Rheumatoid arthritis and anaesthesia



anaesthesia, rheumatoid arthritis, cervical spine, disease modifying anti-rheumatic drugs, peri-operative management


Rheumatoid arthritis (RA) is an autoimmune disease that causes joint stiffness and pain. Life expectancy of patients with RA is reduced and the aetiology is unknown. Multi-organ system involvement is common, and the perioperative assessment is important. Joints involved that are crucial for the anaesthesiologist are temporomandibular joint (TMJ), cervical spine and cricoarytenoid.

Early involvement of the cervical spine in RA is common, and a majority are asymptomatic.The most common cervical spine disorder is atlantoaxial subluxation (AAS). RA can affect the TMJ with decreased mouth opening and cervical stiffness that can lead to a difficult airway. Involvement of the cricoarytenoid joint can be acute or chronic.

Systemic features of RA may be more prominent than articular manifestations. Heart failure is the most common cause of mortality; however, pulmonary fibrosis and valvular involvement have been described.

Serum rheumatoid factor (80%), HLA-DR4 subtypes (70%) and anti-citrullinated protein antibody are elevated in patients with RA. Other factors like female gender and family history may play an additional role.

The main goal of therapy is to relieve symptoms and long-term prevention of joint destruction and systemic involvement. Corticosteroids alleviate the pain, swelling and structural progression. Nonsteroidal anti-inflammatory drugs (NSAIDs) also provide effective symptom relief for RA. Early use of disease-modifying anti-rheumatic drugs (DMARDs) is recommended. Methotraxate (MTX) is the cornerstone for RA treatment and tumour necrosis factor (TNF) blockers reduce inflammation.

Preoperative assessment is crucial to evaluate the disease severity and drug therapy side-effects. RA can result in a wide range of airway involvement; therefore, preoperative airway assessment is imperative. The investigations necessary depend on the degree of organ involvement. Anaesthetic choice will be dictated by the type of operation and the patient. Orthopaedic surgeries are the most common procedures in patients with RA, and most regional anaesthetic methods may be applied. General anaesthesia has the advantage of maintaining respiratory and haemodynamic stability, however, airway manipulation and maintenance are crucial in patients with RA. In the postoperative period, precautions should be exercised during emergence with appropriate patient positioning and prevention of excessive neck movement.

Author Biography

AV Nkuna, University of the Witwatersrand

Department of Anaesthesiology, Faculty of Health Sciences, School of Clinical Medicine, University of Witwatersrand, Charlotte Maxeke Johannesburg Academic Hospital, South Africa






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