What is the next best step in management for a 72-year-old man with untreated Rheumatoid Arthritis (RA) undergoing pre-operative evaluation?

Cervical Spine X-rays for Pre-operative Evaluation in Rheumatoid Arthritis

For a 72-year-old man with untreated rheumatoid arthritis undergoing pre-operative evaluation, cervical spine x-rays (option B) are the next best step in management due to the high risk of cervical spine instability that could significantly impact anesthesia management and surgical outcomes.

Rationale for Cervical Spine Imaging

Rheumatoid arthritis (RA) frequently affects the cervical spine, which can lead to serious perioperative complications if not identified before surgery. The patient's presentation shows several concerning features:

• Advanced, untreated RA (bilateral ulnar deviation, MCP subluxation)
• Positive RF and anti-CCP antibodies
• Radiographic evidence of joint erosions
• Older age (72 years), which increases risk of cervical spine involvement

Cervical Spine Involvement in RA

RA commonly affects the cervical spine in the following ways:

• Anterior atlantoaxial subluxation (most common manifestation)
• Cranial settling
• Subaxial subluxation
• Combination of these conditions 1

These conditions can lead to cervical spine instability, which poses significant risks during intubation and positioning for surgery, potentially resulting in spinal cord compression and neurological damage.

Evidence Supporting Cervical Spine Evaluation

The American College of Rheumatology (ACR) guidelines specifically mention that perioperative evaluation of RA patients should include assessment of "concurrent disease, such as that affecting the cervical spine of patients with RA" 2. This is particularly important for anesthesia planning and surgical positioning.

The ACR/AAHKS guidelines note that while they don't specifically address "the perioperative evaluation and management of concurrent disease, such as that affecting the cervical spine of patients with RA," this evaluation remains an important part of pre-operative assessment 2.

Why Cervical Spine X-rays Over Other Options

1. Cervical spine x-rays (Option B): Directly addresses the most significant perioperative risk specific to RA patients - cervical spine instability that could lead to spinal cord compression during intubation or positioning.

2. Stress test (Option A): While cardiac evaluation is important for elderly surgical patients, there is no specific indication (cardiac symptoms, high-risk surgery) mentioned that would prioritize this over addressing the RA-specific cervical spine risk.

3. Pulmonary function tests (Option C): No pulmonary symptoms are mentioned, and while RA can affect the lungs, cervical spine instability presents a more immediate perioperative risk.

4. Chest radiograph (Option D): While useful for general pre-operative evaluation, it doesn't address the specific high-risk complication of cervical spine instability in RA.

Practical Approach to Cervical Spine Evaluation

• Obtain lateral flexion-extension dynamic views of the cervical spine
• Look for atlantoaxial subluxation (>3mm distance between posterior aspect of anterior arch of C1 and odontoid process)
• Assess for cranial settling and subaxial subluxation
• If abnormalities are detected, consider advanced imaging (MRI) to evaluate for spinal cord compression 1

Impact on Perioperative Management

Identification of cervical spine instability will directly impact:

• Anesthesia approach (may require fiber-optic intubation or alternative airway management)
• Patient positioning during surgery
• Need for cervical spine precautions throughout the perioperative period

Common Pitfalls to Avoid

1. Overlooking cervical spine evaluation: Studies show that cervical spine abnormalities are frequently present in RA patients but may be missed without appropriate imaging 3.

2. Relying solely on neurological symptoms: Many patients with significant cervical spine instability may be asymptomatic until placed in vulnerable positions during anesthesia or surgery.

3. Focusing only on the primary surgical site: While the joint requiring surgery may be the most symptomatic, cervical spine involvement poses the greatest perioperative risk.

By obtaining cervical spine x-rays as the next step in management, you can identify potential cervical spine instability that would significantly impact anesthesia planning and surgical positioning, potentially preventing catastrophic neurological complications during surgery.