Risk factors for cervical spine instability in patients with rheumatoid arthritis



Cervical spine (C-spine) instability is a unique and significant characteristic of rheumatoid arthritis (RA) because its occurrence is not rare and it can cause compressive cervical myelopathy, which may lead to serious neurologic sequelae. This study evaluated the prevalence and risk factors of C-spine instabilities in RA patients with a focus on anti-citrullinated protein antibody (ACPA) and biologic disease-modifying antirheumatic drug (DMARD) therapies.


The presence of C-spine instabilities in 1114 patients with RA was evaluated using C-spine radiographies according to the defined metrics. Multivariable logistic regression analyses were performed to identify independent predictors of C-spine instability. The initiation of biologic DMARDs was assessed via a Kaplan–Meier analysis and compared using log-rank tests.


In total, 306 (27.5%) patients presented with C-spine instabilities. The most common type was atlantoaxial subluxation (AAS; n = 199 [17.9%]). Male sex, positivity for rheumatoid factor and ACPA, erosive change in the peripheral joints, and presence of osteoporosis were independently associated with C-spine instabilities (all P < 0.05). In particular, positivity for ACPA was the most powerful risk factor (odds ratio: 2.33 [95% confidence interval: 1.37, 3.96], P = 0.002), and it was closely associated with AAS. Patients with AAS were at a higher risk for early initiation of biologic DMARDs.


Positivity for ACPA was a significant risk factor for C-spine instability, and AAS was remarkably correlated to the early initiation of biologic DMARDs, a surrogate index of poor long-term outcomes.

Key Points
The presence of antibodies against citrullinated proteins was a strong risk factor for C-spine instability in patients with rheumatoid arthritis.
Atlantoaxial subluxation was significantly associated with early initiation of biologic DMARDs, a surrogate index of poor long-term outcome.

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Correspondence to Ki-Jo Kim.

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The study was conducted in accordance with the Helsinki Declaration and approved by the Institutional Review Board of St. Vincent’s Hospital, the Catholic University of Korea (No. VC20RISI0068).

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Baek, I., Joo, Y.B., Park, K. et al. Risk factors for cervical spine instability in patients with rheumatoid arthritis. Clin Rheumatol (2020). https://doi.org/10.1007/s10067-020-05243-9

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  • Anti-citrullinated proteins antibody
  • Atlantoaxial subluxation
  • Cervical spine instability
  • Rheumatoid arthritis