Early, Intensive Treatment Reduces Cervical Spine Involvement in Early RA

Early, remission-targeted treatment for rheumatoid arthritis reduces the incidence of cervical spine involvement and prevents its development in the long term.

Early and intensive treatment reduces the incidence of cervical spine involvement in patients with rheumatoid arthritis (RA), according to study data published in the Journal of Rheumatology.

The NEO-RACo trial (ClinicalTrials.gov Identifier: NCT00908089) is an ongoing study of patients with early, active RA treated at multiple sites in Finland. Participants were recruited between 2003 and 2005; eligible patients had no prior exposure to disease-modifying antirheumatic drugs (DMARDs) or glucocorticoids. Early, active RA was defined per American College of Rheumatology criteria and a disease duration of ≤12 months was required for participation. Radiographs of the hands and feet were taken at baseline and at 2, 5, 7, and 10 years. Cervical spine radiographs were taken at 10 years. For the first 2 years of trial participation, patients received a triple combination of conventional synthetic DMARDs (methotrexate, sulfasalazine, and hydroxychloroquine) and prednisolone.

Patients were also randomly assigned to receive either infliximab or placebo infusions at weeks 4, 6, 10, 18, and 26. After year 2, treatment methods became unrestricted. If the patient was in remission at the 2-year visit, prednisolone and DMARDs were tapered at the treating rheumatologist’s discretion. Remission was defined as the presence of 5 of the following criteria: (1) morning stiffness <15 minutes, (2) no fatigue, (3) no joint pain, (4) no tender joints, (5) no swollen joints, and (6) erythrocyte sedimentation rate <30 mm/h in women and <20 mm/h in men.

A total of 85 patients with RA received treatment and completed cervical spine radiographs at 10 years. Demographic and clinical characteristics were similar between the infliximab and placebo infusion groups. The majority of patients were women (n=57; 67.1%). Mean age at baseline was 48±9 years in the infliximab group and 47±11 years in the placebo group.

Most patients achieved low disease activity and maintained their functional capacities at 2, 5, and 10 years. Radiographic joint damage progression was minimal. Overall, 4 patients (4.7%) had cervical spine involvement by 10 years. Of these 4 patients, 2 (2.4%) had atlantoaxial subluxation, 1 (1.2%) had atlantoaxial impaction, and 1 (1.2%) had subaxial subluxation. Three of these patients had received treatment with infliximab, whereas the patient with subaxial subluxation had received placebo. All 4 patients with cervical spine involvement were seropositive.

Per these results, early and intensive treatment with DMARDs and prednisolone appeared to reduce the likelihood of cervical spine involvement in patients with early RA. As a study limitation, investigators cited the small number of cases with cervical spine involvement. In addition, no control group was available; intensive treatment could not be directly compared with less-intense treatment. Even so, these data suggest that early, remission-targeted treatment reduces the incidence of cervical spine involvement and prevents its development in the long term.


Sandström T, Rantalaiho V, Yli-Kerttula T, et al. Cervical spine involvement among patients with rheumatoid arthritis treated actively with treat-to-target strategy: 10-year results of the NEO-RACo study [published online June 1, 2020]. J Rheumatol. doi:10.3899/jrheum.190139