Back ground: Cervical spine involvement in patients with rheumatoid arthritis (RA) can cause pain and disability, with a variety of neurologic signs and symptoms.                                                    Objectives: To investigate the relationship between structural cervical spine involvement in patients with RA with the age at disease onset and the degree of radiologic severity of RA measured by Larsen scoring. Patients and methods : This cross-sectional study included 50 adult patients with RA. Patients who complained or not complained from symptoms of cervical spine involvement in RA were included; we did X-ray of the cervical spine, hands, and feet; Larsen scoring method; disease activity score (DAS28); and Neck Disability Index.                                                                                                                  Results : The results revealed that patients with cervical involvement tend to be younger at their disease onset than those with no cervical involvement, as detected by cervical X-ray. The relation was significant P < .05 regarding all cervical involvements except for basilar invagination. Disease radiological severity (measured by Larsen score) significantly increases the risk for subaxial subluxation, P = .040. All other cervical complications of RA tend to have nonsignificant relation with disease severity. Using univariate binary regression analysis for risk factors for cervical involvement showed that the only probable risk factor for cervical involvement (detected by X-ray) in patients with RA is age at disease onset. Conclusions: The early age at disease onset tends to affect cervical spine involvement in patients with RA more than the disease radiological severity.                                                                                Keywords : Rheumatoid arthritis, Neck Disability Index, Larsen score, cervical X-ray