title: Pooled data analysis on anterior versus posterior approach for rheumatoid arthritis at the craniovertebral junction.
abstract: OBJECTIVE
  Rheumatoid arthritis (RA) is one of the most debilitating autoimmune diseases affecting the craniovertebral junction (CVJ). Patients predominantly present with myelopathic symptoms and intractable neck pain. The surgical approach traditionally has been either a combined anterior and posterior approach or a posterior-only approach. In this article, the authors review pooled data from the literature and discuss the benefits of the two types of approaches.
  
  
  METHODS
  A search of the PubMed database was conducted using key words that describe spine deformities in RA and specific spinal interventions. The authors evaluated the neurological outcomes based on the Ranawat scale in both the groups through chi-square analysis. Multiple logistic regression was carried out to further examine for potential confounders. Any adverse sequalae resulting from either approach were also documented. Because all the procedures performed via a transoral approach in the analyzed articles also involved posterior fixation, for convenience of comparison, the combined procedures are referred to as "anterior approach" or "anterior-posterior" in the present study.
  
  
  RESULTS
  The search yielded 233 articles, of which 11 described anterior approaches and 14 evaluated posterior approaches. The statistical analysis showed that patients treated with a posterior approach fared better than those treated with an anterior (combined) approach. It was noted that those patients in whom the cervical subluxations were reducible on traction predominantly underwent posterior approaches.
  
  
  CONCLUSIONS
  CVJ instability is a serious complication of RA that requires surgical intervention. Although the anterior-posterior combined approach can provide direct decompression, it is associated with morbidity, and the analysis showed no statistically significant benefit to patients. In contrast, the posterior approach has been shown to provide statistically significant superiority with respect to stabilization and subsequent pannus reduction. Surgical approaches are undertaken based on the reducibility of subluxations with traction and the vector of compressive force. However, the choice of surgical approach should be based on the individual patient's pathology.
authors.affiliation: Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Lee Onn
authors.initials: LO
authors.lastname: Chieng
authors.forename: Karthik
authors.initials: K
authors.lastname: Madhavan
authors.forename: Steven
authors.initials: S
authors.lastname: Vanni
mesh_terms: D001172:Arthritis, Rheumatoid / Q000150:complications*; D001268:Atlanto-Axial Joint / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods*; D006801:Humans; D007593:Joint Instability / Q000209:etiology / Q000601:surgery; D016015:Logistic Models; D009460:Neurologic Examination; D039781:PubMed / Q000706:statistics & numerical data; D013123:Spinal Fusion / Q000379:methods*; D013124:Spinal Injuries / Q000209:etiology* / Q000601:surgery
keywords: AADI = anterior atlantodental interval; CVJ = craniovertebral junction; PADI = posterior atlantodental interval; RA = rheumatoid arthritis; atlantoaxial subluxation; basilar invagination; cranial settling; rheumatoid arthritis