Practice Perfect 912
The Pod Periop Medical Management Series #6:
Patients With Rheumatologic Disorders:
Part 1 - Rheumatoid Arthritis

Welcome back to our short series on medical management of the podiatric patient in the operative setting. Today we begin our sixth and final topic, the patient with rheumatologic disorders. This is a field, somewhat like diabetes, that has gone through a lot of changes in the last few years with a number of new medications and some updates on medical management. To make this more easily absorbable, we’ll begin by discussing patients with rheumatoid arthritis today. In next week’s issue, we’ll focus our attention on patients with gout and those taking oral steroids.

Rheumatic Disorders – Important Non-Medication-Related Concerns

Before we get to the medications where most of the changes have occurred, it’s first important to remember that patients with rheumatologic disorders are at increased risk of cardiac disease,1 so consider a thorough work-up and/or consultation with cardiology before elective surgery.

Next, recall also that patients with rheumatoid arthritis (RA) are at increased risk of atlantoaxial subluxation of the spine and therefore at risk for spinal cord injury during anesthesia. A recent study by Alp, et al found 33% of patients with rheumatoid arthritis in a cohort of 240 patients had anterior atlantoaxial subluxation without neck pain2 – they were asymptomatic. Since the screen for this disorder is simple (a set of cervical radiographs), we should order more of these preoperatively. These authors also found patients with the following characteristics were more likely to have subluxation: younger age at diagnosis of RA, longer duration of RA, a history of more erosions, joint replacement history, joint limitation, and higher levels of anti-citrullinated cytoplasmic antibodies (anti-CCP-Abs).2 Keep these characteristics in mind during your preoperative evaluation and testing.

We would be remiss if we didn’t discuss a little more about atlantoaxial subluxation. Recall that the first and second cervical vertebra are the atlas and axis, respectively. The atlas holds up the skull (like the Greek demigod Atlas holding up the world), while the axis allows the head to turn and rotate, as noted in Figure 1. The transverse ligament keeps the dens, the long process of the axis in place. RA damages the joints between these two vertebrae by causing erosions and synovitis. This inflammation results in laxity of the transverse ligament and/or damage to the dens, allowing subluxation of the atlas, for it to move abnormally in a number of different directions. However, since anterior subluxation of the atlas on the axis is most common, we’ll focus on that.

Figure 1. Anatomy of the C1 and C2 vertebrae.

Inadvertent abnormal movement of the spine during anesthesia in a patient with instability of this joint can lead to neurological damage, including severing the spinal cord in severe cases.

The following standing cervical spine radiographs should be ordered: anteroposterior, open-mouth odontoid, and lateral views in neutral, flexion, and extension. Subluxation is diagnosed when greater than 3 mm of movement is noted between the inferior arch of the atlas and odontoid process (the dens) of the axis3 (see Figure 2).

Figure 2. Properly aligned atlas and axis (left image) with anterior subluxation of the atlas on the axis (right image).

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Flexion of the neck increases the anterior pressure on the atlas which is why the flexion lateral C-spine image is important to appreciate (see Figure 3). This is the reason why extension of the neck and the use of a flat or donut pillow during anesthesia are important measures to protect the patient.4 If subluxation is found cancel any elective surgery and refer the patient for further workup with MRI to determine cord compression and possible stabilizing surgery. In emergent cases in patients with RA where surgery cannot be postponed, a team approach with involvement of the rheumatologist, anesthesiologist and possibly a spine surgeon may be the best approach. Additionally, video laryngoscopy will limit the amount of neck flexion during induction of general anesthesia.

Figure 3. C spine extension and flexion views showing normal alignment of the vertebrae (A) and anterior subluxation of the axis in a patient with RA (B).5

With these initial very important considerations in mind, we’re now able to discuss the perioperative management of the medications used to treat these patients. But we’ll address this in our final edition next week. Until then, Best wishes!

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

  1. Maradit-Kremers H, Crowson CS, Nicola PJ, et al. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum. 2005 Feb;52(2):402–411.
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  2. Alp G, Cinakli H, Akar S, Solmaz D. Prevalence of anterior atlantoaxial subluxation and association with established rheumatoid arthritis. Musculoskeletal Care. 2024 Mar;22(1):e1859.
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  3. Skues MA, Welchew EA. Anaesthesia and rheumatoid arthritis. Anaesthesia. 1993 Nov;48(11):989-997.
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  4. Tokunaga D, Hase H, Mikami Y, et al. Atlantoxial subluxation in different intraoperative head positions in patients with rheumatoid arthritis. Anaesthesiology. 2006 Apr;104(4):765-679.
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  5. Last accessed May 7, 2024.
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