Transoral decompression, anterior plate fixation, and posterior wire fusion for irreducible atlantoaxial kyphosis in rheumatoid arthritis.
METHODS
Fifteen consecutive patients with irreducible atlantoaxial kyphosis caused by rheumatoid arthritis were treated by combined transoral odontoid resection, anterior plate fixation, and posterior wire fusion.


OBJECTIVE
To investigate the clinical results of this new surgical procedure.


BACKGROUND
Irreducible atlantoaxial kyphosis in rheumatoid arthritis results from a destruction of the craniocervical joint ligaments and the anterior aspects of the lateral atlantoaxial joints. The development of a paradental synovial pannus and atlantoaxial joint impaction prevents reduction by conservative treatment, such as skull traction. Posterior surgical procedures for the treatment of the irreducible atlantoaxial kyphosis with spinal cord compression have been associated with high morbidity and mortality.


METHODS
Fifteen consecutive patients were treated by transoral odontoid resection. The fixation was performed with anterior plating, according to the method of Harms in combination with posterior wire fusion according to Brooks. Before and after surgery, evaluation was performed using the parameters of pain (visual analog scale), range of motion, and subjective assessment of improvement and the Health Assessment Questionnaire. The neurologic deficit was defined according to the classifications proposed by Ranawat, Frankel, and Nurwick. Plain radiographs, including lateral flexion and extension views, and magnetic resonance scans were obtained.


RESULTS
No perioperative fatality occurred. The average clinical and radiographic follow-up was 50.7 +/- 15.6 months (range, 26-77). Postoperative pain was relieved (mean pain score before surgery, 7.9 +/- 1.87; after surgery, 3.8 +/- 1.27), and the range of motion of all patients increased (mean 21.5 +/- 14.0 degrees for rotation; mean 17.2 +/- 5. 54 degrees for bending). The score on the Health Assessment Questionnaire increased in three patients, remained unchanged in three and decreased in six patients (three had died). All patients improved at least one Ranawat level after surgery, except a patient in Ranawat Class II, whose condition remained unchanged. All patients were satisfied with the procedure and reported subjective improvement.


CONCLUSIONS
Transoral plate fixation combined with posterior wire fixation after transoral odontoid resectionis an effective, reliable, and safe procedure for the treatment of irreducible atlantoaxial kyphosis in rheumatoid arthritis.
Kerschbaumer
F
F
Abteilung für Rheumaorthopädie, Johann Wolfgang Goethe Universität Frankfurt, Germany.
Kandziora
F
F
Klein
C
C
Mittlmeier
T
T
Starker
M
M
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000473:pathology / Q000601:surgery; D001368:Axis, Cervical Vertebra / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D001860:Bone Plates / Q000009:adverse effects / Q000706:statistics & numerical data*; D001864:Bone Wires / Q000009:adverse effects / Q000706:statistics & numerical data*; D001270:Cervical Atlas / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D019299:Decompression, Surgical / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D004185:Disability Evaluation; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016268:Internal Fixators / Q000009:adverse effects / Q000706:statistics & numerical data*; D007738:Kyphosis / Q000209:etiology* / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009055:Mouth / Q000601:surgery*; D010147:Pain Measurement / Q000706:statistics & numerical data; D017060:Patient Satisfaction; D011859:Radiography; D016059:Range of Motion, Articular; D020127:Recovery of Function; D013123:Spinal Fusion / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D016896:Treatment Outcome