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RA Cervical Spine Intubation — SCE Rheumatology MCQ

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ModerateRheumatology EmergenciesRA Cervical Spine IntubationSCE Rheumatology

A 55-year-old man with longstanding rheumatoid arthritis and documented atlantoaxial instability requires urgent surgery. He is alert, oxygenating adequately and able to cooperate with airway management. Which intubation plan most appropriately reduces the risk of cervical spinal cord injury?

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Correct answer: C — Maintain neutral cervical alignment and minimise movement, using an expert-led technique such as awake flexible bronchoscopic intubation

The correct answer is C. Rheumatoid synovitis can produce atlantoaxial or subaxial instability, so neck movement during airway manipulation may worsen spinal cord or vertebrobasilar compromise. Existing imaging should be reviewed and the cervical spine kept in neutral alignment. In this cooperative, adequately oxygenated patient, an expert-led awake technique—often flexible bronchoscopic intubation—allows the airway to be secured while minimising cervical movement and preserving spontaneous ventilation. Videolaryngoscopy may be an alternative depending on anatomy, urgency and local expertise. Standard sniffing-position laryngoscopy and deliberate extension are inappropriate. Urgency does not justify abandoning cervical precautions. Manual in-line stabilisation may form part of the plan, but it is not by itself sufficient justification for routine direct laryngoscopy irrespective of the instability.

Reference: Wiles MD et al. Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society, Association of Anaesthetists and collaborating UK societies. Anaesthesia. 2024;79:856-868. https://pubmed.ncbi.nlm.nih.gov/38699880/