Key Points
- Screen for myelopathy, impending myelopathy, and instability.
- Focus on detecting signs that may indicate cervical spine involvement in rheumatoid arthritis (RA).
History
- Neck pain:
- Check for chronic or recent onset.
- Occipital headaches:
- Often related to RA-induced neck issues.
- Change to walking:
- New clumsiness, gait changes, or difficulty with balance.
- Functional deterioration:
- Difficulty with activities such as dressing or typing.
- Urinary or bowel disturbance:
- May indicate severe involvement affecting the cervical spine.
- Past treatment:
- Details on previous RA treatments, including medication and biologics.
- Co-morbidities:
- Other medical conditions affecting RA (e.g., diabetes, hypertension).
Examination
Look
- General features of appearance related to rheumatoid:
- Observe for any signs of severe RA (e.g., deformities in hands).
- Hands:
- Look for wasting, deformities, or changes that may be RA-specific (e.g., Swan neck deformity).
Feel
- Neck pain:
- Palpate for tenderness, step deformity, or signs of atlantoaxial instability.
- Sensation in upper limbs:
- Check for any neuropathy related to RA (e.g., median nerve involvement).
Move
- Neck ROM (Range of Motion):
- Reduced neck rotation, flexion, and extension can indicate cervical spine involvement.
- Gait:
- Observe gait for signs of a myelopathic gait (e.g., shuffling, broad-based, or ataxic gait).
Upper Limb Full Neurologic Exam
- Tone, power, reflexes:
- Assess the upper limbs for any signs of weakness, clumsiness, or muscle wasting.
- Myelopathy signs:
- Hofman’s sign: Rapid flicking of the index and thumb causes thumb adduction.
- Scapula tap: Tap on the scapula causes shoulder abduction and elbow flexion.
- Inverted radial reflex: An outward flicking motion of the thumb when lightly flicked.
- Hyperreflexia: May indicate spinal cord involvement.
Feel Lie Down
- Full Lower Limb Examination:
- Sensory, motor, and reflex assessments.
- Check for signs of spasticity or clonus.
Finishing
- PR (Per Rectum) and perianal sensation:
- Assess for sacral root involvement affecting bowel and bladder function.
- Vascular Exam:
- Look for signs of vascular insufficiency affecting the cervical spine.
- X-rays:
- AP (Antero-Posterior) and Lateral views to assess for joint destruction and stability.
- MRI of Cervical Spine:
- For detailed visualization of soft tissue changes, spinal cord compression, and instability.
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