“The emotional consequences of the disease can cause depression, and these patients may be treated with chronic anti-depressant therapy”
known instability presents for elective surgery with no prior x-rays of the neck. While the patient may be asymptomatic, the incidence of silent cervical spine instability is common. Orthopaedic surgeons accustomed to dealing with RA and reconstructive surgery may be aware of the reports of neurological injury from airway management in patients with cervical spine instability. Some centres will require flexion- extension films for elective surgery. If presented with an RA patient with unknown cervical spine stability, the starting point is to evaluate the airway to determine if intubation can be performed without gross spine manipulation. Several factors determine the urgency for flexion- extension x-rays of the neck. The length of time from the onset of symptoms of RA is one, since instability increases with time. Another factor is the other criteria for airway management. If the mouth opens well, thyromental distance is normal, and the physical exam of the oropharynx is normal, the urgency to require neck films is reduced. If not, either x-ray evaluation or awake fiberoptic intubation will be indicated. When instability is known, the x-rays must be repeated at intervals, and the consensus is three years. When neurological
066 ARAB HEALTH MAGAZINE ISSUE 2 2012
findings are present, especially with motion of the neck, an MRI to identify spinal cord compression or nerve root impingement should be considered important. In cases of extreme instability, even awake intubation by itself may not be totally safe, and prior mechanical stabilization of the neck may be necessary.
CONCLUSION RA is a chronic disease with anaesthetic implications. Anaesthesia can be required for reconstructive procedures, co-incident illness or emergencies. Issues with the skin, pulmonary, cardiovascular systems, treatment of RA, as well as serious issues with airway management can complicate pre-anesthesia assessment as well as anaesthesia management. Careful pre-surgical assessment can prevent the potential intraoperative consequences of the pathophysiology of RA.
REFERENCES References available on request (
magazine@informa.com)
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