Patient: 58-year-old female Presentation: 20-year history of seropositive rheumatoid arthritis, 6 months of progressive unsteadiness, occasional suboccipital headaches worse with neck movement, episodes of dizziness, one fainting spell Relevant history: On methotrexate and prednisolone, multiple joint replacements (bilateral THR, right TKR), poorly controlled inflammation recently (elevated CRP) Examination findings:
| Test | Result | Normal Range | Interpretation |
|---|---|---|---|
| Haemoglobin | 108 g/L | 120-160 | Anaemia of chronic disease |
| WCC | 7.2 × 10⁹/L | 4-11 | Normal |
| Platelets | 385 × 10⁹/L | 150-400 | Normal |
| ESR | 65 mm/hr | 0-20 | Elevated - active RA |
| CRP | 42 mg/L | <5 | Elevated - active inflammation |
| Rheumatoid factor | Positive (256 IU/mL) | <14 | Seropositive RA |
| Anti-CCP | Positive (>300 U/mL) | <20 | High titre - erosive disease |
| Creatinine | 85 μmol/L | 60-110 | Normal (important for methotrexate) |
| ALT | 35 U/L | <40 | Normal (methotrexate monitoring) |
Image 1: Cervical Spine Radiographs - AP, Lateral, Flexion-Extension
Radiological features:
Image 2: MRI Cervical Spine with Brainstem
MRI findings:
Image 3: CT Cervical Spine
CT findings:
What are the three patterns of cervical spine involvement in rheumatoid arthritis and how do they present?
What are the clinical features of cervical myelopathy in RA, and how do you grade severity?
What imaging would you order and what measurements are critical?
What are the indications for surgery in RA cervical spine? What procedure would you recommend for this patient?
What are the specific perioperative considerations in RA patients undergoing cervical spine surgery?
What are the expected outcomes and complications of surgery? How do you follow up these patients?
This pattern suggests RA Cervical Spine Involvement:
Three Patterns of Involvement:
| Pattern | Frequency | Key Measurement | Surgical Concern |
|---|---|---|---|
| Atlantoaxial instability | 65% | ADI, PADI | C1-C2 fusion |
| Basilar invagination | 20-25% | Ranawat, McRae | Occipitocervical fusion |
| Subaxial subluxation | 20-25% | >3.5mm translation | Extended fusion |
Q: "What is pannus and why is it important?"
| Aspect | Description |
|---|---|
| Definition | Inflammatory synovial tissue proliferation |
| Location | Forms behind the dens, around the odontoid |
| Effect | Compresses cord, erodes bone, causes instability |
| Treatment response | May reduce with DMARDs/biologics |
| Surgical relevance | May need to excise if causing compression even after fusion |
Pannus can persist even after successful fusion and may need anterior resection if compression continues.
Q: "Why is pre-operative assessment important before other joint surgery in RA patients?"
| Concern | Action |
|---|---|
| AAI may be asymptomatic | Cervical X-rays before any GA |
| Intubation risk | Avoid neck manipulation |
| Positioning risk | Lateral for hip surgery stresses neck |
| Recommendation | Flexion-extension views pre-op if longstanding RA |
Patients with ADI >5mm or PADI <14mm need awake fibreoptic intubation and may need cervical stabilisation before elective surgery.
Q: "What is the difference between Harms-Goel and Magerl techniques?"
| Aspect | Harms-Goel | Magerl |
|---|---|---|
| Screws | Separate C1 lateral mass + C2 pedicle | Transarticular C1-C2 |
| Trajectory | C2 → C1 (two screws per side) | C2 → C1 single screw per side |
| Reducibility | Can reduce then fix | Must reduce before placing |
| VA risk | Lower | Higher (screw crosses VA territory) |
| Current preference | Most common | Less used now |
Harms-Goel is preferred because it allows reduction after screw placement and has lower VA injury risk.