Rheumatoid arthritis (RA) is a chronic, systemic autoinflammatory disorder characterized by

• Deforming symmetrical polyarthritis of varying distribution and severity
• Association with synovitis of joint and tendon sheaths
• Articular cartilage loss
• Erosion of juxta-articular bone (2).

• The initiating cause of RA remains unknown, but several factors may contribute.
• Approximately 70% of cases are associated with the HLA-DR4 subtype, and 80% of patients are seropositive for rheumatoid factor.
• Environmental factors also seem to play a role, including as yet unidentified viral or bacterial agents.
• Other risk factors associated with the development of RA include female gender, a family history of RA, food allergies and intolerances, altered gut flora, psychological stress, exposure to heavy metals, and smoking (4).

There are two popular theories regarding the pathogenesis of RA. The first holds that the T cell, through interaction with an as yet unidentified antigen, is primarily responsible for initiating the disease and driving the chronic inflammatory process. The second theory holds that while T cells may be important in initiating the disease, chronic inflammation is self-perpetuated by macrophages and fibroblasts in a T-cell independent manner.

• Careful assessment for atlantoaxial subluxation (present in up to 25% of patients) and concomitant organ dysfunction. The anesthetic plan should be tailored to specific manifestations (e.g., renal, cardiac, pulmonary disease, etc).
• Stress dose steroids should be considered for patients on chronic therapy.

Morning stiffness, pain, fatigue, malaise, and depression

Total joint arthroplasties can reduce pain and improve function. Other operations include the release of nerve entrapments (e.g., carpal tunnel syndrome), arthroscopic procedures, and occasional removal of a symptomatic rheumatoid nodule.

• NSAIDs
• Corticosteroids
• Disease modifying anti-rheumatic drugs (DMARDs): Methotrexate, sulfasalazine, leflunomide (Arava^®), etanercept (Enbrel^®), infliximab (Remicade^®), adalimumab (Humira^®), abatacept (Orencia^®), rituximab (Rituxan^®), anakinra (Kineret^®), antimalarials, gold salts, D-penicillamine, cyclosporin A, cyclophosphamide, and azathioprine (Imuran) (2).

• Neurological. Peripheral neuropathy in the lower extremities is often present with mild, primarily sensory, dysfunction. Entrapment neuropathy, such as carpal tunnel or tarsal tunnel syndromes, may also be seen. Acute subluxation of the cervical spine is a particularly worrisome complication that can cause permanent quadriparesis or death from spinal cord or vertebral artery compression. There are four subtypes:
  • Anterior comprises 80% of atlantoaxial subluxation. The C1 vertebra moves forward on C2 because of destruction of the transverse ligament and there is a risk of spinal cord compression by the odontoid peg. Subluxation exists when the distance between the atlas and the odontoid peg exceeds 4 mm in patients older than 44 years and 3 mm in younger patients. Anterior atlantoaxial subluxation is worsened by neck flexion.
  • Posterior comprises 5% of atlantoaxial subluxation. Destruction of the odontoid peg may cause backward movement of C1 on C2, which may be evident on lateral extension views of the neck. Posterior atlantoaxial subluxation is worsened by neck extension.
  • Vertical comprises 10–20% of atlantoaxial subluxation. Destruction of the lateral mass of C1 can lead to subluxation of the odontoid peg through the foramen magnum and compression of the cervicomedullary junction.
  • Lateral or rotatory subluxation (rare) results from degenerative changes in the C1/C2 facet joints. It can lead to spinal nerve compression and vertebral artery compression.
• Ocular: Keratoconjunctivitis of Sjögren syndrome (most common), episcleritis (mild pain and intense redness), scleritis and corneal ulcerations (rare, but serious)
• Sjögren syndrome is a chronic inflammatory disorder characterized by lymphocytic infiltration of lacrimal and salivary glands; seen in 10–15% of patients with RA. This leads to impaired secretion of saliva and tears and results in the sicca complex: Dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca).
• Cardiac: Pericardial effusions, pericarditis, cardiac tamponade, myocarditis, amyloidosis, granulomatous disease, endocarditis, left ventricular failure, coronary artery disease (5).
• Pulmonary: Restrictive defects from interstitial lung disease (fibrosing alveolitis), rheumatoid nodules, reduced chest wall compliance (costochondral disease)
• Vascular: Rheumatoid vasculitis (small digital infarcts along the nailbeds). The abrupt onset of an ischemic mononeuropathy (mononeuritis multiplex) or progressive scleritis is typical Raynaud's phenomenon.
• Renal: Chronic renal failure from drug treatment is seen in ~25% of patients.
• Subcutaneous nodules are the most characteristic extraarticular lesion of the disease; occurs in 20–30% of cases. They are located most commonly on the extensor surfaces of the arms and elbows, but are also prone to develop at pressure points on the feet and knees. Rarely, nodules may arise in visceral organs, such as the lungs, the heart, or the sclera of the eye.
• Airway
  • Involvement of the cricoarytenoid joints may result in dyspnea, stridor, hoarseness, and occasionally severe upper airway obstruction (3). Patients may also present with a mass in the larynx, which can cause significant disfiguration of the surrounding structures (4).
  • Laryngeal amyloidosis and rheumatoid nodules may also cause obstruction of the larynx.
  • The temporomandibular joint (TMJ) may be involved causing limitation of mouth opening and render direct laryngoscopy impossible.
  • Acute subluxation may cause spinal cord and/or vertebral artery compression leading to quadriparesis or sudden death
• Felty syndrome is a rare complication and is characterized by splenomegaly and leukopenia (predominantly granulocytopenia). Recurrent bacterial infections and chronic refractory leg ulcers are the major complication.

Unstable atlantoaxial subluxation may require stabilization prior to elective surgery.

Depends on the surgical procedure, concomitant organ disease, or intraoperative events

• Restart anti-inflammatory medications as soon as possible
• Continue steroid dosing

714.0 Rheumatoid arthritis

• M06.9 Rheumatoid arthritis, unspecified
• M06.30 Rheumatoid nodule, unspecified site

Tayab R.andrabi