Transoral decompression, anterior plate fixation, and posterior wire fusion for irreducible atlantoaxial kyphosis in rheumatoid arthritis

Study Design. Fifteen consecutive patients with irreducible atlantoaxial ky phosis caused by rheumatoid: arthritis were treated by combined transoral o dontoid resection, anterior plate fixation, and posterior wire fusion. Objectives. To investigate the clinical results of this new surgical proced ure. Summary and Background Data. irreducible atlantoaxial kyphosis in rheumatoi d arthritis results from a destruction of the craniocervical joint ligament s and the anterior aspects of the lateral atlantoaxial joints. The developm ent of a paradental synovial pannus and atlantoaxial joint impaction preven ts reduction by conservative treatment, such as skull traction. Posterior s urgical procedures for the treatment of the irreducible atlantoaxial kyphos is with spinal cord compression have been associated with high morbidity an d mortality. Methods. Fifteen consecutive patients were treated by transoral odontoid re section. The fixation was: performed with anterior plating, according to th e method of Harms in combination with posterior wire fusion according to Br ooks. Before and after surgery, evaluation was performed using the paramete rs of pain (visual analog scale), range of motion, and subjective assessmen t:of improvement and the Health Assessment Questionnaire. The neurologic de ficit was defined according to the classifications proposed by Ranawat, Fra nkel, and Nurwick. Plain radiographs, including lateral flexion and extensi on views, and magnetic resonance scans were obtained. Results. No perioperative fatality occurred. The average clinical and radio graphic follow-up was 50.7 +/- 15.6 months (range, 26-77). Postoperative pa in was relieved (mean pain score before surgery, 7.9 +/- 1.87; after surger y, 3.8 +/- 1.27), and the range of motion of all patients increased [mean 2 1.5 +/- 14.0 degrees for rotation; mean 17.2 +/- 5.54 degrees for bending). The score on the Health Assessment Questionnaire increased in three patien ts, remained unchanged in three and decreased in six patients (three had di ed). All patients improved at least one Ranawat Lever after surgery, except a patient in Ranawat Class II, whose condition remained unchanged. All pat ients were satisfied with the procedure and reported subjective improvement . Conclusion. Transoral plate fixation combined with posterior wire fixation after transoral odontoid resection is an effective, reliable, and safe proc edure for the treatment of irreducible atlantoaxial kyphosis in rheumatoid arthritis.