Odontoid upward migration in rheumatoid arthritis: An analysis of 45 patients with “cranial settling” (2022)

Journal ArticleDOI: 10.3171/JNS.1988.69.6.0895

Transoral-transpharyngeal approach to the anterior craniocervical junction: Ten-year experience with 72 patients

[...]

Arnold H. Menezes1, John C. VanGilderInstitutions (1)

01 Dec 1988-Journal of Neurosurgery

Abstract: The anterior transoral-transpharyngeal operation to correct ventral irreducible compression of the cervicomedullary junction was utilized in 72 individuals. The patients' ages ranged from 6 to 82 years, and 29 were children. The pathology encountered was primary basilar invagination, rheumatoid irreducible cranial settling, secondary basilar invagination due to migration of odontoid fracture fragments, dystopic os odontoideum, granulation masses, clivus chordoma, osteoblastoma, and chondroma of the atlas. Fifteen patients had associated Chiari malformation with basilar invagination. Fifty-two patients required subsequent atlantoaxial or occipitocervical fusion. Neurological improvement was the rule. There were two deaths within 30 days of surgery: one from myocardial infarction 4 weeks after surgery and one from Gram-negative septicemia of urinary tract origin. There was one pharyngeal wound infection. The ventral transoral approach provides a safe, rapid, and effective means for decompression of the abnormal craniovertebral junction.

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Topics:Basilar invagination(66%), Dystopic os odontoideum(54%), Cervicomedullary Junction(53%)...read more

344Citations

(Video) Approaches to ventral extradural pathologies of craniocervical junction with Dr. Jean-Paul Wolinsky

Journal ArticleDOI: 10.2106/00004623-199309000-00004

Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery.

[...]

Scott D. Boden1, Larry D. Dodge1, Henry H. Bohlman1, Glen Rechtine1Institutions (1)

01 Sep 1993-Journal of Bone and Joint Surgery, American Volume

Abstract: We analyzed the cases of seventy-three patients who were managed over a twenty-year period for rheumatoid involvement of the cervical spine and were followed for a minimum of two years, with an average follow-up of seven years. A neurological deficit did not develop in thirty-one patients (Ranawat et al. Class I) and paralysis developed in the remaining forty-two patients: Class II in eleven and Class III in thirty-one. Of the forty-two patients in whom paralysis developed, thirty-five had operative stabilization. Seven patients were managed with a soft cervical collar because they refused or were medically unable to have the operation; all of the had an increase in the severity of the paralysis. The posterior atlanto-odontoid interval and the diameter of the subaxial sagittal canal measured on the cervical radiographs demonstrated statistically significant correlations with the presence and severity of paralysis. All of the patients who had a Class-III neurological deficit had a posterior atlanto-odontoid interval or diameter of the subaxial canal that was less than fourteen millimeters. In contrast, the anterior atlanto-odontoid interval, which has traditionally been reported, did not correlate with paralysis. The prognosis for neurological recovery following the operation was not affected by the duration of the paralysis but was influenced by the severity of the paralysis at the time of the operation. The most important predictor of the potential for neurological recovery after the operation was the preoperative posterior atlanto-odontoid interval. In patients who had paralysis due to atlanto-axial subluxation, no recovery occurred if the posterior atlanto-odontoid interval was less than ten millimeters, whereas recovery of at least one neurological class always occurred when the posterior atlanto-odontoid interval was at least ten millimeters. If basilar invagination was superimposed, clinically important neurological recovery occurred only when the posterior atlanto-odontoid interval was at least thirteen millimeters. All patients who had paralysis and a posterior atlanto-odontoid interval or diameter of the subaxial canal of fourteen millimeters had complete motor recovery after the operation. In this series, although only patients who had a neurological deficit were operated on, we observed the range of the posterior atlanto-odontoid interval that was associated with poor or no recovery after the operation, and we identified the safe range on the basis of the patients in whom paralysis did not develop.(ABSTRACT TRUNCATED AT 400 WORDS)

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Topics:Paralysis(61%), Cervical collar(55%), Neurological disorder(53%)

325Citations

(Video) Neurokirurg Vicenç Gilete föreläser i Lund

Journal ArticleDOI: 10.3171/JNS.1996.84.1.0001

The transcondylar approach to extradural nonneoplastic lesions of the craniovertebral junction.

