Cervical spine disease and its neurologic risk is well recognized in rheumatoid arthritis and ankylosing spondylitis. In RA, pannus formation and destruction of ligamentous supporting structures may lead to atlantoaxial subluxation; an atlantodental distance in excess of the normal 3.5 mm seen in a lateral flexion view suggests instability (in children under 12, 4 mm of widening is normal). Cord compression may occur acutely following a trivial injury or be more insidious. Subtle clues include a change in bowel or bladder function, new weakness, numbness, or paresthesias. Instability may lead to cranial migration of the odontoid. Complaints relating to vertebral insufficiency (e.g., vertigo) may be reported. Lhermitte sign, an electric shock sensation radiating down the back on neck flexion, is a classic indication of cervical spine instability. Strength may be difficult to assess in an RA patient, so subtle differences in reflexes are particularly informative. Lateral cervical spine films in flexion are essential for evaluation. Neck flexion should not be forced, but rather studied at a degree considered comfortable by the patient.
The ankylosed, inflexible cervical spine in a patient with a seronegative spondyloarthropathy (e.g., ankylosing spondylitis) is susceptible to fracture with minor trauma. A whiplash-type injury or a blow from behind may result in new neck pain in an ankylosed area. The complaint of new neck pain requires a careful history and examination, with attention to possible trauma to the neck and evidence of peripheral nerve damage. Fractures are most commonly transverse through a disc space, leading to greater risk of dislocation and cord compression.
Intubation of patients with rheumatic cervical spine disease is best addressed in an elective, controlled situation after the cervical spine has been assessed. In an emergency, a patient with a stiff or arthritic neck should be intubated by the most experienced operator available. Atlantoaxial instability should be assumed, and extremes of head manipulation avoided.
The spinal cord can be affected by transverse myelitis in SLE, or a number of factors can induce an anterior spinal artery syndrome in patients with rheumatic diseases. The anterior spinal artery is a direct branch of the aorta; dissection of the aorta, vasculitis, or embolism can impair blood supply to the anterior cord and produce a clinical picture distinct from transverse myelitis or metastatic tumor by sparing of posterior column function (position sense and vibration).
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