Technical outcome of atlantoaxial transarticular screw fixation without supplementary posterior construct for rheumatoid arthritis
- Department of Neurosurgery, Acute Services, Belfast Health and Social Care Trust, Royal Hospital, Northern Ireland, United Kingdom,
- National Centre for Neurosurgery, Beaumont Hospital, Beaumont Road, Dublin, Ireland.
DOI:10.25259/SNI_342_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Philip Thomas, Michael Amoo, Jack Horan, Mohammed Ben Husien, Derek Cawley, Jabir Nagaria, Ciaran Bolger. Technical outcome of atlantoaxial transarticular screw fixation without supplementary posterior construct for rheumatoid arthritis. 11-Jul-2020;11:188
How to cite this URL: Philip Thomas, Michael Amoo, Jack Horan, Mohammed Ben Husien, Derek Cawley, Jabir Nagaria, Ciaran Bolger. Technical outcome of atlantoaxial transarticular screw fixation without supplementary posterior construct for rheumatoid arthritis. 11-Jul-2020;11:188. Available from: https://surgicalneurologyint.com/surgicalint-articles/10130/
Background: transarticular screw (TAS) fixation without a supplementary posterior construct, even in rheumatoid arthritis (RA) patients, provides sufficient stability with acceptable clinical results. Here, we present our experience with 15 RA patients who underwent atlantoaxial (AA) TAS fixation without utilizing a supplementary posterior fusion.
Methods: To treat AA instability, all 15 RA patients underwent C1–C2 TAS fixation without a supplementary posterior construct. Patients were followed for at least 24 months. Pre- and postoperative sagittal measures of C1– C2, C2–C7, and C1–C7 angles, atlanto-dens interval (ADI), posterior atlanto-dens interval (PADI), and adjacent segment (i.e., C2–C3) anterior disc height (ADH) were retrospectively recorded from lateral X-ray imaging. The presence or absence of superior migration of the odontoid (SMO), cervical subaxial subluxation, C1–C2 bony fusion, screw pull-out, and screw breakage were also noted.
Results: There was little difference between the pre- and postoperative studies regarding angles measured. Following TAS fixation, the mean ADI shortened, and mean PADI lengthened. There was no difference in the mean measures of C2–C3 ADH. There was no evidence of SMO pre- or postoperatively. Two patients developed anterior subluxation at C5–C6; one of the two also developed anterior subluxation at C2–C3. All patients subsequently showed C1–C2 bony fusion without screw pull-out or breakage.
Conclusion: In RA patients who have undergone C1–C2 TAS fixation, eliminating a supplementary posterior fusion resulted in adequate stability.
Keywords: Atlantoaxial, C1–C2, Rheumatoid arthritis, Transarticular screw fixation
The instability of the atlantoaxial (AA) joint can result from aplasia or hypoplasia of the odontoid process, laxity of the transverse ligament, and assimilation of the atlas. AA can be associated with various conditions including Down’s syndrome, Klippel-Feil syndrome, osteogenesis imperfecta, neurofibromatosis, and rheumatoid arthritis (RA).[
Many spinal surgeons feel the current gold standard for posterior AA arthrodesis which is transarticular screw (TAS) fixation classically, achieved by the placement of a TAS screw from C2 to the anterior surface of C1 (across the facets, bilaterally).[
We retrospectively evaluated the radiographs of 15 consecutive patients (13 females and 2 males), averaging 52 years of age (33–78 years) who underwent bilateral C1– C2 TAS fixation for the treatment of RA-associated AA instability.
Preoperative planning for screw placement utilized CT-based StealthStation® image guidance (Medtronic Sofamor Danek, Memphis, TN). Parallel caudal stab incisions allowed for delivery of all instruments percutaneously to the posterior arch of C2; we used cannulated 3.5 mm diameter titanium screws (UCSS, Medtronic Sofamor Danek, Memphis, TN). The screw trajectory was confirmed intraoperatively under StealthStation® image guidance and fluoroscopy. Before operative closure, the C1–C2 facet joints were curetted and packed with morselized autologous iliac crest bone graft; no supplementary posterior construct was performed.
Patients were followed an average of 26 months (range 24– 39 months). Pre- and postoperative sagittal cervical X-rays measured; C1–C2, C2–C7, and C1–C7 angles [
Compared to the preoperative mean measures, there were no remarkable differences noted in the postoperative fixation, subaxial, and C-spine angles (i.e., the C1–C2, C2–C7, and C1–C7 angles, respectively) [
Satisfactory clinical outcomes are reported utilizing C1–C2 TAS fixation alone with RA.[
Technically satisfactory outcomes of AA segment arthrodesis can be achieved in RA patients using the TAS fixation technique without a supplementary posterior construct.
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