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Study design. Multicenter case-control study. Objective. To identify imaging characteristics of the cervical spine in patients with retro-odontoid pseudotumor (ROP) without rheumatoid arthritis (RA) and determine the pathogenesis of ROP. Background. ROP results from proliferative changes in the soft tissue of the atlantoaxial junction surrounding the region of the transverse ligament, and is commonly seen in RA patients. However, the pathogenesis of ROP caused by mechanical instability of the upper cervical spine in patients without RA is yet to be explained. Materials and Methods. We collected imaging data [preoperative radiographs, magnetic resonance imaging (MRI), and computed tomography (CT)] of patients who underwent surgery between April 2011 and March 2022 at the three university hospitals for ROP (cases) and cervical spondylotic myelopathy (as age, sex, and institution matched controls). The two groups were compared for different parameters on cervical dynamic radiographs, MRI, and CT. Results. The ROP group consisted of 42 patients, and the control group comprised 168 patients. C2-C7 range of motion was significantly smaller in the ROP group (25.8 ± 2.6°) compared with the control group (33.0 ± 1.0°). C2-C7 sagittal vertical axis was significantly larger in the ROP group than the control group (39.3 ± 3.6 vs. 32.2 ± 1.3 mm). MRI and CT assessment showed progressive degeneration at all intervertebral levels in the ROP group. A significant positive correlation was observed between the thickness of the soft tissue posterior to the dental process and the atlantodental interval in the flexion position (r = 0.501). Conclusions. The development of ROP was associated with degeneration of facet joints and intervertebral disks in the middle and lower cervical spine. Our findings suggest that decreased mobility of the middle and lower cervical spine may cause instability in the upper cervical spine, leading to the formation of ROP. [ABSTRACT FROM AUTHOR]

OBJECTIVE: At present, there are many reports on the related factors associated with the incidence of cervical spine instability in patients with rheumatoid arthritis, but there are problems such as small sample size and many confounding factors, and the research results of various studies on the same related factors are also different. This article analyzed the factors related to cervical spine instability in patients with rheumatoid arthritis by means of a systematic review. METHODS: Articles related to cervical spine instability in patients with rheumatoid arthritis were collected by searching both Chinese and English databases until March 2023. The outcome of cervical spine instability in patients with rheumatoid arthritis was used as the grouping criterion to abstract basic information, baseline patient characteristics, laboratory-related tests, medication use, and other relevant risk factors. Meta-analysis was done using Stata 14.0 software. RESULTS: (1) Sixteen relevant studies, all of moderate or above quality, were included, including seven studies with case-control studies and nine with cross-sectional studies. The overall incidence of cervical spine instability in patients with rheumatoid arthritis was 43.08%. (2) Meta-analysis showed: Related risk factors included female (OR=0.60, 95%CI: 0.44-0.82, P=0.002); age at disease onset (SMD=-0.52, 95%CI: -0.86 to -0.18, P=0.003); duration of disease (SMD=0.58, 95%CI: 0.14-1.02, P=0.01); body mass index (OR=0.74, 95%CI: 0.63-0.88, P=0.001); rheumatoid factors positive univariate analysis subgroup (OR=1.33, 95%CI:1.02 to 1.72, P=0.04), C-reactive protein (SMD=0.26, 95%CI: 0.16-0.35, P=0.00), erythrocyte sedimentation rate (SMD=0.15, 95%CI: 0.002-0.29, P=0.047), anti-cyclic-citrullinated peptide antibodies (OR=1.73, 95%CI: 1.19-2.51, P=0.004), 28-joint Disease Activity Score (SMD=0.20, 95%CI: 0.04-0.37, P=0.02), destruction of peripheral joints (OR=2.48, 95%CI: 1.60-3.85, P=0.00), and corticosteroids (OR=1.91, 95%CI: 1.54-2.37, P=0.00) were strongly associated with the development of rheumatoid arthritis-cervical spine instability. Female and corticosteroid use were independently associated with the occurrence of rheumatoid arthritis-cervical spine instability. CONCLUSION: Based on clinical evidence from 16 observational studies, the overall incidence of rheumatoid arthritis-cervical spine instability was 43.08%. However, the incidence of cervical spine instability in rheumatoid arthritis patients varied greatly among different studies. Gender (female) and the use of corticosteroids were confirmed as independent correlation factors for the onset of cervical spine instability in patients with rheumatoid arthritis. The results of this study still provide some guidance for early clinical recognition, diagnosis, and prevention of rheumatoid arthritis-cervical spine instability. [ABSTRACT FROM AUTHOR]

