In a patient with rheumatoid arthritis who requires intubation, which diagnostic study is most important to assess prior to anesthesia?

• A. Cervical spine radiographs
• B. Dual-energy X-ray absorptiometry
• C. Pulmonary function testing
• D. Schirmer test

Answer: (A)

Rheumatoid arthritis often affects the cervical spine, especially at the atlantoaxial joint, which can become unstable. During airway management, neck movement can provoke severe spinal cord compression if instability is present. Therefore, cervical spine radiographs with flexion and extension views are most important preoperatively to detect atlantoaxial subluxation or other dynamic instability. If instability is found, the anesthesia plan should minimize neck movement—maintain the neck in a neutral position, use in-line stabilization, and consider awake fiberoptic intubation or alternate airway strategies. The other tests don’t directly address airway safety: dual-energy X-ray absorptiometry assesses bone density, pulmonary function testing is helpful for known lung disease but not for securing the airway, and the Schirmer test has no relevance to anesthesia.