Rheumatoid Cervical Spine

Key Points

  • Screen for myelopathy, impending myelopathy, and instability.
  • Focus on detecting signs that may indicate cervical spine involvement in rheumatoid arthritis (RA).

History

  1. Neck pain:
    • Check for chronic or recent onset.
  2. Occipital headaches:
    • Often related to RA-induced neck issues.
  3. Change to walking:
    • New clumsiness, gait changes, or difficulty with balance.
  4. Functional deterioration:
    • Difficulty with activities such as dressing or typing.
  5. Urinary or bowel disturbance:
    • May indicate severe involvement affecting the cervical spine.
  6. Past treatment:
    • Details on previous RA treatments, including medication and biologics.
  7. Co-morbidities:
    • Other medical conditions affecting RA (e.g., diabetes, hypertension).

Examination

Look

  1. General features of appearance related to rheumatoid:
    • Observe for any signs of severe RA (e.g., deformities in hands).
  2. Hands:
    • Look for wasting, deformities, or changes that may be RA-specific (e.g., Swan neck deformity).

Feel

  1. Neck pain:
    • Palpate for tenderness, step deformity, or signs of atlantoaxial instability.
  2. Sensation in upper limbs:
    • Check for any neuropathy related to RA (e.g., median nerve involvement).

Move

  1. Neck ROM (Range of Motion):
    • Reduced neck rotation, flexion, and extension can indicate cervical spine involvement.
  2. Gait:
    • Observe gait for signs of a myelopathic gait (e.g., shuffling, broad-based, or ataxic gait).

Upper Limb Full Neurologic Exam

  1. Tone, power, reflexes:
    • Assess the upper limbs for any signs of weakness, clumsiness, or muscle wasting.
  2. 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

  1. Full Lower Limb Examination:
    • Sensory, motor, and reflex assessments.
    • Check for signs of spasticity or clonus.

Finishing

  1. PR (Per Rectum) and perianal sensation:
    • Assess for sacral root involvement affecting bowel and bladder function.
  2. Vascular Exam:
    • Look for signs of vascular insufficiency affecting the cervical spine.
  3. X-rays:
    • AP (Antero-Posterior) and Lateral views to assess for joint destruction and stability.
  4. MRI of Cervical Spine:
    • For detailed visualization of soft tissue changes, spinal cord compression, and instability.
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