Objective: Spinal involvement in rheumatoid arthritis (RA) is limited to the upper cervical spine, leading to cervical spine instability. This study aimed to evaluate the prevalence of anterior atlantoaxial subluxation (aAAS) and its associated risk factors in patients with RA. Method: This single‐centre cross‐sectional study 240 patients consecutively were recruited. Radiographs of the cervical spine were obtained in the flexion and neutral neck positions and read by two blinded observers. The diagnosis of aAAS was based on the distance between the anterior aspect of the dens and the posterior aspect of the anterior arch of the atlas, which was >3 mm during flexion. Statistical analysis was performed to determine the predictive factors of aAAS. Results: Two hundred and forty patients with a mean ± SD age of 56.4 ± 11.4 years were recruited, and 191 (78%) were female. The mean ± SD duration of the disease was 10.2 ± 8.5 years. Of all 25 cases (10.4%) diagnosed with aAAS, the mean anterior atlantodental interval in patients with AAS was 4.19 ± 1.20 mm. One in three patients with aAAS had no neck pain. Patients with aAAS had longer disease duration, lower age at diagnosis, lower body mass index, higher anti‐cyclic citrullinated peptide autoantibodies (anti‐CCP), more frequent erosion, joint restriction, and joint prostheses. In the multivariate regression model, joint limitation, history of joint prostheses, low BMI, and higher anti‐CCP levels were independent predictors of the aAAS. Conclusion: Thirty‐three percent of patients with cervical involvement do not experience neck pain. Cervical involvement should be considered even without neck pain, particularly in established diseases. [ABSTRACT FROM AUTHOR]

Spondyloepiphyseal dysplasia congenita (SEDC) is a type of short-limbed dwarfism characterized by platyspondylia, delayed metaphyseal ossification, and irregularly shaped bones. Anesthetic issues in patients with SEDC have reportedly included airway stenosis caused by laryngotracheal hypoplasia, ventilation difficulty due to facial hypoplasia, and intubation difficulty attributed to microgenia. Furthermore, atlantoaxial instability can lead to cervical dislocation due to excessive or violent manipulation of the head and neck. We present the case of a 5-year-old girl with SEDC scheduled for palatoplasty revision. Airway difficulties were anticipated because of microgenia and the cervical collar she wore for atlantoaxial instability. However, mask ventilation and video laryngoscopy proved relatively easy. The patient was placed in Trendelenburg position (approximately 10°) without head tilt for surgical access. A combination of formulas based on the patient's age and height was used to determine tracheal tube size. However, the 4.5-mm oral Ring, Adair, Elwyn (RAE) tube selected resulted in 1-lung intubation when the tube bend was fixed at the lip, requiring further depth adjustment. Successful anesthetic management of this patient with SEDC incorporated several factors, including an individualized airway management plan, use of a video laryngoscope, careful posturing to avoid excessive cervical strain, and appropriate tube sizing and positioning. [ABSTRACT FROM AUTHOR]

Purpose: To present the clinical features and treatment strategy of degenerative atlantoaxial subluxation (DAAS). Methods: Patients with DAAS treated in our institution from 2003 to 2020 were retrospectively reviewed. We utilized the Japanese Orthopedic Association (JOA) scale to evaluate the neurologic status and distance of Ranawat et al. (DOR) to measure vertical migration. Results: We recruited 40 patients with > 2 years of follow-up and an average age of 62.3 ± 7.7 years. All the patients had myelopathy; only one patient had moderate trauma before exacerbation of symptoms, and the duration of symptoms was 34 ± 36 months. The most frequent radiological features were vertical migration of C1 (100%), sclerosis (100%), and narrowing of the atlantoaxial lateral mass articulations (100%). Two patients underwent transoral release combined with posterior reduction and fusion, and 38 patients underwent posterior reduction and fusion with C1 lateral mass screws-C2 pedicle screws and plate systems only. Forty cases (100%) achieved a solid atlantoaxial fusion, and 38 cases (95%) achieved anatomic atlantoaxial reduction. The JOA score increased from 9.3 ± 2.6 to 14.8 ± 2.1 (P < 0.01). DOR increased from 14.5 ± 2.5 to 17.8 ± 2.2 mm at the final follow-up (P < 0.01). Loosening of the locking caps was detected in one case, bony fusion was achieved, and harvest-site pain was reported in five patients. Conclusion: DAAS differs from other types of AAS and presents with anterior subluxation combined with vertical subluxation arising from degenerative changes in the atlantoaxial joints. We recommend anatomic reduction as an optimal strategy for DAAS. [ABSTRACT FROM AUTHOR]

