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Atlanto-axial subluxation — SCE Rheumatology MCQ

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HardRheumatoid arthritisAtlanto-axial subluxationSCE Rheumatology

A 70-year-old woman with long-standing seropositive rheumatoid arthritis develops occipital pain, hand clumsiness and unsteady gait. Examination shows brisk reflexes, impaired vibration sense and active synovitis in the wrists. Cervical spine radiographs suggest atlanto-axial instability and CRP is 18 mg/L. What is the most appropriate investigation?

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Correct answer: C — MRI cervical spine

The combination of rheumatoid arthritis, occipital pain and upper motor neurone signs raises concern for cervical cord compression from atlanto-axial subluxation. MRI is the best investigation to assess cord compression and inflammatory pannus. Wrist ultrasound or nerve conduction studies would miss a potentially irreversible cervical myelopathy.

Reference: BSR standards for inflammatory arthritis care; NICE NG100