Anesthesiology APPLIED Exam › Ambulatory, non-OR and special populations

Rheumatoid arthritis and ankylosing spondylitis

Ambulatory, non-OR and special populations·~5 min read· Physician-reviewed✓ Sourced · 3

Stem

A 66-year-old woman, 58 kg, with 20 years of seropositive rheumatoid arthritis is scheduled for elective right total knee arthroplasty. She takes weekly methotrexate, adalimumab every two weeks and prednisone 7.5 mg daily. She describes occipital pain and tingling in both hands when she looks down, and her voice has been hoarse for months. Mouth opening is two fingerbreadths, and her hemoglobin is 10.4 g/dL.

Question

What concerns you in her preoperative evaluation, and how will you plan her anesthetic?

Ideal answer

HeadlineHer cervical spine comes first: neck pain and hand paresthesias with flexion suggest atlantoaxial instability, so I image it and plan a spinal that avoids airway manipulation.

Flexion–extension radiographs, plus MRI for her neurologic symptoms, before an elective case; an atlas–dens interval above 3 mm in an adult suggests instability.¹
Nasendoscopy for the hoarseness, because cricoarytenoid arthritis gives a fixed, narrowed glottis that needs a smaller tube and can obstruct after extubation; I ask about stridor. Her limited mouth opening adds risk.
Look for pulmonary fibrosis, pericardial disease, the anemia's cause, because each changes my plan.
Continue methotrexate and her usual prednisone; withhold adalimumab so surgery falls at the end of its cycle, no supraphysiologic stress dose.²
Spinal with an adductor canal block, light sedation, head neutral. I still prepare for general: awake flexible bronchoscopic intubation moves the cervical spine least.¹

Breaking down the answer

Cervical spine before the knee — instability is present in roughly 60–65% of rheumatoid patients with cervical involvement, mostly as anterior subluxation of C1 on C2;¹ pannus erodes the transverse and alar ligaments, flexion lets the dens move toward the cord, riskiest during airway manipulation.¹
Imaging changes the plan, not the decision to be careful — a normal film does not license aggressive laryngoscopy in a symptomatic patient; positive films may justify neurosurgical review before an elective joint.
Deep sedation defeats the spinal — sedation that leads to obstruction and jaw thrust brings back the neck movement I avoided, so I keep it light with the airway plan ready.
Medications follow the ACR/AAHKS approach — continue conventional DMARDs, time surgery to the end of the biologic's cycle, and restart biologics once the wound is healing, typically about 14 days.²
Steroid advice conflicts — ACR/AAHKS keeps usual prednisone with no stress dose;² endocrine guidance gives parenteral hydrocortisone cover for surgery under general or neuraxial anesthesia above about 5 mg daily (see adrenal-insufficiency-and-steroids); I say which I follow and watch for refractory hypotension.
Ankylosing spondylitis is a different airway — a fixed flexion, "chin-on-chest" deformity can make direct laryngoscopy nearly impossible, and awake fiberoptic intubation is the usual standard.³ The fused, osteoporotic cervical spine fractures with minor force, so forceful videolaryngoscopy is also dangerous.³

Follow-up question

After three attempts the spinal fails, and the surgeon asks you to "just put her to sleep." Her flexion–extension films from this morning show an atlas–dens interval of 4 mm in neutral that widens markedly in flexion. How do you secure her airway?

Follow-up answer

HeadlineDocumented atlantoaxial instability with a likely narrowed glottis. I tell the surgeon we will secure the airway awake.

Awake flexible bronchoscopic intubation is the gold standard here, because the airway is entered under direct vision with the least cervical movement.¹ I topicalize, use minimal sedation, keep her neck neutral with manual in-line stabilization, and choose a smaller tube for the cricoarytenoid disease. If I must use a videolaryngoscope as backup, it reduces occiput–C1 motion compared with direct laryngoscopy.¹ After intubation I check hand grip and movement before induction, and I repeat a neurologic check when she wakes.

Pitfalls that cost points

Stopping or forgetting her daily prednisone.
Forcing laryngoscopy in ankylosing spondylitis with a fixed flexion deformity.

Rapid-fire

Q: What cardiac lesions occur in ankylosing spondylitis? A: Aortitis with aortic regurgitation, and septal fibrosis causing AV block, so watch for bradycardia at induction.³

Q: Why is neuraxial anesthesia hard in ankylosing spondylitis? A: Ossified midline ligaments; a paramedian approach with ultrasound helps, failure rates are high, and repeated attempts raise hematoma risk.³

Q: How do you position an ankylosing spondylitis patient? A: Support the head and neck in their own neutral, often flexed, position and pad every gap to avoid fractures.³

Q: What is their pulmonary pattern? A: Restrictive, from fused costovertebral joints, so breathing depends on the diaphragm and postoperative monitoring matters.³

Q: What does manual in-line stabilization cost you? A: It limits gross neck motion but worsens the glottic view with direct laryngoscopy.¹

Numbers to know

Item	Value
AAI in RA with cervical disease	~60–65%¹
Abnormal atlas–dens interval (adult)	>3 mm¹
Videolaryngoscope vs direct, occiput–C1 motion	~40–50% less¹
Restart biologic after surgery	~14 days, once healing²

Sources

1.Atlantoaxial instability (keyword) · OpenAnesthesia · openanesthesia.org
2.ACR/AAHKS guideline for perioperative management of antirheumatic medication in elective total hip or knee arthroplasty (summary) · The Rheumatologist (ACR) · the-rheumatologist.orgSummary of the ACR/AAHKS recommendations; the 2022 update kept withholding biologics for one dosing cycle and continuing conventional DMARDs.
3.Ankylosing spondylitis (keyword) · OpenAnesthesia · openanesthesia.org

Facts on this page were checked against these sources on Oct 16, 2026. Guidelines change; confirm doses against current institutional protocols.