Abstract Background This work aims to develop a deep learning model, assessing atlantoaxial subluxation (AAS) in rheumatoid arthritis (RA), which can often be ambiguous in clinical practice. Methods We collected 4691 X-ray images of the cervical spine of the 906 patients with RA. Among these images, 3480 were used for training the deep learning model, 803 were used for validating the model during the training process, and the remaining 408 were used for testing the performance of the trained model. The two-dimensional key points’ detection model of Deep High-Resolution Representation Learning for Human Pose Estimation was adopted as the base convolutional neural network model. The model inferred four coordinates to calculate the atlantodental interval (ADI) and space available for the spinal cord (SAC). Finally, these values were compared with those by clinicians to evaluate the performance of the model. Results Among the 408 cervical images for testing the performance, the trained model correctly identified the four coordinates in 99.5% of the dataset. The values of ADI and SAC were positively correlated among the model and two clinicians. The sensitivity of AAS diagnosis with ADI or SAC by the model was 0.86 and 0.97 respectively. The specificity of that was 0.57 and 0.5 respectively. Conclusions We present the development of a deep learning model for the evaluation of cervical lesions of patients with RA. The model was demonstrably shown to be useful for quantitative evaluation.

Abstract Background C1-C2 subluxation is a rare complication of enthesitis-related arthritis (ERA). If left untreated, it may lead to functional impairment or cervical spinal cord compression. This study aims to highlight key points regarding the management of C1-C2 subluxation in ERA. Case presentation We present two cases of C1-C2 subluxation: an 8-year-old boy with ERA and 16-year-old boy with ERA with bilateral sacroiliitis. Ten cases of ERA in the literature were reviewed. The diagnosis of C1-C2 subluxation is mostly based on radiographs and cervical spine computed tomography. All patients were treated with non-steroidal anti-inflammatory drugs. Six ERA patients were treated surgically for cervical fusion. Most ERA patients with sacroiliitis had cervical collar protection. Neurologic abnormalities after treatment were not reported. Despite the use of cervical collar, cervical fusion and persisting ankylosis were found in two ERA patients with sacroiliitis without surgical treatment. Conclusions Cervical spine protection and ruling out spinal cord compression should be prioritized, in addition to controlling the underlying inflammation in ERA. Cervical halter traction may be applied after severe cervical inflammation is excluded. To reduce the risk of complications, early recognition and appropriate treatments of C1-C2 subluxation in ERA are essential.

Background: Atlantoaxial dislocation (AAD) refers to loss of stability between atlas and axis vertebrae, resulting in loss of normal articulation. It may be due to congenital, traumatic, or inflammatory reasons. Various techniques of atlantoaxial fixation have been described and used in patients over the years, but each has its own merits and demerits. Aims and Objectives: The aim of the study was to study clinicoradiological evaluation and outcome assessment of single-stage posterior correction of AAD. Materials and Methods: This is a prospective study done in the Department of Neurosurgery, JA group of hospitals, Gajra Raja Medical College, Gwalior, from July 2021 to July 2022. The study was conducted on 20 randomly selected patients whose presentation and imaging showed indication for surgery. Results: C1 lateral mass C2 pars screw fixation had one Frankel grade improvement in 6 months in 96% patient with a fusion rate of 100% and the patient also has modified Japanese orthopedic association score improvement of 15.25±0.98. Conclusion: This study reviewed single-stage posterior correction of AAD using C1 lateral mass and C2 pedicle screw and rod fixation; it enables the stabilization of atlantoaxial motion and preserves motion at occipito-atlantal level with high fusion rates, good neurological recovery, and minimal complications.

