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conjunction with methotrexate. Biologic medications, which are antibodies devel-
oped to block key mediators of in
ammation such as tumor necrosis factor-alpha or
interleukin-6, are also effective in controlling in
fl
ammation and slowing joint
damage. Biologics are often added when conventional disease-modifying medica-
tions have proven to be insuf
fl
cient at controlling joint pain and swelling. For most
patients, treatment is needed for years or decades, although slow tapering of
medications is often possible as the in
ammation comes under control.
Physical therapy and occupational therapy can help improve joint function and
range of motion. Joint replacement surgery or joint fusion surgery is indicated when
dysfunction or persistent pain of damaged joints limits the patient
fl
s ability to do
daily activities. These surgeries are very effective in relieving pain and restoring
functional ability. Treatment of cervical spine involvement includes traction to help
relieve pressure on the impinged nerves or spinal cord, surgery to decompress the
area by removing excess synovial tissue, and surgical fusion of the vertebrae to
stabilize regions of subluxation. Cervical spine surgery is often effective in pro-
viding at least partial pain relief and preventing worsening of the neurological
problems. However, existing neurological damage may not reverse with surgery.
Recovery from quadriparesis is uncommon and the survival of these patients is low
[
73
].
'
3.5.4 Imaging
Plain radiographs of peripheral joints are very useful in the diagnosis of RA, as well
as helping to distinguish other types of arthritis that may have clinical features that
mimic RA [
74
]. In early RA, radiographs may be normal or show only prominent
shadows of the joint linings or excess joint
fluid. Osteopenia next to the joints may
also be visible. Tell-tale bone erosions at the margins of the joints are the most
speci
fl
c radiographic sign of RA, and occur in up to 60 % of patients. Radiographs
can also demonstrate joint space narrowing due to cartilage loss, bony fusion, and
bone malalignment or subluxations. In the cervical spine, radiographs can ade-
quately show each of the three main types of involvement, although
films taken
with both neck
flexion and extension may be needed to reveal dynamic atlanto-axial
subluxation (Fig.
12
). Radiographs are useful in planning surgical approaches and
evaluating the results of surgical corrections. Development of new bone erosions
and progressive joint space narrowing on radiographs is used in clinical trials to test
the ef
fl
cacy of medications and in clinical practice to monitor patient
'
s responses to
medications.
Diagnostic ultrasound has been increasingly used to detect thickening of the
joint linings and other signs of joint in
ammation, such as enhanced Power Doppler
signals, which may help in diagnosis [
75
]. Improvement or resolution of these
features can also be used to assess remission and response to treatment. Erosions of
bone are also visible on ultrasound, but the time needed for examination may limit
its use for assessing progression of erosions. Ultrasound can also be used to guide
the injection of medications into a joint.
fl
