[Rheumatoid atlanto-axial dislocation: a surgical approach]

Pathological processes in the craniovertebral region (CVR) are usually accompanied by dislocation complications leading to gross neurological disorders. One of the diseases that affect the CVR and lead to atlanto-axial dislocation (AAD) is rheumatoid arthritis. Errors in the diagnosis of rheumatoid disease and in the choice of a treatment approach may cause adverse outcomes.

To define the approach for surgical treatment of AAD associated with rheumatoid disease of the CVR, with allowance for the rigidity of deformity.

Five patients with rheumatoid AAD, 4 females and 1 male, aged 54 to 73 years underwent surgery. All dislocations were anterior ones. Three patients had mobile pannus-associated dislocation. In 2 cases, AAD was rigid and combined with odontoid invagination into the foramen magnum (FM).

In all mobile AAD cases, decompression of the brainstem and restoration of the normal anatomical relationships in the CVR were achieved by dislocation correction and atlanto-axial fusion performed from the posterior approach, avoiding transoral interventions. In this case, spontaneous resorption of the pannus occurred within several months after surgery. In the postoperative period, all patients achieved significant regression of pain and neurological disorders. Complications in the form of wound infection developed in 1 case.

A decision algorithm for choosing a surgical treatment option was based on the degree of deformity stability. Mobile AADs serve as an indication for indirect decompression using instrumental correction of dislocation and atlantoaxial fixation from the posterior approach. In the case of fixed AAD, posterior fixation is complemented by anterior decompression via the transoral approach.