Atlantoaxial rotatory fixation (AARF) in children presents with an acute onset of neck pain. Almost all cases heal within a few days of onset and are treated conservatively. Because few cases of AARF have been reported, the age distribution or gender ratio of AARF in the child population have not been described enough. In Japan, the social insurance system covers all citizens. Thus, we used insurance claims data to investigate the features of AARF. The aim of this study is to examine the age distribution, compare gender ratio and determine the recurrence proportion of AARF. We used the JMDC database to search for claims data submitted between January 2005 and June 2017 for cases of AARF in patients aged <20 years. We identified 1949 patients with AARF, of which 1102 (56.5%) were male. The mean age was 98.3 ± 42.2 months and 91.6 ± 38.4 months in males and females, respectively, and males with AARF were significantly older at onset than females with AARF (p < 0.001). In both sexes, the highest frequency of AARF occurred when the patient was 6 years old. There were 121 (6.2%) cases of recurrent AARF (male: 61, 5.5%; female: 60, 7.1%), but the age differences between the sexes in these cases were not statistically significant. This is the first report to describe the characteristics of the study population of AARF. Males were more likely to suffer from AARF than females. Furthermore, age (in months) at AARF onset was significantly higher in males than in females. Recurrence rate was not significant in both sexes. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to describe clinical and imaging features of atlantoaxial subluxation (AAS) and the associated risk factors in patients with rheumatoid arthritis (RA). Methods: We conducted a retrospective and comparative study including 51 RA patients with AAS and 51 RA patients without AAS. Atlantoaxial subluxation was defined by the presence of an anterior C1C2 diastasis on the cervical spine radiograph in hyperflexion and/or an anterior, posterior, lateral or rotatory C1C2 dislocation on MRI with/without inflammatory signal. Results: In G1, clinical presentations revealing AAS were mainly neck pain (68.7%) and neck stiffness (29.8%). MRI revealed: diastasis C1C2 (92.5%), periodontoid pannus (92.5%), odontoid erosion (23.5%), vertical subluxation (9.8%) and spinal cord involvement (7.8%). A collar immobilisation and corticosteroid boluses were indicated in 86.3% and 47.1% of cases. C1‐C2arthrodesis was performed in 15.4% of cases. Atlantoaxial subluxation was significantly associated with: age at disease onset (p = 0.009), history of joint surgery (p = 0.012), disease duration (p = 0.001), rheumatoid factor (p = 0.01), anti‐cyclic citrullinated peptide (p = 0.02), erosive radiographic status (p < 0.005), coxitis (p < 0.001), osteoporosis (p = 0.012), extra‐articular manifestations (p < 0.001), and high disease activity (p = 0.001). Multivariate analysis identified RA duration (p < 0.001, OR = 1.022 CI[1.01–1.034]) and erosive radiographic status (p = 0.01, OR = 21.236 CI[2.05–219.44]) as predictive factors of AAS. Conclusion: Our study showed that longer disease duration and joint destruction are the major predictive factors of AAS. Early treatment initiation, tight‐control and regular monitoring of cervical spine involvement are required in these patients. [ABSTRACT FROM AUTHOR]

Objective radiographic measurements for determining atlantoaxial instability (AAI) in dogs have been reported. However, choosing a single optimal parameter among different studies is challenging. This study aimed to identify optimal parameters for AAI in small-breed dogs by simultaneously evaluating the flexed and nonflexed lateral radiographs. Moreover, the potential of using serial trichotomization with multiple parameters was investigated. Radiographs of 10 dogs diagnosed with AAI on magnetic resonance imaging (MRI) were compared with 26 control dogs to select parameters with the area under the curve ≥0.9 or ≤0.1. Parameters with outstanding discrimination included cranial border distance and C1–C2 angle on nonflexed radiographs and dens length on ventrodorsal radiographs. Using cutoff values reflecting 100% sensitivity and 100% specificity, the subject was determined into AAI diagnosed, ruled-out or indeterminate. The accuracy rate was 100% for each of the parameters. However, 31–47% of dogs were classified as indeterminate. Serial trichotomization in the order of dens length, cranial border distance, and C1–C2 angle significantly reduced the proportion of dogs in the uncertainty zone while maintaining accuracy. The established method was tested on 19 new subjects. A similar trend of high accuracy (100%) and small uncertainty zone (5%) was observed in the validation cohort. For certain breeds, serial trichotomization with dens length on the ventrodorsal radiograph and cranial border distance and C1–C2 angle on the nonflexed lateral radiograph showed good potential for determining AAI and identifying dogs in which advanced imaging is indicated for diagnosis. [ABSTRACT FROM AUTHOR]

Background: C1-C2 subluxation is a rare complication of enthesitis-related arthritis (ERA). If left untreated, it may lead to functional impairment or cervical spinal cord compression. This study aims to highlight key points regarding the management of C1-C2 subluxation in ERA. Case presentation: We present two cases of C1-C2 subluxation: an 8-year-old boy with ERA and 16-year-old boy with ERA with bilateral sacroiliitis. Ten cases of ERA in the literature were reviewed. The diagnosis of C1-C2 subluxation is mostly based on radiographs and cervical spine computed tomography. All patients were treated with non-steroidal anti-inflammatory drugs. Six ERA patients were treated surgically for cervical fusion. Most ERA patients with sacroiliitis had cervical collar protection. Neurologic abnormalities after treatment were not reported. Despite the use of cervical collar, cervical fusion and persisting ankylosis were found in two ERA patients with sacroiliitis without surgical treatment. Conclusions: Cervical spine protection and ruling out spinal cord compression should be prioritized, in addition to controlling the underlying inflammation in ERA. Cervical halter traction may be applied after severe cervical inflammation is excluded. To reduce the risk of complications, early recognition and appropriate treatments of C1-C2 subluxation in ERA are essential. [ABSTRACT FROM AUTHOR]

