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.