title: Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis.
abstract: BACKGROUND
  Rheumatoid arthritis is the most common inflammatory disease involving the spine with predilection for the craniovertebral segment. Surgery is usually reserved to patients with symptomatic craniovertebral junction (CVJ) instability, basilar invagination, or upper spinal cord compression by rheumatoid pannus. Anterior approaches are indicated in cases of irreducible ventral bulbo-medullary compression. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA).
  
  
  OBJECTIVE
  The aim of this article is to demonstrate the feasibility of performing an odontoidectomy and a rheumatoid pannus removal by a minimally invasive EEA, preserving the anterior C1 arch continuity and avoiding a posterior fixation procedure.
  
  
  METHODS
  Technical description and cohort report.
  
  
  METHODS
  We report three cases of elderly patients with a long history of rheumatoid arthritis and irreducible anterior bulbo-medullary compression secondary to basilar invagination and/or rheumatoid pannus. Anterior decompression was achieved by an endonasal image-guided fully endoscopic approach.
  
  
  RESULTS
  Neurological improvement and adequate bulbo-medullary decompression were obtained in all cases. The anterior C1 arch continuity was preserved, and none of the patients required a subsequent posterior fixation.
  
  
  CONCLUSIONS
  Anterior decompression by a minimally invasive EEA could represent an innovative option for the treatment of irreducible ventral CVJ lesions in elderly patients with rheumatoid arthritis. This approach permits the preservation of the anterior C1 arch and the avoidance of a posterior fixation, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.
authors: Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy. neurotra@tiscali.it
authors: Maurizio
authors: M
authors: Iacoangeli
authors: Maurizio
authors: M
authors: Gladi
authors: Lorenzo
authors: L
authors: Alvaro
authors: Alessandro
authors: A
authors: Di Rienzo
authors: Nicola
authors: N
authors: Specchia
authors: Massimo
authors: M
authors: Scerrati
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000150:complications*; D001268:Atlanto-Axial Joint / Q000601:surgery; D001270:Cervical Atlas / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods*; D004724:Endoscopy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D009809:Odontoid Process / Q000601:surgery*; D013117:Spinal Cord Compression / Q000209:etiology / Q000601:surgery*