Background: Atlantoaxial dislocation (AAD) refers to loss of stability between atlas and axis vertebrae, resulting in loss of normal articulation. It may be due to congenital, traumatic, or inflammatory reasons. Various techniques of atlantoaxial fixation have been described and used in patients over the years, but each has its own merits and demerits. Aims and Objectives: The aim of the study was to study clinicoradiological evaluation and outcome assessment of single-stage posterior correction of AAD. Materials and Methods: This is a prospective study done in the Department of Neurosurgery, JA group of hospitals, Gajra Raja Medical College, Gwalior, from July 2021 to July 2022. The study was conducted on 20 randomly selected patients whose presentation and imaging showed indication for surgery. Results: C1 lateral mass C2 pars screw fixation had one Frankel grade improvement in 6 months in 96% patient with a fusion rate of 100% and the patient also has modified Japanese orthopedic association score improvement of 15.25±0.98. Conclusion: This study reviewed single-stage posterior correction of AAD using C1 lateral mass and C2 pedicle screw and rod fixation; it enables the stabilization of atlantoaxial motion and preserves motion at occipito-atlantal level with high fusion rates, good neurological recovery, and minimal complications. [ABSTRACT FROM AUTHOR]

Objectives: In rheumatoid arthritis, neck pain can be caused by inflammatory reactions or cervical lesions, but the prevalence and associated factors have not been well studied. This study aimed to investigate the prevalence of neck pain in patients with rheumatoid arthritis and elucidate the related factors. Methods: This study included 146 patients with rheumatoid arthritis. Neck pain, quality of life, and levels of anxiety and depression were evaluated using a questionnaire. Cervical lesions and spinal alignment were evaluated using plain radiograph and magnetic resonance imaging. Factors associated with neck pain were analysed using a logistic regression model. Results: Fifty-six per cent of the patients had neck pain, and the quality of life scores were significantly worse in these patients. Multivariate analysis revealed age, C7 sagittal vertical axis, upper cervical lesion, and endplate erosion as factors associated with neck pain in patients with rheumatoid arthritis. Conclusions: More than half the patients with rheumatoid arthritis suffer from neck pain, and neck pain affects the quality of life and activities of daily living. Neck pain was associated with upper cervical lesion and endplate erosion suggesting the importance of radiological examination in patients with rheumatoid arthritis and neck pain. [ABSTRACT FROM AUTHOR]

Background/Aim: Atlantoaxial subluxation (AAS) is a congenital or traumatic condition that often requires surgical stabilization. Surgery is performed via a ventral or dorsal approach. A ventral approach is challenging in toy breed dogs due to their small-sized bones. Reducing AAS by orthopedic wire via a dorsal approach can cause iatrogenic spinal cord damage. Due to these limitations, a Kishigami atlantoaxial tension band (Kishigami AATB) that remains in the epidural space has been devised. Similar to the Kishigami AATB, the present study developed a modified dorsal wiring method and evaluated it in toy breed dogs with AAS. Materials and Methods: Medical data of toy breed dogs with AAS that underwent surgical stabilization using the modified dorsal wiring method from 2017 to 2020 were retrospectively reviewed. Results: A total of 10 dogs were analyzed. Regarding the history of these dogs, six dogs had congenital AAS, and the remaining four dogs had traumatic AAS. Evaluation via computed tomography was available for five dogs, of which two dogs were identified as having incomplete ossification of their atlas. Although four dogs required a revision surgery because of recurrence of clinical signs or fracture of the atlas, final functional improvement was achieved in nine dogs. One dog showed worsened neurological status that led to death. Conclusion: Clinical results with the modified dorsal wiring method were similar to those with the Kishigami AATB. The modified dorsal wiring method is versatile as it could be applied to various shapes of dogs' atlas. Considering the shape of the atlas, it is recommended to apply the implant as far from the midline of the dorsal arch as possible to avoid fractures. With selection of suitable patients, this modified dorsal wiring method can be applied to dorsal stabilization of AAS in toy breed dogs. [ABSTRACT FROM AUTHOR]

