A 55-year-old woman with long-standing seropositive rheumatoid arthritis is posted for total knee replacement under general anaesthesia. She reports neck stiffness but no neurological deficit. Which preoperative investigation is most appropriate before airway management planning?

• A CT brain with contrast
• B Nerve conduction studies of all four limbs
• C Flexion and extension lateral cervical spine radiographs ✓
• D MRI lumbar spine

Explanation

Rheumatoid arthritis can cause atlantoaxial subluxation from erosion of the transverse ligament, risking spinal cord compression during laryngoscopy and neck manipulation. Dynamic flexion and extension lateral radiographs demonstrate instability and guide whether awake fibreoptic intubation or manual in-line stabilisation is needed. Symptoms correlate poorly with radiographic findings, so imaging is indicated even without neurological signs. Brain CT, limb nerve conduction studies, and lumbar MRI do not assess craniocervical stability.

Reference: Miller's Anesthesia, 9th ed.

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