Rheumatoid Atlantoaxial Subluxation Research Articles

Successful Prevention of Bow Hunter’s Stroke Associated with Rheumatoid Atlantoaxial Subluxation via Coil Occlusion (P8-5.027)

Successful Prevention of Bow Hunter’s Stroke Associated with Rheumatoid Atlantoaxial Subluxation via Coil Occlusion (P8-5.027)

Surgical techniques for degenerative cervical spine in Finland from 1999 to 2015

PurposeThe purpose of this study is to assess the trends and regional variations in the operative techniques used for degenerative or rheumatoid cervical spine disease in Finland between 1999 and 2015.MethodsThe Finnish Hospital Discharge Register (FHDR) was searched for the data on all the primary operations for degenerative cervical spine disease (DCSD) or rheumatoid atlanto-axial subluxation (rAAS). Operative codes were used to identify the patients from the FHDR and combined with diagnosis codes to verify patient inclusion. The patients were classified into three groups: anterior cervical decompression and fusion (ACDF), posterior decompression and fusion (PDF) and decompression.ResultsA total of 19,701 primary operations were included. The adjusted incidence of ACDF rose from 6.5 to 27.3 operations/100,000 adults. ACDF became the favoured technique in all the diagnostic groups except AAS, and by 2015, ACDF comprised 84.5% of the operations. The incidence of PDF for DCSD increased from 0.2 to 0.7/100,000 people. Solely decompressive operations declined from 13.7 to 4.0 operations/100,000 people. The regional differences in the incidence of operations were most marked in the incidence of ACDF, with overall incidences ranging from 11.2 to 37.0 operations/100,000. The distribution of the operative techniques used varied as well.ConclusionsBetween 1999 and 2015, the operative techniques used for DCSD changed from prevalently decompressive to utilising ACDF in 68.8 to 91.0% of the operations, depending on the treating hospital. ACDF became the most commonly applied technique for all degenerative diagnoses except AAS.

Surgery for degenerative cervical spine disease in Finland, 1999\u20132015

BackgroundThe incidence of surgery for degenerative cervical spine disease (DCSD) has risen by almost 150% in the USA in the last three decades and stabilized at slightly over 70 operations/100,000 people. There has been significant regional variation in the operation incidences. We aim to assess the diagnosis-based, age-adjusted trends in the operation incidences and the regional variation in Finland between 1999 and 2015.MethodsData from the Finnish Hospital Discharge Register (FHDR), the Cause of Death Register, and the registers of the Social Insurance Institution were combined to analyze all the primary operations for DCSD or rheumatoid atlanto-axial subluxation (rAAS). Combinations of the operative and the diagnosis codes were used to classify the patients into five diagnostic groups.ResultsA total of 19,701 primary operations were included. The age-adjusted operation incidence rose from 21.0 to 36.5/100,000 people between 1999 and 2013 and plateaued thereafter. The incidence of surgery for radiculopathy increased from 13.1 to 23.3 operations/100,000 people, and the incidence of surgery for DCM increased from 5.8 to 7.0 operations/100,000 people. The rise was especially pronounced in surgery for foraminal stenosis, which increased from 5.3 to 12.4 operations/100,000 people. Of the five diagnostic groups, only operations for rAAS declined. Operations increased especially in the 40- to 65-year-old age group. The overall operation incidences varied from 18.3 to 43.1 operations/100,000 people between the university hospitals.ConclusionsThe age-adjusted incidence of surgery for DCSD has risen in Finland by 76%, but the rise has plateaued. Surgery for radiculopathy, especially for foraminal stenosis, increased more steeply than surgery for degenerative medullopathy, with vast regional differences in the operation incidences.

Syringomyelia associated to rheumatoid-atlantoaxial subluxation: about a new case.

We report a case of 64-year-old Tunisian woman with a 12-year history of rheumatoid arthritis, who presented with a 3-month history of increasing inflammatory neck pain. Neurological examination noted a quadripyramidal syndrome without any neurological deficit. Radiographs of her neck showed ananterior atlantoaxial subluxation (A). MRI revealed a pannus around the atlanto axial joint. It also showed a co-existing syringomyelia (B). The cervical spine is frequently involved in patients with rheumatoid arthritis. However, rheumatoid atlantoaxial subluxation with syringomyelia is very rare. Many hypothesised mechanisms were suggested for thesyrinx formation. The most commonly admitted, suggested that atlanto axial sub luxation may reduce the rate of ascending cerebrospinal fluid, so it would travel through the spinal cord producing syringomyelia.