Study design: Technical note. Objectives: To present a novel C-arm-free technique guided by navigation to insert and place a C1 lateral mass screw. Background and Objectives: Atlantoaxial subluxation (AAS) is a relatively common sequelae in patients with rheumatoid arthritis (RA) and upper cervical trauma. If they present with severe symptoms, surgical intervention such as posterior fusion is indicated. The established treatment for AAS is fixation with a C1 lateral mass screw and C2 pedicle screw (modified Goel technique) to achieve bony fusion. However, this technique requires fluoroscopy for C1 screw insertion. To avoid exposing the operating team to radiation, we present here a novel C-arm-free C1 lateral mass screw insertion technique for AAS. Materials and Methods: A 67-year-old man was referred to our hospital with neck pain, quadriparesis, and clumsiness and numbness of both upper and lower limbs. He had undergone C3–6 posterior fusion previously in another hospital. In physical examination, he had severe muscle weakness of bilateral upper limbs and hypoesthesia of all four limbs. He had hyper-reflexia of bilateral lower limbs and pollakiuria. His Japanese orthopedic score was 8 points out of 17. Preoperative radiograms showed AAS with an atlantodental interval (ADI) of 7 mm. MRI indicated retro-odontoid pseudotumor and severe spinal cord compression at the C1–2 level. The patient underwent posterior atlantoaxial fixation under navigation guidance. To prevent epidural bleeding during the insertion and placement of a C1 lateral mass screw, we have here defined a novel screw insertion technique. Results: The surgical time was clocked as 127 min and blood loss was 100 mL. There were no complications per-operatively or in the postoperative period. The patient showed almost full recovery (JOA 16/17) at two months follow-up and a solid bony fusion was noticed in the radiograms at one year follow-up. Conclusions: This novel surgical procedure and C1 lateral mas screw placement technique is a practical and safe method in recent advances of AAS treatment. Procedurally, the technique helps prevent epidural bleeding from the screw entry point and also allows for proper C1 screw insertion under navigation guidance without exposing surgeons and staff to the risk of fluoroscopic radiation. [ABSTRACT FROM AUTHOR]

In the first part we reviewed the issues of perioperative administration of steroids, disease-modifying antirheumatic drugs, biologics and nonsteroidal anti-inflammatory drugs. In this part we will discuss cardiovascular risks, prevention of infectious and thromboembolic complications and the impact of some structural alteration on the process of surgery and perioperative management.

Os odontoideum (OO) is a rare craniocervical anomaly that is characterized by a round ossicle separated from the C2 vertebral body. With a controversial etiology and unknown prevalence in the population, OO may be asymptomatic or present in patients with myelopathic and neurological symptoms. In this literature review, we aimed to investigate epidemiology, embryology, pathophysiology, clinical presentation, and the role of diagnostic radiography in OO. By providing an overview of different management strategies, surgical complications, and postoperative considerations for OO, our findings may guide neurosurgeons in providing proper diagnosis and treatment for OO patients. A literature review was conducted using the PubMed, EMBASE, and Scopus databases. A search using the query “os odontoideum” yielded 4319 results, of which 112 articles were chosen and analyzed for insights on factors such as etiology, clinical presentation, and management of OO. The presentation of OO varies widely from asymptomatic cases to severe neurological deficits. Asymptomatic patients can be managed either conservatively or surgically, while symptomatic patients should undergo operative stabilization. Although multiple studies show different techniques for surgical management involving posterior fusion, the diversity of such cases illustrates how treatment must be tailored to the individual patient to prevent complications. Conflicting studies and the paucity of current literature on OO highlight poor comprehension of the condition. Further understanding of the natural history of OO is critical to form evidence-based guidelines for the management of OO patients. More large-center studies are thus needed to promote accurate management of OO patients with optimal outcomes.

Objective: Investigating the causal relationship between rheumatoid arthritis (RA) and atlantoaxial subluxation (AAS) and identifying and quantifying the role of C-reactive protein (CRP) as a potential mediator. Methods: Using summary-level data from a genome-wide association study (GWAS), a two-sample Mendelian randomization (MR) analysis of genetically predicted rheumatoid arthritis (14,361 cases, and 43,923 controls) and AAS (141 cases, 227,388 controls) was performed. Furthermore, we used two-step MR to quantitate the proportion of the effect of c-reactive protein-mediated RA on AAS. Results: MR analysis identified higher genetically predicted rheumatoid arthritis (primary MR analysis odds ratio (OR) 0.61/SD increase, 95% confidence interval (CI) 1.36-1.90) increased risk of AAS. There was no strong evidence that genetically predicted AAS had an effect on rheumatoid arthritis risk (OR 1.001, 95% CI 0.97-1.03). The proportion of genetically predicted rheumatoid arthritis mediated by C-reactive protein was 3.7% (95%CI 0.1%−7.3%). Conclusion: In conclusion, our study identified a causal relationship between RA and AAS, with a small proportion of the effect mediated by CRP, but a majority of the effect of RA on AAS remains unclear. Further research is needed on additional risk factors as potential mediators. In clinical practice, lesions of the upper cervical spine in RA patients need to be given more attention. [ABSTRACT FROM AUTHOR]

