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Rheumatoid arthritis-associated cervical myelopathy — MSRA MCQ

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HardMRIRheumatoid arthritis-associated cervical myelopathyMSRA

A 64-year-old woman with 22 years of seropositive erosive rheumatoid arthritis attends for review. Her peripheral joint disease has been stable on methotrexate and abatacept. Over 3 weeks, she has developed increasing clumsiness of both hands, paraesthesia affecting several fingers bilaterally and unsteadiness when walking. She has dropped cups twice and now uses the bannister on stairs. She reports no neck pain, fever, recent trauma, radicular arm pain or bladder disturbance. Examination shows brisk upper- and lower-limb reflexes, bilateral extensor plantar responses and mildly reduced power of finger abduction bilaterally. There is no focal wrist synovitis and Tinel's test at both carpal tunnels is negative. She has no implanted devices or other contraindication to MRI. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Arrange urgent MRI of the cervical spine and specialist spinal surgical referral

Explanation lettering: D = shown as A · A = shown as B · B = shown as C · E = shown as D · C = shown as E

This presentation is cervical myelopathy until proved otherwise. Longstanding erosive rheumatoid arthritis confers risk of cervical spine involvement, while bilateral hand paraesthesia and weakness, gait unsteadiness, hyperreflexia and extensor plantar responses indicate a cervical cord process rather than isolated peripheral entrapment neuropathy. The absence of neck pain does not reduce the significance of these upper motor neurone signs. NICE specifically recommends urgent cervical MRI and referral for specialist surgical opinion when a person with rheumatoid arthritis develops symptoms or signs suggestive of cervical myelopathy. MRI is required to define cord compression and relevant soft-tissue, inflammatory and spinal cord abnormalities for operative decision-making. A is insufficient because plain dynamic radiographs may demonstrate instability but do not adequately assess cord compromise in established myelopathy. B would be a reasonable alternative only if MRI were contraindicated or unavailable urgently; this patient can undergo MRI. D initially appeals because hand paraesthesia and clumsiness may suggest peripheral neuropathy, but the pyramidal signs and gait disturbance make this unsafe as the primary pathway. E would be appropriate for uncomplicated suspected carpal tunnel syndrome, not bilateral progressive neurological signs with long-tract involvement.

Reference: NICE NG100: Rheumatoid arthritis in adults: management, recommendation 1.10.5 (Published 11 July 2018; last updated 12 October 2020; surveillance reviewed November 2024) — https://www.nice.org.uk/guidance/ng100/chapter/recommendations