5.3 Rheumatoid Arthritis Flashcards
75-year-old female patient,
suffering from severe Rheumatoid arthritis,
is booked for a total knee replacement.
Can you tell me the positive findings on her chest X-ray.
Bilateral airspace disease with:
* Extensive reticular change throughout both lungs
* Reduced volume
* Honeycomb pattern
* Shaggy heart border
Diagnosis: Pulmonary fibrosis. This can be because of the disease
progression or as a side effect of drugs for rheumatoid disease.
What does her c spine X-ray show? see Figure 5.5
Lateral radiograph of the neck with the head in flexion
shows an increased distance between the
anterior border of the dens and the posterior border
of the anterior tubercle of C1.
This “pre-dentate space,”
should be less than 3 mm in the adult.
Also there is forward subluxation of C1 on C2.
Mainly two types of changes might be seen:
Atlanto-axial subluxation
Anterior
+
Posterior
and
sub-axial subluxation.
Atlanto-axial subluxation
Anterior
- Anterior:
Most common (80%) finding in rheumatoid arthritis
involving the neck,
where C1 vertebra is moved forward on body of C2 vertebra
due to damage to transverse ligament and
can cause spinal cord compression by odontoid peg.
Subluxation occurs when distance between atlas and
odontoid is > 4 mm in adults and > 3 mm in children.
It is best seen in lateral neck X-ray with neck flexion
(which makes subluxation worse).
Atlanto-axial subluxation
- Posterior
Occurs in 5% of the patients
and is due to destruction of odontoid peg,
which causes backward movement of
C1 vertebra over C2 vertebra.
It is best seen in lateral X-ray with neck extension,
which makes the condition much worse.
sub-axial subluxation
It is not very common,
occurs below C2 level,
and can cause fixed flexion deformity
due to ankylosis and osteoporosis.
What is rheumatoid arthritis?
- It is an autoimmune, systemic chronic inflammatory disease associated with:
a. * Polyarthritis of joints with pannus formation
b. * Synovitis of joints and tendon sheaths
c. * Loss of articular cartilage and erosion of bone and joint destruction
- Women are affected more than men.
- Age group is 30–55 years.
- Seventy percent are HLA DR4 +ve &
seropositive for rheumatoid factor.
What are the other system manifestations in rheumatoid arthritis?
- RS
* Pulmonary fibrosis,
vasculitis
* Pulmonary hypertension,
nodules - CVs
* Arteriosclerosis,
MI,
stroke
* Mitral valve disease,
pericardial effusion,
conduction defects - Blood
* Anaemia - Nervous system
* Peripheral neuropathy
* Autonomic dysfunction
* Compression neuropathy, myelopathy - Renal
* Amyloid,
nephropathy - Liver
* Felty’s syndrome
What are the other system manifestations in rheumatoid arthritis?
- Eye/skin
* Episcleritis, rheumatoid nodules, thin papery skin - Due to drugs
- NSAIDS—
renal and GI impairment - Methotrexate, gold, penicillamine—
immunosuppression, pancytopenia,
liver and renal dysfunction - Steroids—
hypertension, osteoporosis
- Joints
* Pain and morning stiffness due to inflammation of synovium
* Reduced bone density, cartilage loss
Should you be worried about this patient’s airway?
- Anterior or posterior subluxation and spinal cord compression
- Sub-axial subluxation—fixed flexion deformity
- TMJ involvement—reduced mouth opening
- Cricoarytenoid involvement—stridor
- Steroids—cause osteoporosis
How will you anaesthetise this patient?
Regional anaesthesia in form of spinal is the best for this patient, if there
is no absolute contraindication. It is also ideal from the surgical (enhanced
recovery pathway in major arthroplasty) point of view.
Preassessment
- Routine anaesthetic history and examination
- Airway assessment—
Mallampati assessment,
thyromental distance,
mouth opening,
jaw protrusion,
neck extension - Drug history and its effect on various organ systems
Investigations
- FBC, renal, and liver function tests
to assess type of anaemia and for a baseline function - Chest X-ray to look for pulmonary involvement
- Because of the nature and effect of the disease on cervical spine,
lateral C spine X-ray is deemed necessary
both in neck extension and flexion view
- Routine ECG and echocardiography if any significant cardiac symptoms
Intraoperative
- Position during the procedure
needs extra care and take precautions for
pressure area to be protected to prevent any injury
- Position during the procedure
- Full asepsis is maintained,
as a general measure and also due to the
state of immunocompromise in this group of patients
- Full asepsis is maintained,
- Warming and fluid management to prevent
any renal failure in the postoperative period
- Warming and fluid management to prevent
- Steroid replacement during surgery
- Good pain relief in postoperative period;
exercise caution with the use of
NSAIDs for fear of renal dysfunction and gastric ulcer
- Good pain relief in postoperative period;
- Patient control analgesia may not be appropriate
if hand deformities are present
- Patient control analgesia may not be appropriate
Postoperative
- ITU/HDU care in patients with severe respiratory disease
- Early mobilisation and postoperative physiotherapy
is useful in preventing postoperative respiratory
and other complications
What airway problems can rheumatoid arthritis present?
Cervical instability caused by weakening of the transverse ligament of the
atlas resulting in potential cord compression.
Assess with flexion and extension X-rays looking for a 3 mm gap
between odontoid peg and posterior border of anterior arch of atlas