Background/Aim: Atlantoaxial subluxation (AAS) is generally a congenital condition that mainly affects toy breed dogs. Previous studies in several toy breed dogs revealed that dogs with AAS had a relatively high proportion of incomplete ossification (IO) of the atlas and dens anomalies compared to dogs without AAS. These anatomical characteristics may be important in surgical decisionmaking. Thus, the present study evaluated morphological differences in the atlas and axis between Maltese dogs with and without AAS. Materials and Methods: The medical records of Maltese dogs with and without AAS from 2015 to 2020 were analyzed. Abnormalities of the atlas and axis were evaluated using computed tomography (CT). Results: A total of 45 dogs were reviewed. Maltese dogs with AAS revealed a higher ratio of IO of the atlas (56%) than nonaffected dogs (19%). Dens anomalies were identified in 78% of the dogs with AAS and in 26% of non-affected dogs. The shape of the atlas has been identified as thin, solid compact bone in Maltese dogs. Dogs that revealed IO of the dorsal arch of the atlas showed significantly lower CT values (in Hounsfield units) than dogs without IO. The CT values of the midline of the dorsal arch were significantly lower than those of the outer surrounding region. Dens hypoplasia was defined by measuring the dens-to-axis length ratio according to a previous study. A significantly lower ratio was identified in dogs with AAS than in non-affected dogs. Conclusion: The incidence ratio of abnormalities of the atlas and axis in Maltese dogs with AAS was similar to that of previous studies. The dorsal arch of the atlas is composed of thin cortical bone with a vulnerable midline region. As dogs with AAS are more likely to be afflicted with abnormalities in the atlas and axis, considering these morphological features is important when planning the surgical stabilization of AAS. [ABSTRACT FROM AUTHOR]

Os odontoideum is considered a rare cervical spine anomaly. Depending on its type, it may or may not result in atlantoaxial instability, which can lead to anterior subluxation (the most common type) or posterior subluxation, with the latter being extremely rare. Posterior atlantoaxial subluxation is particularly dangerous, as it can progressively lead to myelopathy through various mechanisms and may ultimately result in quadriplegia or even death., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Elbana et al.)

The atlantoaxial joint C2 (axis) with the anterior arch of C1 (atlas) allows 50% of cervical lateral rotation. It is responsible for precise and important movements that allow us to perform precise actions, both in normal and working life. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed and the outcome is worse. An early diagnosis and treatment are essential to ensure satisfactory neurological and functional outcomes. The aim of this review is to analyze C1-C2 rotatory subluxation in adults, given its rarity. The time between injury and reduction is key, as it is directly related to prognosis and the severity of the treatment options. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed as a lot of cases are not related to a clear trauma, with a poor prognosis just because of the late diagnosis and the outcome is worse. The correct approach and treatment of atlantoaxial dislocation requires a careful study of the radiological findings to decide the direction and plane of the dislocation, and the search for associated skeletal anomalies. [ABSTRACT FROM AUTHOR]

Os odontoideum (OO) is a rare craniocervical anomaly that is characterized by a round ossicle separated from the C2 vertebral body. With a controversial etiology and unknown prevalence in the population, OO may be asymptomatic or present in patients with myelopathic and neurological symptoms. In this literature review, we aimed to investigate epidemiology, embryology, pathophysiology, clinical presentation, and the role of diagnostic radiography in OO. By providing an overview of different management strategies, surgical complications, and postoperative considerations for OO, our findings may guide neurosurgeons in providing proper diagnosis and treatment for OO patients. A literature review was conducted using the PubMed, EMBASE, and Scopus databases. A search using the query "os odontoideum" yielded 4319 results, of which 112 articles were chosen and analyzed for insights on factors such as etiology, clinical presentation, and management of OO. The presentation of OO varies widely from asymptomatic cases to severe neurological deficits. Asymptomatic patients can be managed either conservatively or surgically, while symptomatic patients should undergo operative stabilization. Although multiple studies show different techniques for surgical management involving posterior fusion, the diversity of such cases illustrates how treatment must be tailored to the individual patient to prevent complications. Conflicting studies and the paucity of current literature on OO highlight poor comprehension of the condition. Further understanding of the natural history of OO is critical to form evidence-based guidelines for the management of OO patients. More large-center studies are thus needed to promote accurate management of OO patients with optimal outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: Ventral-approach techniques have been broadly employed for the surgical stabilization of atlantoaxial subluxation. The postoperative complications following ventral stabilization may include upper-respiratory, pharyngeal, and laryngeal dysfunction due to inadvertent damage to adjacent structures, such as the larynx, trachea, and neuronal tissues. The exact causes and management methods for postoperative complications after ventral stabilization have not yet been fully elucidated. Implanted polymethylmethacrylate cement can cause multiple cranial nerve palsies affecting the adjacent nuclei of the cranial nerves or their peripheral roots or axons. Early revision surgery may promote the full recovery of the affected neurological dysfunctions. Clinicians should consider cranial nerve palsies as major complications of ventral stabilization surgery in patients with atlantoaxial subluxation and be cautious about the volume and extent of polymethylmethacrylate during ventral stabilization, especially in very-small-breed dogs. A 4-year-old spayed female miniature poodle dog presented with a 1-week history of acute tetraparesis. A neurological examination revealed severe neck pain and non-ambulatory tetraparesis. Computed tomography and magnetic resonance imaging showed hypoplastic dens with moderate compression of the spinal cord at C1–C2. The atlantoaxial subluxation (AAS) was surgically stabilized using ventral pins and polymethylmethacrylate (PMMA) cement. On the second postoperative day, the patient showed significant dyspnea, and aspiration pneumonia was identified on radiography. The patient exhibited dysphagia with abnormal food prehension and an inability to protrude the tongue, with no gag reflex. We tentatively diagnosed the patient with multiple cranial nerve (CN) palsies involving the 9th, 10th, and 12th CNs following surgical ventral stabilization. The protruding cranial part of the implanted PMMA cement, which could mechanically contribute to the corresponding CNs dysfunction, was surgically removed. The symptoms gradually improved, and the patient showed normal tongue movement 1 month after revision surgery. In conclusion, we report herein a canine case of multiple CN palsies following ventral stabilization surgery for AAS. The experience gained from this case suggests an optimized management plan for postoperative neurological complications associated with ventral stabilization. [ABSTRACT FROM AUTHOR]