Dominant vertebral artery injury during posterior atlantoaxial transarticular screw fixation in a juvenile rheumatoid arthritis patient with atlantoaxial subluxation.

Many authors have reported on iatrogenic vertebral artery (VA) injury, but, to our knowledge, this is the first report of a dominant VA injury with compensatory blood flow from the hypoplastic VA. A 23-year-old woman with juvenile rheumatoid arthritis and atlantoaxial subluxation sustained injury to her dominant VA after occipitocervical fusion using transarticular screws. This did not result in lethal consequences due to compensation from her hypoplastic contralateral VA. Postoperative angiography, however, illustrated occlusion of the dominant left side, while the hypoplastic VA of the right side was enlarged. The patient experienced vertigo and loss of consciousness several times during rehabilitation. At the 4-year follow-up exam, bony fusion was observed, with no neurological deficits or correction loss. She had had no episodes of unconsciousness and no recurrence of any symptoms over the previous 3 years.

Positional occlusion of the vertebral artery in a case of rheumatoid atlantoaxial subluxation presenting with multiple cerebral and cerebellar infarction

We report an uncommon case of positional occlusion of the vertebral artery associated with rheumatoid arthritis (RA). Plain radiography showed reducible atlantoaxial subluxation, and dynamic vertebral arteriography demonstrated positional occlusion of the left vertebral artery. The patient was treated with C1-2 posterior fusion and has since experienced no recurrent symptoms. Insufficiency of the vertebrobasilar artery is a relatively uncommon complication with cervical lesions in RA patients. However, when RA patients manifest recurrent cerebral and cerebellar symptoms, this condition should be kept in mind and actions taken to avoid further irreversible cerebral damage. Recommended imaging methods include vertebral dynamic lateral plain radiography of the cervical spine and vertebral arteriography at multiple cervical positions.

Acute Retropharyngeal Calcific Tendinitis in an Unusual Location: a Case Report in a Patient with Rheumatoid Arthritis and Atlantoaxial Subluxation

Acute Retropharyngeal Calcific Tendinitis in an Unusual Location: a Case Report in a Patient with Rheumatoid Arthritis and Atlantoaxial Subluxation

Rheumatoid Atlantoaxial Subluxation Can Be Prevented by Intensive Use of Traditional Disease Modifying Antirheumatic Drugs

To evaluate the 5-year incidence of cervical spine disorders in patients with early rheumatoid arthritis (RA) treated by 2 different disease modifying antirheumatic drug (DMARD) strategies. In a national, multicenter, prospective FIN-RACo-trial, a cohort of 199 patients with early, clinically active RA was randomly assigned to treatment with a combination of 3 DMARD and prednisolone (Combi group) or with a single DMARD (Single group) with or without prednisolone, aiming to induce remission. After 2 years, the DMARD therapy was unrestricted. Lateral view cervical spine radiographs during full flexion and extension were taken at the 5-year followup visits. The presence of anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI), and subaxial subluxation (SAS) was assessed in the 149 patients with radiographs available (80 Single and 69 Combi). At the 5-year visits, aAAS, AAI, and SAS were found in 13 (9%), 6 (4%), and 9 (6%) patients, respectively. The corresponding Single/Combi group ratios were 11/2, 5/1, and 5/4. Of the baseline data, only poor physical function [Health Assessment Questionnaire (HAQ); p = 0.024] and Single treatment strategy (p = 0.019) were significantly associated with aAAS. Worse HAQ scores and Disease Activity Score 28 values were found in patients who developed aAAS during the 5-year followup. RA patients with sustained clinical disease activity and poor HAQ are at increased risk of developing aAAS. The development of aAAS during the first 5 years of RA was rare among the patients treated with a combination of DMARD for at least 2 years from the diagnosis. Intensive treatment with traditional DMARD prevents or retards the development of aAAS in patients with recent-onset RA.

