M, Sotniczuk M, Gietka P, et al. Imaging of cervical spine involvement in inflammatory arthropathies: a review. Pol J Radiol. 2021 Nov 20:86:e620-e629. doi: 10.5114/pjr.2021.111363.

19. Nayak A, Thakur V, Patil P. Magnetic resonance imaging features of atlantoaxial osteoarthritis in rheumatic diseases. Eur J Radiol Open. 2019 Jun 18;6:131-7. doi: 10.1016/j.ejro.2019.06.001.

20. Puttlitz CM, Goel VK, Clark CR, et al. Biomechanical rationale for the pathology of rheumatoid arthritis in the craniovertebral junction. Spine (Phila Pa 1976). 2000 Jul 1;25(13):1607- 16. doi: 10.1097/00007632-200007010-00003.

21. Sharma PN, Kothari A, Bhargava S. Fatty degeneration of atlantoaxial joint in rheumatic diseases: MR imaging features. J Neuroradiol. 2018 Mar;45(2):103-8. doi: 10.1016/j.neurorad.2017.12.003.

22. Shi J, Ermann J, Weissman BN, et al. Thinking beyond pannus: a review of retro-odontoid pseudotumor due to rheumatoid and nonrheumatoid etiologies. Skeletal Radiol. 2019 Oct; 48(10):1511-23. doi: 10.1007/s00256-019-03187-z.

23. Subagio EA, Wicaksono P, Faris M, et al. Diagnosis and prevalence (1975-2010) of sudden death due to atlantoaxial subluxation in cervical rheumatoid arthritis: a literature review. ScientificWorldJournal. 2023 Oct 5;2023:6675489. doi: 10.1155/2023/6675489

24. Garaeva AR, Lapshina SA, Anisimov VI, et al. Clinical and instrumental diagnostics of early changes in the atlantoaxial area in ankylosing spondylitis. Prakticheskaya meditsina. 2023; 21(3):68-73. (In Russ.).

25. Na MK, Chun HJ, Bak KH, et al. Risk factors for the development and progression of atlantoaxial subluxation in surgically treated rheumatoid arthritis patients, considering the time interval between rheumatoid arthritis diagnosis and surgery. J Korean Neurosurg Soc. 2016 Nov;59(6):590-6. doi: 10.3340/jkns.2016.59.6.590.

26. Di Muzio C, Conforti A, Bruno F, et al. The assessment of atlantoaxial joint involvement in patients with rheumatoid arthritis: results from an observational real-life study. Sci Rep. 2023 Nov 17;13(1):20146. doi: 10.1038/s41598-023-46069-0.

27. Halla JT, Hardin JG Jr. The spectrum of atlantoaxial facet joint involvement in rheumatoid arthritis. Arthritis Rheum. 1990 Mar;33(3): 325-9. doi: 10.1002/art.1780330304.

28. Sheen JJ, Seo DK, Rhim SC, et al. Hemorrhagic synovial cyst associated with rheumatoid atlantoaxial subluxation. Korean J Spine. 2013 Jun;10(2):85-7. doi: 10.14245/kjs.2013.10.2.85.

29. Noto G, Salvetti F, Demaj A, et al. Pathogenesis of rheumatoid arthritis: one year in review 2025. Clin Exp Rheumatol. 2025 Sep;43(9): 1533-1540. doi: 10.55563/clinexprheumatol/53rkan.

30. Häkkinen A, Makinen H, Ylinen J, et al. Stability of the upper neck during isometric neck exercises in rheumatoid arthritis patients with atlantoaxial disorders. Scand J Rheumatol. 2008 Sep-Oct;37(5):343-7. doi: 10.1080/03009740802007522.

31. Kiefer D, Soltani M, Damirchi P, et al. Prevalence and location of inflammatory and structural lesions in patients with rheumatoid arthritis and radiographic axial spondyloarthritis with chronic neck pain evaluated by magnetic resonance imaging. Arthritis Res Ther. 2024 Jul 25;26(1):138. doi: 10.1186/s13075-024-03377-8.