CERVICAL SPINE INSTABILITY IN RHEUMATOID ARTHRITIS IN THE ERA OF MODERN ANTIRHEUMATIC THERAPY: PREDICTORS OF PROGRESSION AND TIMING OF NEUROSURGICAL REFERRAL

Background and Objectives. To synthesize contemporary clinical evidence on rheumatoid cervical spine instability, identify predictors of structural progression, and distinguish the threshold for neurosurgical referral from the threshold for operative intervention. Materials and Methods. A focused narrative clinical review was based on a PubMed/MEDLINE search updated through August 2026. Original clinical studies addressing cervical involvement, imaging, longitudinal progression, predictors, neurological consequences, and surgical outcomes were prioritized. Forty clinical publications formed the principal evidence base, no meta-analysis or formal risk-of-bias grading was performed. Results. Modern disease-modifying antirheumatic therapy appears to reduce some de novo cervical lesions, but established instability may continue to progress. Pre-existing cervical abnormalities, destructive peripheral disease, longer rheumatoid arthritis duration, seropositivity, glucocorticoid exposure, osteoporosis, and previous joint surgery are associated with cervical involvement or progression. Serial imaging is particularly important because mechanical deterioration may precede overt neurological compromise. Conclusions. Assessment should integrate rheumatological phenotype, established structural disease, longitudinal mechanical progression, and neural consequences. Neurologically intact patients with documented structural progression represent a clinically important intermediate group in whom earlier spine or neurosurgical assessment may be considered without implying prophylactic surgery.