There may not be any cases of paralysis after intubation but it may not be recognized as these patients often die as a presenting symptom when complete subluxation occurs. If you pub med search sudden death and rheumatoid arthritis you will be surprised.
Can't access the actual case report (not at work currently) - here is one of sudden death:
http://journals.lww.com/spinejourna...D__Sudden_Death_from_Cord_Compression.17.aspx
If your colleagues are just looking for a note in the chart and order the incorrect studies, maybe educate them. That doesn't make any sense and is a waste of time and money.
Here is the advisory I wrote. Take it or leave it. I usually don't practice in a CYA manner - I do what I feel is right for the patient (and what I would want if I had a specific disease/condition). Having said that, if it is a same day case and I can't wait for an x-ray (which by the way takes less then 30 minutes if ordered correctly), then yes - do the precautions. But make sure you don't move that neck after intubation (positioning can cause some major neck movement too). Additionally, be prepared to have difficulty with the airway because subluxation isn't the only problem these patients have with their airways.
Introduction
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown etiology with an incidence of approximately 1.5/100K in men and 3.6/100K in women. RA is characterized by destruction of primarily small synovial joints, resulting in fibrosis and hypertrophy. RA typically presents with persistent, painful swelling of the joints with morning stiffness. Patients can present with multiple organ systems affected by both the disease and the treatments for the disease.
Particularly relevant to anesthesiologists is the impact the disease has on the airway; both the cervical spine and the larynx. Radiological studies of patients with RA suggest that up to 80% have some disease involvement of the cervical spine and up to 30% may have instability. Of those patients with cervical spine disease, roughly 40-85% will complain of neck pain while only 7-13% of patients with radiographic evidence of instability have neurologic deficits.
It is estimated that up to 10% of patients with RA die from unrecognized brainstem or spinal cord compression. Temporomandibular joint dysfunction may produce arthritis with limitations on mouth opening and cricoarytenoid disorders are seen in as many as 75% of patients resulting in decreased movement and possibly difficulty with airway manipulation. Rheumatoid involvement of the cervical facet joints can lead to stenosis of the nearby vertebral arteries causing varying degrees of symptoms from vertebral artery insufficiency and spinal cord ischemia.
Head and neck manipulation during airway management and patient positioning can result in neurologic injury. Fortunately, serious complications are rare.
History and Physical:
- Thorough history including severity and duration of disease, drug treatments and systemic review of complications.
- Vertebral artery insufficiency: vestibular or visual changes, vertigo, dysphagia, tinnitus, dysarthria and loss of consciousness.
- Cervical Spine: o Atlantoaxial (C1-C2) subluxations may be asymptomatic or may cause various vague complaints such as a ‘deep ache’ in the occiput or cervical spine. Myelopathic symptoms such as hand clumsiness or paresthesias and gait dysfunction, specifically a wide based gait, should be investigated with an MRI and treated.
o Cranial settling may occur. The odontoid ascends into the foramen magnum and can cause brainstem compression. Signs and symptoms of myelopathy signal the need for evaluation and treatment.
o Subaxial subluxations can be unstable and cause canal stenosis and spinal cord compression. Most commonly this occurs at C4-5. Again, signs and symptoms of myelopathy require evaluation and treatment.
- Temporomandibular joint: arthritis can result in limited mouth opening.
- Cricoarytenoid: symptoms are rarely severe but may include a sense of fullness in the throat, dysphagia, exertional dyspnea, hoarseness and rarely stridor with upper airway obstruction.
Tests and Studies:
- Cervical spine X-rays: o Most common abnormality found is atlanotaxial subluxation.
o Obtain upright flexion-extension films for diagnosis.
o Normal anterior atlantodental interval (ADI) is less than 4mm.
- MRI: o Poor correlation between MRI changes and clinical symptoms.
o The benefit of the MRI is that it visualizes the soft tissues including the spinal cord. Stenosis with spinal cord compression can be seen and the patient referred to a spine surgeon for evaluation and treatment.
Management:
There are absolutely no guidelines or randomized controlled trials suggesting when to obtain radiographic studies of the cervical spine, specifically x-rays in preparation for surgery. A review of the literature finds varying opinions; some researchers state that obtaining C-spine X-rays is “mandatory prior to anesthesia … since instability can be completely asymptomatic” while others recommend assessing on a case by case basis. Almost all agree that in patients with neurologic symptoms, x-rays should be ordered and neurosurgical/orthopedic spine consult. Best practice standards suggest that the anesthesiologist obtain x-rays for any patient that has had Rheumatoid Arthritis for greater than ten years or has had poor control of the disease. Any patient with neurologic symptoms or signs should have an MRI and evaluation by a spine surgeon.
Determining when to perform surgical stabilization of patients with significant c-spine disease is difficult due to the lack of correlation between radiographic and neurologic progression. Generally, operative management should be considered for patients with atlantoaxial subluxations greater than 8mm or any patient with myelopathic symptoms or signs.
Whenever possible, surgical procedures not associated with the spine should be performed using regional anesthesia to minimize airway manipulation. However, there is always the possibility of difficult or impossible regional placement (especially neuraxial) and the dreaded complication of local anesthetic toxicity which presents the provider with an potentially difficult airway which now needs to be secured emergently. If endotracheal anesthesia must be performed, the “sniffing” position should be avoided since it can worsen subluxation and cause spinal cord compression. One should always have adjunctive airway devices available, specifically the fiberoptic scope. Consideration to inline stabilization should be made in all rheumatoid patients with elective fiberoptic intubation being preferred due to little neck manipulation needed.
Referral to surgeon:
Any patient with RA and an abnormal ADI (> 4mm), cranial settling, or subaxial subluxation should be referred for consultation to a spine surgeon. Also, any patient with myelopathic symptoms by history or signs on exam should be referred to a spine surgeon. These include hand clumsiness, gait dysfunction, pathologic reflexes, and brisk reflexes or clonus.
References:
1. Wasko, Mary M. "Perioperative Management of Patients with Rheumatoid Arthritis."
Perioperative Management of Patients with Rheumatic Disease. By Lisa L. Schroeder. Vol. XIV. New York: Springer, 2012. 209-20. Print.
2. Samanta, R., K. Shoukrey, and R. Griffiths. "Rheumatoid Arthritis and Anaesthesia."
Anaesthesia 66 (2011): 1146-159. Print.
3. Skues, M. A., and E. A. Welchew. "Anaesthesia and Rheumatoid Arthritis."
Anaesthesia 48.11 (1993): 989-97. Print.
4. Dreyer, Susan J., and Scott D. Boden. "Natural History of Rheumatoid Arthritis of the Cervical Spine."
Clinical Orthopaedics and Related Research 366 (1999): 98-106. Print.
5. Vieira, Eneida M., Stuart Goodman, and Pedro P. Tanaka. "Anesthesia and Rheumatoid Arthritis."
Revista Brasileira De Anesesiologia 61.3 (2011): 367-75. Print.
6. Schur, Peter H., and Bradford L. Currier. "Cervical Subluxation in Rheumatoid Arthritis."
Cervical Subluxation in Rheumatoid Arthritis. Penn State Medical Center, 11 Dec. 2012. Web. 17 May 2013.
7. Menezes, Arnold H.” Rheumalological Disorders.” In
Principles of Spinal Surgery. Menenzes, Arnold H, Sonntag, Volker K.H. ed. pp. 705-722.
8. Greenberg, Mark S. Handbook of Neurosurgery. Pp. 338-340.
