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3.5.2 Clinical Manifestations
RA affects multiple joints simultaneously, with pain, stiffness, and swelling [
69
].
These symptoms in turn cause problems in using the joints to accomplish move-
ments and tasks, such as walking or getting dressed. RA primarily affects peripheral
joints, and less commonly the spine. Small joints of the
ngers and hands, and
wrists are affected in almost all patients. Knees, ankles, and small joints of the feet
and toes are also commonly affected. While other joints are less commonly
involved in RA, any synovial joint may be affected. Without treatment, the joint
pain and swelling tends to persist and can last weeks or months. Even with treat-
ment, symptoms may at times wax and wane, with
“
fl
ares
”
of worsening joint
in
ammation occurring episodically. A feeling of stiffness, or restricted ease of
movement, in and around the joints is common, particularly in the morning or after
periods of inactivity. Fatigue is also common during periods of active in
fl
ammation,
and joint pain may interfere with sleep. Patients often experience depression as a
consequence of chronic pain and concern about their future health.
Chronic joint in
fl
ammation that leads to cartilage, bone, and ligament damage
can result in joint deformities. Common deformities include
fl
xed
fl
flexion of the
fingers at the knuckles, and inward deviation of the
knees and ankles. Muscle weakness may result from both these deformities and
from disuse of painful joints. Loss of cartilage can also lead to limited range of
motion of the joints, which in severe cases can fuse and become immobile.
The cervical spine is involved in up to 80 % of patients with RA, although
symptoms related to the cervical spine may be present in less than one-half of
patients [
70
]. Cervical spine problems are more common later in the course of RA
than at the onset. The main symptoms are neck pain, headache at the back of the
head, and less commonly, numbness of the arms, hands, or legs. Rarely, instability
of the cervical spine as a result of in
fingers, sideways drifting of the
ammation can cause the vertebrae to impinge
on nerve roots or even the spinal cord, causing radiculopathy or myelopathy.
Depending on the location of the impingement, serious neurological complications
may occur. If the spinal cord is impinged, paralysis may result. If the brainstem is
impinged, sudden death may occur. These problems may be provoked by move-
ments that
fl
flex or extend the neck, and so raise particular concerns about whiplash
injuries in automobile accidents. Inadvertent injuries may also occur during the
placement of breathing tubes prior to general anesthesia, which requires the head
and neck to be extended. Impingement of major blood vessels at the base of the
skull may also occur and cause dizziness, weakness, and vision changes. The
Ranawat classi
fl
cation system is commonly used to grade the degree of neuro-
logical damage in patients with RA-related cervical spine disease. Class I indicates
no neurological de
cits. Class II indicates subjective weakness and numbness.
Class IIIA represents objective weakness and signs of spinal cord compression but
with preserved ability to walk, while Class IIIB represents weakness and signs of
cord compression with inability to walk.
Three types of cervical spine involvement are commonly recognized, which are
distinguished by the speci
