[Rheumatoid atlanto-axial dislocation: a surgical approach]

Area of Science:

• Neurosurgery
• Rheumatology
• Orthopedics

Background:

• Pathological processes in the craniovertebral region (CVR) can cause dislocation and neurological deficits.
• Rheumatoid arthritis is a common cause of atlanto-axial dislocation (AAD).
• Diagnostic and treatment errors in rheumatoid disease can lead to adverse outcomes.

Purpose of the Study:

• To define a surgical treatment approach for rheumatoid AAD in the CVR.
• To account for deformity rigidity in surgical planning.

Main Methods:

• Surgical treatment of five patients (4 female, 1 male; aged 54-73) with rheumatoid AAD.
• Classification of dislocations as anterior, mobile (pannus-associated), or rigid (with odontoid invagination).
• Surgical approaches included posterior-only for mobile AAD and combined anterior/posterior for rigid AAD.

Main Results:

• Mobile AADs were treated with posterior decompression, dislocation correction, and atlanto-axial fusion, leading to brainstem decompression and anatomical restoration.
• Spontaneous pannus resorption occurred post-surgery in mobile AAD cases.
• Significant regression of pain and neurological deficits was observed in all patients; one case had wound infection.

Conclusions:

• A decision algorithm for surgical treatment of rheumatoid AAD is based on deformity stability.
• Mobile AADs are indicated for indirect decompression via posterior approach correction and fusion.
• Fixed AADs necessitate posterior fixation combined with anterior decompression via a transoral approach.