Spine Surgery for Rheumatoid Arthritis

Medically Reviewed by David Zelman, MD on March 29, 2022
4 min read

Rheumatoid arthritis often involves your wrists, knees, and feet. But it can also affect your spine. Most of the time, this kind of back pain responds well to arthritis treatments such as biologics. But in rare cases, you might need spine surgery.

Usually, when you have RA, it affects the neck region of your spine (an area called the cervical spine). This can happen within the first couple of years of the disease, later on, or you may never have spinal problems at all.

If symptoms do develop, they can include:

  • Neck pain
  • Headache at the base of the skull
  • Loss of flexibility and function around the neck joint

Some people with RA get a condition called atlanto-axial subluxation. It affects the bones in your upper spine or in your neck under the base of your skull. The ligaments that hold these bones together weaken due to inflammation from RA. This puts your first and second spinal bones out of alignment, which could compress your spinal cord.

In some cases, this can lead to paralysis. You’re more likely to develop atlanto-axial subluxation the longer you have RA.

More rarely, rheumatoid arthritis can damage the joints of your lumbar spine, or lower back.

While about 1 in 4 people with RA develop symptoms in their spine, it’s very rare to need surgery for this. Newer and more effective treatments for RA, such as biologics, tend to prevent the disease from progressing to the point where you need surgery.

But over time, the joints around your cervical spine can wear down so much that they pinch your spinal cord. This is called spinal stenosis. It can cause serious problems, such as:

  • Loss of coordination
  • Loss of bowel or bladder function
  • Pain that radiates down the arms or legs
  • Muscle weakness

If you notice any of these symptoms, see your doctor immediately to make sure you don’t have atlanto-axial subluxation. That usually requires immediate surgery. Otherwise, your doctor may prescribe medicine and physical therapy and watch you closely for several months. If your symptoms don’t get better, you might need surgery to relieve the pressure on your spinal cord and nerves.

Laminectomy is a surgery to remove the lamina, a bone at the back of each vertebra, from the affected area of your spine. Most people who have spinal stenosis on the back part of their spinal cord will need a cervical laminectomy. That’s removal of the lamina from the neck portion of your spine.

During a laminectomy, the surgeon makes an incision down the middle of the back of your neck to take out the lamina. This relieves pressure on your spinal cord. Sometimes, the surgeon removes some bone from a joint called the facet joint at the same time. This procedure is called a foraminotomy. It helps relieve nerve compression.

Normally, you stay in the hospital for 2-3 days with this surgery. When you leave, you’ll get a soft collar to make you more comfortable as you recover. You’ll also need physical therapy after surgery.

If your spinal compression is at the front, rather than the back of your spine, your doctor might recommend spinal fusion over laminectomy. You might also need this if you have severe compression in multiple spots.

Spinal fusion permanently connects at least two vertebrae in your spine. This eliminates the motion between these vertebrae that may be causing you pain.

Spinal fusion mimics the normal process of healing broken bones. Your surgeon places a bonelike material between two spinal vertebrae, then fuses them together with metal plates, screws, or rods. This prevents movement that irritates or inflames the spinal nerves. The surgery usually takes 3-6 hours. As with laminectomy, you’ll stay in the hospital for 2-3 days. You may wear a brace and need physical therapy after surgery.

Spinal fusion comes with a greater risk of complications and a longer recovery than other spine surgeries. But the results of this surgery are always improving, and rates of complications are falling among people with RA.

When you have RA, your risk for complications after spinal surgery is greater than it is for other people. That’s because:

  • Steroids, a common arthritis medication, raise your risk for osteoporosis, which can make it harder for bones to fuse. If you take these drugs, the surgery is less likely to work.
  • Steroids and biologics for rheumatoid arthritis suppress your immune system. A weak immune system raises your risk for an infection after surgery and makes healing time longer.
  • Some people with RA have lung and heart problems, which increases the risk of complications from surgery.
  • People with RA may have other joint problems in other parts of their bodies, like the hips or knees. This can make it harder to move around and complete physical therapy to speed recovery.

As for medications that weaken your immune system, your doctor may want you to stop taking them before surgery. For example, if you take a biologic drug once a week, you’ll schedule surgery for 2 weeks after your last dose. You’ll start taking these meds again 2 weeks after surgery.

Stopping this medication helps with infection risk, but your RA can get worse during that time. That’s why it’s important for your rheumatologist to work closely with your spine surgeon to ensure the best outcome.