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

Pre-operative Management for Untreated Rheumatoid Arthritis

Cervical spine x-rays are the next best step in management for this 72-year-old man with untreated rheumatoid arthritis undergoing pre-operative evaluation. 1

Rationale for Cervical Spine Imaging

Untreated RA commonly affects the cervical spine, which can lead to serious perioperative complications if not identified before surgery. The American College of Rheumatology (ACR) guidelines specifically recommend cervical spine evaluation as a critical part of pre-operative assessment, especially in patients with advanced, untreated RA 1. This patient presents with several concerning features:

• Long-standing, untreated RA (evidenced by bilateral ulnar deviation and joint subluxation)
• Positive RF and anti-CCP antibodies
• Radiographic evidence of joint erosions

These findings suggest advanced disease with high risk for cervical spine involvement.

Types of Cervical Spine Pathology in RA

Cervical spine involvement in RA can manifest as:

• Anterior atlantoaxial subluxation (most common)
• Cranial settling
• Subaxial subluxation
• Combination of these conditions 1, 2

These conditions can lead to spinal cord compression during intubation or surgical positioning, potentially resulting in catastrophic neurological complications 1.

Optimal Imaging Technique

• Lateral flexion-extension dynamic views should be obtained to properly assess for atlantoaxial subluxation
• A distance of >3mm between the posterior aspect of the anterior arch of C1 and the odontoid process indicates subluxation 1

Impact on Anesthesia and Surgical Planning

Identifying cervical spine instability directly impacts:

• Anesthesia approach
• Patient positioning during surgery
• Need for cervical spine precautions throughout the perioperative period
• Potential requirements for fiber-optic intubation or alternative airway management 1

Prevalence and Clinical Significance

The prevalence of cervical spine abnormalities in long-standing RA is substantial:

• Anterior atlantoaxial subluxation: 23% after 20 years of disease
• Atlantoaxial impaction: 26% after 20 years
• Subaxial subluxations: 19% after 20 years 3

Common Pitfalls to Avoid

1. Relying solely on symptoms: Many patients with cervical spine involvement remain asymptomatic despite radiographic abnormalities 4. This patient's lack of reported neck symptoms does not rule out significant cervical spine disease.

2. Inadequate imaging: Complete radiographic examination should include flexion-extension views to properly evaluate atlantoaxial subluxation 2. Standard views alone may miss dynamic instability.

3. Delaying evaluation: Early identification of cervical spine involvement is crucial, as operative intervention before the onset of advanced myelopathy results in improved outcomes 2.

While some older research has questioned the necessity of routine cervical spine radiographs in asymptomatic RA patients 5, the current ACR guidelines clearly emphasize their importance, particularly in patients with advanced, untreated disease like this 72-year-old man 1.

In summary, cervical spine x-rays represent the most critical next step in this patient's pre-operative evaluation to ensure safe anesthesia administration and appropriate surgical positioning.