Rheumatoid Arthritis in the Cervical Spine: An Updated Review of Epidemiology, Imaging, and Surgical Indications.

Background: Rheumatoid cervical spondylitis (RCS) is a potentially devastating manifestation of rheumatoid arthritis (RA), typically presenting as atlantoaxial instability, basilar invagination, and/or subaxial subluxation. Despite modern disease-modifying antirheumatic drugs and biologics, established cervical instability often progresses and may result in myelopathy, brainstem compression, vertebrobasilar insufficiency, or sudden death. Many patients remain minimally symptomatic until late, emphasizing the need for structured surveillance and timely surgical referral. This review aimed to synthesize contemporary evidence on the epidemiology, imaging evaluation, risk stratification, and management of RCS and outline a pragmatic screening and treatment framework in the biologic era. Methods: We performed a narrative review of the English-language literature using PubMed and major rheumatology and spine journals. Topics included the prevalence and natural history of cervical involvement in RA, mechanisms of instability, radiographic assessment (anterior/posterior atlantodental interval, Ranawat and Redlund-Johnell indices, cervicomedullary angle), clinical predictors of neurological decline, and outcomes of contemporary medical and surgical strategies. Results: Cervical involvement remains common in RA, with atlantoaxial instability, basilar invagination, and subaxial subluxation often coexisting and following a characteristic progression. Many patients demonstrate radiographic instability without neurologic deficit, whereas a subset develops myelopathy or catastrophic injury. Radiographic parameters and clinical grading systems correlate with neurological status and recovery and inform timing of surgery. Modern disease-modifying antirheumatic drugs/biologic regimens reduce but do not abolish RCS progression. Pattern-specific stabilization procedures, including C1-C2 fusion, occipitocervical fusion, and subaxial instrumentation, generally yield pain relief, neurologic improvement, and durable fusion but carry meaningful perioperative risk. Conclusions: RCS remains an important cause of preventable myelopathy and mortality in RA. Routine cervical screening of high-risk patients, appropriate advanced imaging, and early referral for stabilization before fixed deficits are critical to optimizing outcomes.