Elsevier

World Neurosurgery

Volume 107, November 2017, Pages 820-829
World Neurosurgery

Original Article
Endoscopic Endonasal Odontoidectomy with Anterior C1 Arch Preservation in Rheumatoid Arthritis: Long-Term Follow-Up and Further Technical Improvement by Anterior Endoscopic C1-C2 Screw Fixation and Fusion

https://doi.org/10.1016/j.wneu.2017.08.063Get rights and content

Objective

To examine the long-term outcomes (minimum of 4.5 years) of endoscopic endonasal odontoidectomy (EEO) with preservation of anterior C1 ring to treat irreducible ventral bulbo-medullary compressions in rheumatoid arthritis (RA) and to illustrate a novel technique of anterior pure endoscopic craniovertebral junction (CVJ) reconstruction and fusion. In fact, long-term clinical studies are still lacking to elucidate the effective role of EEO and whether it can obviate the need for posterior fixation.

Methods

From November 2008 to January 2012, clinical and radiologic data of 7 patients presenting with RA and associated irreducible bulbo-medullary compression treated with EEO were analyzed retrospectively. In all patients, decompression was achieved by EEO with anterior C1 arch preservation. In the last 2 patients, after EEO, we used the spared anterior C1 arch for reconstruction of anterior column of CVJ by positioning, under pure endoscopic guidance, autologous bone and 2 tricortical screws between the anterior arch of C1 and the residual odontoid. All patients were examined clinically with Ranawat classification and radiographically with computed tomography, magnetic resonance imaging, and dynamic radiography immediately after surgery and during follow-up.

Results

Adequate bulbo-medullary decompression with anterior C1 arch preservation was obtained in all cases. At follow-up (average, 66.2 months; range, 51–91 months) all patients experienced an improvement at least of one Ranawat classification level and presented no clinical or radiologic signs of instability.

Conclusions

EEO with anterior C1 arch sparing provides satisfying long-term results for irreducible ventral CVJ lesions in RA. The preservation of anterior C1 arch and, when possible, the reconstruction of anterior CVJ can prevent the need for posterior fusion.

Introduction

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that often affects the cervical spine.1 Surgery is usually reserved for patients with symptomatic craniovertebral junction (CVJ) instability or neural compression secondary to basilar invagination (BI) or rheumatoid pannus (RP), or both.2 An irreducible symptomatic anterior neural compression, secondary to BI or RP, or both, represents a clear indication to anterior approaches, usually combined with a posterior fusion.2, 3 Classically performed through a transoral approach, the odontoidectomy can be performed using an endoscopic endonasal approach.4

At present, few case reports and small clinical series of endonasal endoscopic odontoidectomy (EEO) have been published. They have highlighted some advantages of this approach, including earlier extubation and feeding, significant reduction of hospitalization, and patient discomfort, compared with the transoral approach that still represent the gold-standard approach for pathologies of the odontoid process.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17

Moreover, some articles, including our previous study on EEO in RA,6 have suggested the possibility of performing EEO without posterior fusion. Indeed, this minimally invasive technique, thanks to its peculiar working angle, may allow the preservation of the anterior C1 arch that plays an important role for CVJ biomechanical stability and can serve as a pivot for cervical anterior column reconstruction.5, 6, 13, 16, 17 This may avoid the need for a posterior fixation with its related risk of subaxial instability development, which is relevant in patients with RA, and cervical motion limitations.3, 18, 19, 20, 21, 22, 23, 24, 25 However, long-term clinical studies confirming the conceptual issue regarding the effectiveness of the minimally invasive EEO in addressing the disease and in preserving biomechanical spine stability are still lacking.

The aim of this study is to analyze the long-term outcomes (minimum of 4.5 years) of 7 consecutive patients affected by RA who underwent EEO with preservation of anterior C1 ring for irreducible CVJ compression and to illustrate a novel technique for anterior pure endoscopic CVJ fixation and fusion.

Section snippets

Materials and Methods

From November 2008 to January 2012, clinical and radiologic data for 7 consecutive patients presenting a long-lasting history of RA and associated symptomatic irreducible anterior neural compression secondary in all cases to basilar invagination and to retro-odontoid pannus were collected prospectively in a database and analyzed retrospectively (Figures 1 and 2). The Ranawat classification of neurological impairment was used. Neuroradiologic preoperative investigation for all patients included

Results

Patient age ranged from 62 to 84 years (average of 72.8 years). There were 1 man and 6 women. The mean duration of RA was 15.7 years (range, 9–35 years). The etiology of the ventral compression was in all cases BI with associated RP. The mean follow-up period was 66.2 months (range, 51–91 months). The endoscopic endonasal approach facilitated adequate decompression of the upper cervical medulla in all patients with the preservation of the anterior C1 arch.

No patient deteriorated neurologically

Discussion

The introduction of new disease-modifying antirheumatic drugs have had a major influence on the natural history of this disease and have reduced the amount of patients with advanced stages of the disease needing surgery.1 At the same time, the surgical management of cervical rheumatoid disease has evolved considerably, and advancement in instrumentation techniques has improved patient outcomes and fusion rates.4, 6, 23, 24

When RA involving the CVJ becomes symptomatic because of basilar

Conclusion

The endoscopic transnasal approach may represent an effective and safe alternative to the transoral route for the resection of the odontoid process, causing irreducible bulbo-medullary compression in rheumatoid arthritis, even over a long-term period.

This approach offers an adequate and minimally invasive straightforward natural surgical corridor to the anterior craniocervical junction, allowing a better working angle while minimizing potential comorbidities with more respect of the cervical

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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