Safety of atlantoaxial fusion using laminar and transarticular screws combined with an atlas hook in a patient with unilateral vertebral artery occlusion (case report)

A disadvantage of transarticular and C2 pedicle screws is vertebral artery (VA) injury as a result of screw misplacement. If unilateral occlusion of the VA is present, VA injury of the dominant side will cause fatal complications as a result of collateral flow insufficiency. Several authors have recently reported the usefulness of C2 laminar screws because of their safety on VA injury. We used transarticular and C2 laminar screws combined with the atlas hook in a patient with C1-2 instability and unilateral VA occlusion, in order to reduce the risk of further VA injury. A 64-year-old woman with rheumatoid atlantoaxial subluxation complained of cervical myelopathy and neck pain. Preoperative MR angiography showed a left side VA occlusion. The patient underwent atlantoaxial, posterior fusion using a transarticular screw on the side of the occlusion and a C2 laminar screw on the dominant side combined with a bilateral atlas hook. The transarticular screw was inserted using a navigation system and image intensifier, and the laminar screw was inserted free hand. Bone grafting from the iliac crest was performed. Transarticular and C2 laminar screws fixation combined with the atlas hook in a patient with unilateral VA occlusion is a useful technique, in order to reduce the risk of further VA injury.

Sagittal Alignment of the Subaxial Cervical Spine After C1-C2 Transarticular Screw Fixation in Rheumatoid Arthritis

Several articles reported the association between the development of subaxial kyphosis and the hyperlordotic fixation of C1-C2. However, their patients were heterogeneous in both primary disease and operative procedure. Transarticular screw fixation has become a popular procedure for C1-C2 arthrodesis instead of wiring techniques in which C1-C2 is difficult to fix in the intended alignment. Furthermore, in rheumatoid arthritis (RA) patients, subaxial lesions play an important role in potential subaxial alignment changes. The subaxial influences after C1-C2 transarticular screw fixation in patients with RA are unclear. To investigate the radiographic features of the subaxial cervical spine after C1-C2 transarticular screw fixation for RA, we reviewed 28 cases of C1-C2 transarticular screw fixation for rheumatoid atlanto-axial subluxation. The sagittal alignment of C1-C2 and the subaxial cervical spine was measured and the factors that affect subaxial alignment were investigated. Subaxial alignment became less lordotic in the postoperative course. The C1-C2 fixation angle and subaxial alignment showed a negative linear correlation. However, no significant correlation was found between changes in the C1-C2 angle and changes in the subaxial alignment. Four patients had a postoperative kyphotic subaxial deformity. Neurologic deterioration recurred in 4 patients, because of the postoperative development of subaxial subluxation. Common radiographic changes included an increase in C1-C2 lordosis, constant inclination of C1, an anterior shift of C2, and a decrease in C2-C7 lordosis. Many factors, not only C1-C2 angle, are associated with subaxial sagittal alignment change after C1-C2 transarticular screw fixation.

Safe Atlantoaxial Fixation Using a Laminar Screw (Intralaminar Screw) in a Patient With Unilateral Occlusion of Vertebral Artery

A case of atlantoaxial fusion using an intralaminar (unilateral-crossing laminar screw) screw is presented in a patient with unilateral vertebral artery communication with the basilar artery. To document the significance of the intralaminar screw technique in the aforementioned case. Vertebral artery injury is directly linked with intraoperative or perioperative death if the vertebral artery communicates only unilaterally to the basilar artery or has an obvious dominant side. In this situation, irrespective of whether the pedicle is confirmed to be sufficient for pedicle screw placement, if the vertebral artery is violated, fatal complications will occur. The literature reports that even proficient surgeons cannot guarantee 100% accuracy in pedicle screw placement. The intralaminar screw technique is currently the safest with regard to avoiding violation of the vertebral artery. Biomechanical studies have also shown this technique to ensure sufficient strength. The patient had rheumatoid atlantoaxial subluxation, and the right vertebral artery alone communicated with basilar artery, while the left ended blind. She underwent atlantoaxial fixation with an intralaminar screw (unilateral-crossing laminar screw) of the axis and lateral mass atlas screws inserted via the posterior arch. The intralaminar screw (unilateral-crossing laminar screw) was completed, and comprised lateral mass atlas screws and rods. There were no complications during and after surgery. Good bone union was achieved. Patients with unilateral dominant vertebral artery are good candidates for the intralaminar screw technique, even if the pedicle anatomy is sufficient to insert pedicle screws.

