Review Question - QID 220356

This patient has a history of rheumatoid arthritis and symptoms of cervical spine instability such as neck pain and paresthesias. The patient should undergo cervical spine imaging to test for cervical subluxation before intubation.

Rheumatoid arthritis is a systemic inflammatory condition that commonly presents with symmetric joint pain that is worse in the morning and improves with activity. Rheumatoid arthritis may affect the cervical spine via destruction of the cervical joints resulting in cervical spine instability and atlantoaxial instability. Subluxation may occur where the vertebrae translate over one another, potentially compressing the spine and causing neurologic deficits including weakness, paresthesias, paralysis, and hyperreflexia. Radiographs or CT imaging of the cervical spine should be performed to rule out atlantoaxial instability prior to procedures that manipulate the neck such as intubation. Intubation should be done with great care with cervical precautions given the possibility of paralysis.

Neva et al. review the risk of cervical spine abnormalities in patients with rheumatoid arthritis. They discuss how a high proportion of patients waiting for elective surgery have possible subluxation of the cervical spine. They recommend screening for this issue in pre-operative testing.

Figure/Illustration A is a clinical photograph of the hands demonstrating severe deformity with ulnar deviation of the hand (red circle). This deformity is classically seen in patients with rheumatoid arthritis.

Incorrect Answers:
Answer 1: An echocardiogram can be performed to risk stratify patients who have elevated cardiac risk before surgery. Since this patient had an echocardiogram performed with normal results recently, a repeat echocardiogram is not necessary at this time.

Answer 2: MRI of the abdomen can be used to evaluate for equivocal cases of abdominal pain without a clear etiology. Additional abdominal imaging is not needed at this time since the diagnosis has already been confirmed.

Answer 3: Proceed without further testing is incorrect because patients with rheumatoid arthritis and symptoms consistent with cervical spine instability should undergo additional imaging of the cervical spine prior to undergoing intubation for elective surgery.

Answer 5: Serum calcium levels might be considered in patients who are taking denosumab because this medication can result in hypocalcemia. The neck pain and history of rheumatoid arthritis in this case is more suggestive of cervical spine instability.

Bullet Summary:
Patients with rheumatoid arthritis should undergo cervical spine screening prior to intubation due to the risk of subluxation and paralysis.