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Surgical treatment involving the cervical spine can be risky in patients with RA
Douglas W. Jackson, MD, asks 4 Questions of Michael G. Neuwirth, MD, about risk factors and outcomes of surgery in patients with RA.
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Few of us orthopedic surgeons frequently operate on patients with rheumatoid arthritis (RA). However, many of us occasionally perform surgery on patients with RA. In rare instances, there can be a potential problem handling their cervical spines during the procedure.
I turned to Michael G. Neuwirth, MD, who is currently the director at the Spine Institute of New York, with some specific questions on this topic. I feel his responses serve as a good review and stimulus to think of this the next time you are planning surgery on a patient with RA.
Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: Surgeons taking patients with RA to the OR need to remember the possibility of cervical involvement. What is the incidence in general for RA, and in particular those patients with cervical involvement?
Michael G. Neuwirth, MD: The prevalence of RA in the general population has been reported to be 1% to 2% and it increases with age. The mean annual incidence in the United States is about 70 in 100,000 people annually. Both the prevalence and incidence of RA are two- to three-times greater in women than in men. Patients are most commonly affected in the third to sixth decades of life.
The reported prevalence of cervical spine involvement varies greatly. Between 43% and 86% of patients with RA have radiographic evidence of instability. There are three main types of instability that present in RA patients which may present in any combination. The most common type of instability is atlantoaxial subluxation. About 20% of RA patients with cervical spine instability display basilar invagination alone, or in combination with atlantoaxial involvement. Approximately 15% of patients may also have subaxial subluxation.
Jackson: What are the risk factors and progression signs in RA patients for functional deterioration and/or sudden death?
Neuwirth: Risk factors and signs of progression in these patients for functional deterioration and/or sudden death are hard to elucidate, principally because of the lack of correlation of radiographic findings with clinical presentations. Certainly, patients with clinical signs of cervical myelopathy, progressive neurological deficit, rapid decline in function, or recent loss of ambulation should be monitored very closely for progression of their symptoms and radiographic disease. However, asymptomatic patients with cervical disease and sagittal canal diameter of less than 14 mm should be considered at risk for potential neurologic deficit, and should also be closely monitored for neurologic deterioration, paralysis and sudden death.
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Practically speaking, any patient with a PADI (posterior atlanto-dens interval) of less than 14 mm, basilar invagination, and/or a subaxial canal diameter of less than 14 mm are at highest risk for neurological deterioration regardless of symptomatology.
Jackson: What do you recommend for screening of the cervical spine in a patient with RA who will undergo anesthesia and what precautions should the anesthesiologist take in positioning and monitoring?
Neuwirth: Cervical spine X-rays, including flexion and extension lateral views, must be performed as part of the presurgical screening for all patients with RA, regardless of symptomatology, in order to assess the patient for atlanto-axial instability, atlanto-axial subluxation, and subaxial subluxation.
In a retrospective cross-sectional study, preoperative cervical spine X-rays were obtained for 128 patients with asymptomatic RA scheduled for elective orthopedic surgery. The overall incidence of craniocervical instability was 16% and previously undetected atlanto-axial subluxation was found in 6%. None of the patients had signs or symptoms related to cervical cord compression. In patients who demonstrate cervical instability, anesthetic techniques which diminish or avoid cervical manipulation (laryngeal mask airway, face mask, regional/epidural blocks) should be employed. Endotracheal intubation, if unavoidable, should be performed with endoscopic assistance with the neck held in a neutral position.
Jackson: What are some other special considerations for patients with RA and surgical outcomes?
Neuwirth: A thorough history and physical including the cervical spine is paramount when dealing with patients with RA. Their symptoms may be as subtle as migraines or as obvious as the sensation of their head falling forward with neck flexion. The physical exam should be directed toward a diagnosis of myelopathy until proven otherwise. Signs such as lower-extremity hyperreflexia or other upper motor neuron findings should be carefully examined. Late findings include motor weakness and bowel or bladder changes. The cervical spine of a patient with RA should always be a priority regardless of the anatomic location of a surgical procedure.
For more information:
- Michael G. Neuwirth, MD, Director, Spine Institute of New York, can be reached at Spine Institute of New York, Beth Israel Medical Center, 10 Union Square East, Suite 5P, New York, NY 10003; 212 844-8682; e-mail: mneuwirt@chpnet.org.
References:
- Campbell RS, Wou P, Watt I. A continuing role for pre-operative cervical spine radiography in rheumatoid arthritis. Clin Radiol. 1995;50(3):157-159.
- Cha CW, Boden SD, Clark CR. Rheumatoid arthritis in the cervical spine. Clark CR, ed. The Cervical Spine. Philadelphia: Lippincott Williams-Wilkins; 2005:901-913.
- Wollowick, AL, Casden, AM; Kuflik, PL; Neuwirth, MG. Rheumatoid Arthritis in The Cervical Spine: What You Need to Know. Am J Orthop. 2007;36(8):400-406.