[...]

Ossama Al-Mefty1, Luis A. B. Borba, N. Aoki, Edgardo C. Angtuaco +1 moreInstitutions (1)

01 Jan 1996-Journal of Neurosurgery

Abstract: Ventral extradural lesions at the craniovertebral junction are commonly exposed through the transoral or transmaxillary approach The disadvantages of these approaches include: 1) difficulty in reaching laterally located lesions; 2) ineligibility of patients with an intradental distance of less than 25 mm or severe macroglossia; 3) the need for a separate procedure for stabilization and fusion; and 4) the risk of infection from transgressing a contaminated field In this report, the authors describe the use of the transcondylar approach to extradural nonneoplastic lesions of the anterior craniovertebral junction for decompression and stabilization Advantages of this approach include: 1) a short distance to the lesion; 2) a wide surgical envelope; 3) direct visualization of the dural sac, eliminating manipulation of the brainstem or upper spinal cord; 4) easy identification and control of the ipsilateral vertebral artery; 5) direct visualization and preservation of the lower cranial nerves; and 6) a sterile field In addition, occipitocervical fusion and instrumentation can be performed during the same procedure The transcondylar approach, based on anatomical studies in cadavers, was used to treat eight patients with ventral nonneoplastic lesions at the craniocervical junction The technique and results are described

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196Citations

Journal ArticleDOI: 10.3171/JNS.1992.77.4.0525

Curtis A. Dickman1, Jacqueline Locantro, Richard G. FesslerInstitutions (1)

01 Oct 1992-Journal of Neurosurgery

Abstract: Twenty-seven cases of craniovertebral junction compression treated with transoral surgery were reviewed to assess the influences of pathological processes and surgical interventions on spinal stability. All patients presented with signs and symptoms of spinal-cord or brain-stem dysfunction. Pathology included rheumatoid arthritis in 11 patients, congenital osseous malformations in 11, spinal fractures in two, plasmacytoma in one, osteomyelitis in one, and a gunshot injury in one. Instability was defined as clear radiographic evidence of mobile subluxation in conjunction with clinical assessment. Of 19 patients (70%) requiring internal fixation, nine underwent upper cervical fusion and 10 had occipitocervical fusion. When instability occurred, all subluxations were at the C1-2 level. There were no occipito-atlantal subluxations. Eight patients (30%) had preoperative instability of the craniovertebral junction due solely to their pathology, 11 patients (40%) suffered instability after transoral surgery, and eight (30%) were without clinical or radiographic evidence of instability (mean follow-up period 14 months). Craniovertebral junction instability predominated among patients with rheumatoid arthritis: 91% required fusion and 45% presented with pre-existing instability. Among individuals with congenital osseous malformations, 45% required fusion and only one patient (9%) had pre-existing instability. Patients who required subsequent posterior decompression of a Chiari malformation were at risk for developing instability; three of four became unstable after posterior decompression. Transoral resection of the dens, the anterior arch of C-1, and the lower clivus does not fully destabilize the spine; however, this operation may potentiate incipient pathological instability. The primary determinants of instability are the extent of pathological bone destruction, ligamentous weakening, and operative bone removal. Long-term follow-up monitoring is needed after transoral surgery to detect cases of late instability.

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Topics:Chiari malformation(52%), Spinal fusion(52%), Clivus(50%)...read more

142Citations

Journal ArticleDOI: 10.1227/01.NEU.0000157929.85251.7C

Stretch-associated injury in cervical spondylotic myelopathy: new concept and review.

[...]

