A 63-year-old woman with 22 years of seropositive rheumatoid arthritis is listed for elective total knee replacement. She reports occasional neck pain and transient electric shocks down the arms on flexing the neck. Power in all limbs is intact. Which preoperative investigation is most appropriate to evaluate her neck symptoms before anaesthesia?

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

Explanation

Long-standing RA erodes the transverse ligament of C1, producing anterior atlantoaxial subluxation, and can also cause vertical (basilar) invagination of the odontoid process into the foramen magnum. Flexion and extension lateral cervical films demonstrate dynamic instability and guide airway precautions during intubation. Lhermitte-like symptoms raise concern for cord compression, making imaging of the cervical column, not the brain, nerves or chest, the correct first step.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.