An Overview of Rheumatoid Arthritis Back Pain

While rheumatoid arthritis (RA) tends to affect the peripheral joints—such as in the hands, feet, and knees—some people with RA also have back pain. RA usually affects the cervical spine located at the top of the spinal cord, forming the neck. It may also affect your middle and low back.  

Symptoms of RA back pain include pain and stiffness. Treatment is aimed at relieving pain and reducing inflammation that may be contributing to pain. Some people may require surgery to prevent damaged vertebrae from putting pressure on nerves located in the cervical spine.  

Here is what you need to know about RA back pain, including prevalence, symptoms, diagnosis, and treatment.

The back and the spine are affected when RA progresses. In other words, inflammation in the back and spine may indicate a more advanced disease. When back pain is RA related, inflammation is usually the cause.

One study reported in 2013 suggests up to 65.5% of people with RA may experience low back pain. The researchers also reported people with RA and lower back pain were reporting a lower quality of life and had an increased risk for depression.

Another report—this one from 2015—suggests more than 80% of people with RA have some radiographic cervical spine involvement. In fact, the damage can be seen as early as two years after diagnosis.

A 2017 report in the German medical journal Zeitschrift für Rheumatologie finds lower back pain in RA leads to a higher degree of disability and depression and contributes to a lower quality of life, this in comparison to people with RA who do not experience back pain. The report's authors further noted surgery could improve disability and quality of life provided that specific aspects of RA were addressed—notably, “poor bone quality and the immunosuppressive effect of antirheumatic drug treatment.”  

RA causes swelling and pain in the joints throughout the body. It can also affect the facet joints of the spine. You have a pair of facet joints that run along the spine on both sides. They connect to the bony bumps you feel down your back. The facet joints support the movement and flexibility of your spine.

RA can cause the facet joints to become inflamed resulting in back pain. Sometimes, chronic inflammation can cause damage to the facet joints and make the spine less stable.

Instability in the spine causes a vertebra to slip out of their place where an upper vertebra slide over the lower one. This is called spondylolisthesis. 

Spondylolisthesis is different from a slipped disc, or correctly named, a herniated disc. A herniated disc is usually the result of injury. However, if one of the bones of the vertebrae is affected by severe inflammation, your risk for a herniated disc might be higher.

The bones of the vertebrae are cushioned by discs that protect against shocks to the spine and vertebrae from daily activities, such as walking, lifting, and twisting. A herniated disc may press on one of the spinal nerves, causing pain and numbness, along an affected nerve. If this gets too severe, surgery may be needed to repair or remove the herniated disc.

RA inflammation in the back affects the cervical spine—the top seven vertebrae, which include the neck. Inflammation can also affect the lumbar area of the lower back and the facet joints.

Some of the symptoms of RA back pain are: 

• Headaches
• Joint swelling and stiffness in affected parts of the back
• Loss of function and movement
• Pain in the neck, shoulders, upper back, and base of the skull
• Stiffness in the back and neck
• Warmth around affected joints
• Tenderness in the affected areas of the back
• Pain radiating down one or both arms, indicating cervical nerve root involvement 
• A crunching feeling—called crepitus—which is most notable in the neck.

If a slipped disk starts to put pressure on the low back, it may cause sciatica. Symptoms of sciatica include: 

• Problems with walking
• Loss of bowel or bladder function
• Loss of coordination
• Pain radiating into the legs

An unstable or damaged vertebra can press on other vital parts of the body. It can also cause severe pain, deformity, and loss of height.

Your doctor can diagnose your back pain and figure out if it is related to RA or if something else is causing it. The first thing he or she needs to do is determine whether back pain is acute or chronic. 

Acute back pain tends to be caused by straining of the back with twisting, lifting something heavy, or other injury-related cause. On the other hand, chronic back pain is usually caused by a problem in the spine or another body area.

To diagnose the source of back pain, your doctor will perform a physical exam, ask questions about where it hurts and when. He or she may send you for X-rays and other imaging, including magnetic resonance imaging (MRI), computerized tomography (CT) scans, myelography, bone scans, and/or ultrasounds to determine damage and nerve and spinal cord involvement.

If your doctor thinks there is facet joint involvement, a medial branch nerve block might be done. If the pain resolves, this confirms facet joint involvement. A medial branch nerve block involves injecting anesthetic near the small medial nerves connected to a specific facet joint. More than one level is injected. This procedure is for diagnostic purposes only. If your doctor thinks you need a longer pain relief treatment, a medial branch radiofrequency neurotomy (or ablation) will be done.

The goals of treatment for RA back pain are usually to reduce or eliminate pain, make it easier for you to function, and to reduce disease progression and damage, especially as to its effects on your back and spine health. 

For most people with RA back pain, treatment is non-surgical and will include a combination of therapies. 

Non-surgical treatments may include: 

• Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids—either in pill form by injection—to reduce pain and swelling
• Other medications that treat inflammation symptoms and triggers
• Physical therapy to improve your back strength and range of motion of the spine
• Occupational therapy may teach ways to protect your back. This can include how to pick up and carry objects while keeping your back safe from injury and pain.
• Lifestyle changes help to reduce inflammation and stress on the back and spine, including an anti-inflammatory diet, losing weight, exercise, correcting posture, and practicing good ergonomics while sitting.
• Spinal injections can be quick way to relieve RA back pain. This usually involves a corticosteroid or anesthetic in the nerve region affected by RA inflammation. The effects of the medication may last weeks or even months.

Surgical intervention might be recommended if your back pain does not resolve despite other treatments. Goals of spinal surgery may include: 

• Decompressing the spinal cord and freeing up nerve roots from bone spurs or anything else that may be pressing on them
• Stabilizing the spine with a procedure called a spinal fusion that involves fusing several sections of the spinal bones 

Decompression surgery and spinal fusions can be open procedures or done using a minimally invasive approach. A surgeon can discuss all your options and the pros and cons of each method. 

If you have RA and develop chronic back pain, talk your rheumatologist or other treating doctor to determine the source of the back pain and so your doctor can prescribe treatments before things get worse. Your doctor is in the best position to determine the source of your back pain, whether back pain is short-term treatment like pain relievers or longer-term pain management strategies, such as physical therapy, or more aggressive therapies, including surgery.