Fraser Henderson1, Jennian F Geddes2, Alexander R. Vaccaro3, Eric J. Woodard4 +2 moreInstitutions (6)

01 May 2005-Neurosurgery

Abstract: The simple pathoanatomic concept that a narrowed spinal canal causes compression of the enclosed cord, leading to local tissue ischemia, injury, and neurological impairment, fails to explain the entire spectrum of clinical findings observed in cervical spondylotic myelopathy A growing body of evidence indicates that spondylotic narrowing of the spinal canal and abnormal or excessive motion of the cervical spine results in increased strain and shear forces that cause localized axonal injury within the spinal cord During normal motion, significant axial strains occur in the cervical spinal cord At the cervicothoracic junction, where flexion is greatest, the spinal cord stretches 24% of its length This causes local spinal cord strain In the presence of pathological displacement, strain can exceed the material properties of the spinal cord and cause transient or permanent neurological injury Stretch-associated injury is now widely accepted as the principal etiological factor of myelopathy in experimental models of neural injury, tethered cord syndrome, and diffuse axonal injury Axonal injury reproducibly occurs at sites of maximal tensile loading in a well-defined sequence of intracellular events: myelin stretch injury, altered axolemmal permeability, calcium entry, cytoskeletal collapse, compaction of neurofilaments and microtubules, disruption of anterograde axonal transport, accumulation of organelles, axon retraction bulb formation, and secondary axotomy Stretch and shear forces generated within the spinal cord seem to be important factors in the pathogenesis of cervical spondylotic myelopathy

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Topics:Myelopathy(72%), Spinal cord compression(64%), Anterograde axonal transport(60%)...read more

A neurological deficit did not develop in thirty-one patients (Ranawat et al. Class I) and paralysis developed in the remaining forty-two patients: Class II in eleven and Class III in thirty-one.. All of the patients who had a Class-III neurological deficit had a posterior atlanto-odontoid interval or diameter of the subaxial canal that was less than fourteen millimeters.. In patients who had paralysis due to atlanto-axial subluxation, no recovery occurred if the posterior atlanto-odontoid interval was less than ten millimeters, whereas recovery of at least one neurological class always occurred when the posterior atlanto-odontoid interval was at least ten millimeters.. All patients who had paralysis and a posterior atlanto-odontoid interval or diameter of the subaxial canal of fourteen millimeters had complete motor recovery after the operation.. In this series, although only patients who had a neurological deficit were operated on, we observed the range of the posterior atlanto-odontoid interval that was associated with poor or no recovery after the operation, and we identified the safe range on the basis of the patients in whom paralysis did not develop.. Abstract: Ventral extradural lesions at the craniovertebral junction are commonly exposed through the transoral or transmaxillary approach The disadvantages of these approaches include: 1) difficulty in reaching laterally located lesions; 2) ineligibility of patients with an intradental distance of less than 25 mm or severe macroglossia; 3) the need for a separate procedure for stabilization and fusion; and 4) the risk of infection from transgressing a contaminated field In this report, the authors describe the use of the transcondylar approach to extradural nonneoplastic lesions of the anterior craniovertebral junction for decompression and stabilization Advantages of this approach include: 1) a short distance to the lesion; 2) a wide surgical envelope; 3) direct visualization of the dural sac, eliminating manipulation of the brainstem or upper spinal cord; 4) easy identification and control of the ipsilateral vertebral artery; 5) direct visualization and preservation of the lower cranial nerves; and 6) a sterile field In addition, occipitocervical fusion and instrumentation can be performed during the same procedure The transcondylar approach, based on anatomical studies in cadavers, was used to treat eight patients with ventral nonneoplastic lesions at the craniocervical junction The technique and results are described. Eight patients (30%) had preoperative instability of the craniovertebral junction due solely to their pathology, 11 patients (40%) suffered instability after transoral surgery, and eight (30%) were without clinical or radiographic evidence of instability (mean follow-up period 14 months).. Craniovertebral junction instability predominated among patients with rheumatoid arthritis: 91% required fusion and 45% presented with pre-existing instability.. Patients who required subsequent posterior decompression of a Chiari malformation were at risk for developing instability; three of four became unstable after posterior decompression.. Abstract: The simple pathoanatomic concept that a narrowed spinal canal causes compression of the enclosed cord, leading to local tissue ischemia, injury, and neurological impairment, fails to explain the entire spectrum of clinical findings observed in cervical spondylotic myelopathy A growing body of evidence indicates that spondylotic narrowing of the spinal canal and abnormal or excessive motion of the cervical spine results in increased strain and shear forces that cause localized axonal injury within the spinal cord During normal motion, significant axial strains occur in the cervical spinal cord At the cervicothoracic junction, where flexion is greatest, the spinal cord stretches 24% of its length This causes local spinal cord strain In the presence of pathological displacement, strain can exceed the material properties of the spinal cord and cause transient or permanent neurological injury Stretch-associated injury is now widely accepted as the principal etiological factor of myelopathy in experimental models of neural injury, tethered cord syndrome, and diffuse axonal injury Axonal injury reproducibly occurs at sites of maximal tensile loading in a well-defined sequence of intracellular events: myelin stretch injury, altered axolemmal permeability, calcium entry, cytoskeletal collapse, compaction of neurofilaments and microtubules, disruption of anterograde axonal transport, accumulation of organelles, axon retraction bulb formation, and secondary axotomy Stretch and shear forces generated within the spinal cord seem to be important factors in the pathogenesis of cervical spondylotic myelopathy

