Musculoskeletal Assessment 1

Question 1

Preop Considerations

Answer 1

Basic patho
Pt’s hx/symptoms/deficits
Current tx/meds to manage disease
What diagnostic tests are indicated/previous results/must be ordered
Anesthetic implications

Question 2

Rheumatoid arthritis is considered to have ________ manifestations

Answer 2

Systemic

Question 3

RA Patho

Answer 3

Autoimmune mediated systemic inflammatory disease; characterized by morning stiffness that improves over the course of the day

Question 4

RA Presentation

Answer 4

pain & disability associated with destruction of synovial joints

Question 5

RA Presentation

Answer 5

Cellular hyperplasia of the synovium
Painful synovial inflammation with inc synovial fluid
Destruction of cartilage & articular surfaces
Periarticular osteopenia
Ligament damage leading to deformity & instability

Question 6

In RA, what type of cells causes the activation of endothelial cells that lead to autoantibodies & accelerates inflammatory cascade?

Answer 6

Cytokines
B-lymphocytes

Question 7

Symptoms of RA

Answer 7

**C-spine mobility (upper cervical spine affected in 85% of patients which can result in atlanto-axial subluxation & spinal cord compression)

Malaise, fatigue, multi-joint inflammation with morning stiffness, hoarseness, HA, accelerated atherosclerosis (increased incidence MI), restrictive lung dz, predisposed to pulmonary infections

Question 8

RA Hx

Answer 8

onset/course of dz, location/severity of joint dysfunction (C-spine, hoarseness-cricoarytenoid arthritis)

Comorbidities/affected organ systems (hand/wrists involved first, knees most common LE joint)

Management (physical therapy, current meds)

Question 9

Management of RA

Answer 9

PT, exercise, meds (analgesic, anti-inflammatory, steroids, DMARDS-dz modifying anti-rheumatic drugs)

Question 10

RA Medications

Answer 10

**Methotrexate (first line drug) → check CBC, LFTs
Corticosteroids → blunt immune response, does not slow progression
DMARDs → slow progression & prevent deformities, target T & B cells
NSAIDs, leflunomide, A TNF agents, IL 1 antagonist

Question 11

RA Airway exam

Answer 11

Degree of cord compression may not correlate w pt symptoms

-TMJ dz (limits oral opening)
-Arytenoid dz (VC dysfunction) → cricoarytenoid, cricothyroid, TMJ
-Sjogren’s dz (chronic dry mouth leading to poor dentition)

Question 12

What is a major airway concern for pts with RA?

Answer 12

C-spine instability (50-80% asymptomatic)

Atlanto-axial instability, atlanto-occipital subluxation (pinch SC), cranial settling onto C1 can cause HA & dysphagia, Ankylosis/mobility loss

Question 13

RA Diagnostic Testing

Answer 13

CBC, metabolic panel, LFT, C-spine flexion/extension

Question 14

RA Anesthesia Implications

Answer 14

-Airway mgmt (neuro deficit/obstruction risk post op, c-spine eval-want neutral, hoarseness/dysphagia, jaw locking, hx difficult intubation)
-Positioning (maybe pt position self)
-Regional Anesthesia (peripheral nerve block ok, challenging neuraxial block)

Question 15

What disease process is considered to chronic progressive inflammation of the spine & thorax that causes pain, stiffness, fatigue?

Answer 15

Ankylosing Spondylitis

Question 16

Ankylosing Spondylitis is a SYSTEMIC dx that progresses how?

Answer 16

Starts with SI joints & progresses cephalad (up) → lower back pain w morning stiffness (referred pain to buttocks)

Question 17

In Anky Spondylitis, fibrosis/ossification of ligaments leads to what?

Answer 17

difficult airway, risk spinal fractures, bamboo spine

Question 18

H&P considerations for Anky Spond?

Answer 18

-location/severity joint involvement (cervical & thoracic spine think airway)
-Functional capacity (ocular inflammation,
-**40% aortic valve insufficiency
-restrictive lung dz, malaise/fever)

Question 19

Tx of Anky Spond

Answer 19

PT, stretching, exercise, NSAIDS, DMARDS

Question 20

Anky Spond diagnostic Testing

Answer 20

no specific labs indicated, based on pt underlying pathology & pre op meds…CBC, BMP, LFTs (d/t dmards)

Question 21

Anky Spond anesthesia implications

Answer 21

Have mult plans for airway (ABCDEFG lol)

***Airway mgmt (neuro deficit/obstruction risk post op, c-spine eval-limited mobility, hoarseness/dysphagia, jaw locking)

Question 22

T/F: Spine/neck are very immobile in Anky Spond.

Answer 22

True

Question 23

What type of anesthesia is challenging for pts with Anky Spond?

Answer 23

Regional Anesthesia

(peripheral nerve block, challenging neuraxial block d/t ossification of ligaments & limited flexion)