ATLANTOAXIAL ARTHRODESIS FOR VERTEBROBASILAR INSUFFICIENCY DUE TO RHEUMATOID ARTHRITIS

Patients with rheumatoid arthritis often have involvement of the cervical spine, which may lead not only to impairment of activities of daily living but also to sudden death 1. Cervical instability secondary to rheumatoid arthritis is associated with compression myelopathy in many patients and with vertebrobasilar insufficiency in some patients. To our knowledge, this is the first report of the surgical treatment of vertebrobasilar insufficiency in a patient with rheumatoid atlantoaxial subluxation without evidence of a compression myelopathy. The subject of this case report was informed that data concerning the case would be submitted for publication. A woman was diagnosed with rheumatoid arthritis in 1982, at the age of forty-five years, and hemodialysis was begun in 1997 to treat chronic renal insufficiency. She was hospitalized repeatedly since 1998 because of difficulty walking due to arthritis of both hips and knees and, in 1998, she underwent a right total hip arthroplasty. Cervical pain developed in the spring of 1999. A diagnosis of atlantoaxial subluxation was made, and the patient wore a cervical collar to help control the pain. In the fall of 1999, she began experiencing neuralgia of the left greater occipital nerve when she extended the neck. At the same time, she had vertigo, a feeling of faintness, and slurred speech. These symptoms were transient and resolved shortly after their onset. In December 1999, the patient had a spontaneous seizure and was unconscious for approximately five minutes. After that episode, she could not speak clearly for several hours. She was examined for signs of cerebral infarction and underwent electroencephalography, the findings of which were reported to be normal. In June 2000, she lost consciousness again and had difficulty with her speech immediately thereafter; she …

Navigated transoral approach to the cranial base and the craniocervical junction: technical note.

The transoral approach is an elegant reliable surgical procedure that provides anterior exposure of the cranial base and the craniocervical junction. Our objective was to demonstrate the advantages of neuronavigation in planning and performing the transoral approach. Three patients with chordomas and one patient with rheumatoid atlantoaxial subluxation were considered for a neuronavigated transoral procedure. For image guidance, the Stryker navigation system (Stryker Instruments, Kalamazoo, MI) was used. Registration was performed with individually constructed occlusal splints with four markers. The transoral approach was successfully used for two patients with chordomas involving the cranial base and the upper spine and for one patient with dislocation of the dens and medullary compression. In one case, preoperative simulation of the approach and trajectory planning demonstrated that adequate resection could not be achieved via the transoral route, and a paracondylar suboccipital approach was used. The registration accuracy achieved with the occlusal splint was less than 1 mm. Neuronavigation is a useful tool for planning and performing a transoral approach. It optimizes preoperative planning, clarifies and secures resection limits, and reduces overall surgical morbidity. Registration with an occlusal splint with four markers proved to be an attractive alternative to conventional systems.

Periodontoid pannus migration into the spinal canal with reduction of rheumatoid atlantoaxial subluxation: a case report

AbstractWe report a patient with rheumatoid arthritis in whom periodontoid pannus migrated into the spinal canal with reduction of atlantoaxial subluxation. In this case, magnetic resonance imaging in the extension position was valuable for determining the therapeutic strategy.

Headmaster collar restricts rheumatoid atlantoaxial subluxation.

A radiographic study of the effect of a modern orthotic device in the treatment of rheumatoid atlantoaxial subluxation. To study the ability of a new open-type collar to restrict atlantoaxial subluxation. Atlantoaxial subluxation is common in rheumatoid arthritis, and thus, the development of conservative treatments is important. It has been shown that a custom-made stiff collar significantly restricts atlantoaxial subluxation in approximately half of patients with unstable atlantoaxial subluxation. In 30 successive patients with rheumatoid atlantoaxial subluxation, lateral view radiographs were taken in flexion, extension, and neutral positions without a collar and in flexion with the Headmaster collar. The mean atlantoaxial distance during flexion was 7.1 +/- 1.8 mm and during extension was 1.0 +/- 1.0 mm, and the mean instability was 6.1 +/- 2.3 mm. In the 20 cases with the greatest stabilizing effect, the mean atlantoaxial distance during flexion with a collar was 1.1 +/- 1.3 mm, whereas in 10 patients with lesser effect it was 6.7 +/- 2.5 mm (P < 0.0001). The lesser stabilizing effect was associated with the presence of atlantoaxial subluxation in the neutral position. The Headmaster collar is an effective and useful tool in the conservative treatment of simple unstable atlantoaxial subluxation, but an ordinary custom-made stiff collar is still often needed. These two collars are complementary, and their selection and use must be determined individually.