Subaxial subluxation (SAS) also develops after previous upper cervical fusions .. The use of rheumatoid factor as a predictor of neurologic involvement has not been established; therefore, it does not have a role in the surveillance of patients with rheumatoid arthritis with cervical involvement.. All patients with rheumatoid arthritis should have radiographic examination of the cervical spine because cervical involvement can remain asymptomatic.. An approach to surgical and nonsurgical management for rheumatoid arthritis and for rheumatoid spondylitis can be developed based on the natural history of rheumatoid involvement of the cervical spine and radiographic predictors of paralysis.. Patients with irreducible subluxations or significant neurologic deficit may best be treated with anterior decompression and fusion alone or in concert with posterior fusion.. Frequency of cervical spine involvement in rheumatoid arthritis.. Long-term incidence of subaxial cervical spine instability following cervical arthrodesis surgery in patients with rheumatoid arthritis.. Rheumatoid arthritis of the cervical spine.. Arthrodesis of the cervical spine in rheumatoid arthritis.. Outcome of cervical spine surgery in patients with rheumatoid arthritis.. Rheumatoid arthritis of the cervical spine.. The role of plate and screw fixation in occipitocervical fusion in rheumatoid arthritis.

TL;DR: The range of the posterior atlanto-odontoid interval that was associated with poor or no recovery after the operation was observed, and the safe range was identified on the basis of the patients in whom paralysis did not develop.. Seven patients were managed with a soft cervical collar because they refused or were medically unable to have the operation; all of the had an increase in the severity of the paralysis.. In patients who had paralysis due to atlanto-axial subluxation, no recovery occurred if the posterior atlanto-odontoid interval was less than ten millimeters, whereas recovery of at least one neurological class always occurred when the posterior atlanto-odontoid interval was at least ten millimeters.. In this series, although only patients who had a neurological deficit were operated on, we observed the range of the posterior atlanto-odontoid interval that was associated with poor or no recovery after the operation, and we identified the safe range on the basis of the patients in whom paralysis did not develop.. As the arthritis progressed, sometimes with acute inflammatory exacerbations, more joints became involved and, by the sixteenth to the twentieth weeks of the experiment, a progressive polyarthritis, with gross joint deformities and restricted function, developed in the majority of the limb joints.. These mice did not usually develop arthritis.. TL;DR: The results of a study of the natural history of cervical luxation in patients with rheumatoid arthritis are reported, with particular reference to the development of dangerous neurological complications.. Occasionally the presenting symptoms are transient blackouts, tetraplegia, sudden death, or other neurological complications resulting from damage to the cervical cord or interference with the flow of the vertebral arteries (Ball and Sharp, 1971).. In this paper we report the results of a study of the natural history of cervical luxation in patients with rheumatoid arthritis, with particular reference to the development of dangerous neurological complications.. Improvement occurred during traction, implying that compression might be the etiology for the neurological signs.. Thus, "cranial settling" is a frequent complication of rheumatoid arthritis; although it is poorly recognized, it has serious implications and is treatable.. Neurological symptoms correlated poorly to fatal a.a.d.. Sudden death occurred in 7 of the cases.. Signs of active inflammation in the axial joints were present in 4 cases.. This study, based on systematic post mortem examinations, revealed an unexpectedly high and not previously reported incidence of fatal medulla compression in RA patients with a.a.d.

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