Original ArticleEndoscopic 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
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
References (25)
- et al.
Posterior fixation with C1 lateral mass screws and C2 pars screws for type II odontoid fracture in the elderly: long-term follow-up
World Neurosurg
(2016) - et al.
Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis
Spine J
(2013) - et al.
Advantages and limitations of endoscopic endonasal odontoidectomy. A series of nine cases
Orthop Traumatol Surg Res
(2014) A less-invasive technique for harvesting autologous iliac crest grafts for cervical interbody fusion: technical note
Surg Neurol
(2007)- et al.
Endoscopic endonasal approach to the odontoid pathologies
World Neurosurg
(2016) - et al.
Advances in the treatment of cervical rheumatoid: less surgery and less morbidity
World J Orthop
(2014) - et al.
Rheumatoid arthritis of the craniovertebral junction
Neurosurgery
(2010) - et al.
Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease
Am J Rhinol
(2007) - et al.
Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion
Eur Spine J
(2012) - et al.
A rare case of chordoma and craniopharyngioma treated by an endoscopic endonasal, transtubercular transclival approach
Turk Neurosurg
(2014)
Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture
Cancer Manag Res
Anterior cervical epidural abscess treated by endoscopy-assisted minimally invasive microsurgery via posterior approach
Minim Invasive Neurosurg
Cited by (0)
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.