Sensitivity of lateral view cervical spine radiographs taken in the neutral position in atlantoaxial subluxation in rheumatic diseases.

The value of lateral view cervical spine radiography in various positions of the neck was assessed in patients with rheumatoid atlantoaxial subluxation (AAS). We wanted to find out how much information is lost if only neutral position radiographs are used. The series consisted of 65 rheumatoid patients with unstable AAS. Lateral view cervical spine radiographs were taken in the neutral position and during flexion and extension. Neutral position radiographs would have failed to confirm the diagnosis of AAS in 31 cases (48%) and would have failed to record its true severity in 43 cases (66%); their diagnostic sensitivity was 52%. The sensitivity of the neutral radiographs in showing the reversibility of AAS was 48%. Routine cervical spine radiography of rheumatoid patients should include lateral view radiographs taken during flexion and extension. The result may be applied to magnetic resonance imaging, which is usually performed in the neutral position.

Active conservative treatment of atlantoaxial subluxation in rheumatoid arthritis.

Twenty patients with rheumatoid atlantoaxial subluxation (AAS) underwent an active conservative treatment programme, aiming at relieving the symptoms and influencing the natural course of AAS. The treatment consisted of intensive multiprofessional intervention in the hospital for a fortnight, and control and motivational visits 6 and 12 months later. The patients self-evaluated the symptoms several times, and the cervical spine radiographs were taken at the first and last visit. Seventeen of the 20 patients adopted the instructions well and undertook the exercise programme at least weekly, even after a 12 month follow-up. Cervical pain was significantly reduced (P < 0.001) during the first intervention, and the favourable effect continued at least 12 months. Promising changes were also seen in some cervical radiographs. It is possible to educate and motivate AAS patients to take active care of their neck, and to relieve their chronic neck pain significantly. Atlantoaxial instability may also be reduced during active conservative treatment.

Posterior fusion for atlanto-axial subluxation in rheumatoid arthritis.

Posterior cervical fusion was performed in 34 patients with advanced rheumatoid atlanto-axial subluxation. Atraumatic surgical technique was used with local anesthesia and without skull traction. Intractable occipital rhizopathy and long-tract signs were the main indications. Anterior atlanto-axial subluxation in 28 patients was operated on with posterior fusion of C1-C2. Superior migration of the odontoid process into the foramen magnum in six patients was treated with posterior fusion of occiput C1-C2. Immediate mobilization in a plastic brace followed surgery. Average follow-up was 3 years. All patients became symptom-free, except for three who had remaining long-tract signs. Bony fusion was achieved in 17 patients; stable fibrous fusion, in 8 patients; and pseudoarthrosis, in 4 patients. There were no major postoperative complications. Five deaths occurred after 1-2 years from unrelated causes.

Transoral decompression and posterior fusion for rheumatoid atlanto-axial subluxation.

Cervical myelopathy is an uncommon but potentially fatal complication of rheumatoid atlanto-axial subluxation. Computerised myelotomography with three-dimensional reconstruction shows that rheumatoid pannus, together with the odontoid peg, contributes significantly to anterior cervico-medullary compression. These findings were the basis for treatment by transoral anterior decompression and posterior occipitocervical fusion, which removes both bony and soft-tissue causes of compression and allows early mobilisation without major external fixation. We report encouraging results from this combined approach in 14 patients who had progressive neurological deterioration.

Medullary compression in rheumatoid atlanto-axial subluxation evaluated by computerized tomography.

CT examination of rheumatoid dislocation in the C1-C2 region was performed in 20 patients with advanced disease. The patients were classified in three grades according to the degree of medullary compression caused by the odontoid process in the extended position of the neck. Five patients showed no dural or medullary compression (grade 1), nine dural compression (grade 2), and six medullary compression (grade 3). CT grading was found to correlate best with long tract symptoms. These were present in 4/6 grade 3 and 0/5 grade 1 patients, while 3/9 grade 2 patients had long tract symptoms. Tissue attenuation values over the anterior atlanto-axial joint indicated interposing firm connective tissue in patients showing no reduction of the subluxation on extension of the neck.