We report a rare case of dysphagia after occipitocervical fixation, and aim to emphasize the importance of occiput-C2 angle. The kyphotic change of occiput-C2 alignment after operation might lead to dysphagia due to decreased oropharyngeal cross-section area and increased basal pressure of upper esophageal sphincter. Carefully align the occiput-C2 angle during occipitocervical fixation might reduce the incidence of postoperative dysphagia. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective cohort study.Objective: To examine factors related to severe aggravation of preexisting cervical lesions in patients with rheumatoid arthritis (RA) under current pharmacologic treatments with biologics.Summary Of Background Data: Advanced RA cervical lesions carry a risk of irreversible damage to the spinal cord; however, risk factors for aggravation are unclear after the use of biologics became more popular.Methods: Of 166 patients with preexisting cervical lesions at baseline, 87 who had cervical X-ray images taken at baseline and at the final visit (with an interval of more than 1 yr) were evaluated retrospectively. Aggravated instabilities determined at the final visit, were defined as follows: atlantoaxial subluxation (AAS) = atlantodental interval ≧ 10 mm; vertebral subluxation (VS) = a Ranawat value < 10 mm; and subaxial subluxation (SAS) = an anterior vertebral slip ≧ 4 mm or a multilevel slip ≧ 2 mm. Patients were divided into two groups based on the radiographic results: severe aggravation and non-severe aggravation. Explanatory variables were gender, age of RA onset, duration of disease, average observation period, Disease Activity Score 28 based on C-reactive protein (DAS28-CRP) at baseline, drug treatment history, presence of mutilating deformities in the hands, presence of RA-related joint surgery, and the prevalence of each cervical lesion at baseline.Results: The severe group comprised 14 patients (16.1%). There was no significant difference between the two groups with respect to demographic data. Multivariate logistic regression analysis revealed that preexisting SAS lesions (odds ratio: 7.59, 95% confidence interval: 1.16-49.6) and no history of biologic treatment (odds ratio, 0.10; 95% confidence interval, 0.17-0.58) were associated with aggravation.Conclusion: Preexisting SAS lesions were associated with aggravation. Meanwhile, biologics may be effective at preventing aggravation.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Abstract Background Approximately 50–70% of patients with Kawasaki disease (KD) could present with cervical lymphadenopathy associated with deep neck inflammation, which may result in Grisel’s syndrome (GS). Given the possibility of neurological impairment owing to GS, it is important to understand the disease profile in KD. Therefore, we carried out this study to investigate this possible complication of KD, with the aim of improving pediatricians’ recognition and awareness. Methods Patients with KD complicated by GS in our hospital were retrospectively recruited for our study. The profiles of patients with GS (n = 10) were compared to those patients without GS (n = 1254). All the available literature describing these complications of KD was reviewed. Results The incidence of GS in KD was 0.6% in our population. Compared to patients without GS, KD patients with GS were older, presented with a significantly lower male:female ratio, and a higher incidence of cervical lymphadenopathy, a higher level of neutrophil count, and erythrocyte sedimentation rate. Ten articles reporting 14 KD patients with GS were reviewed. Of the total 24 patients, GS affected 7 males and 17 females, aged from 3.5 to 9 years old. Encouragingly, no delayed diagnosis and treatment of KD was found, and all patients received conservative therapy for GS, without intravenous immunoglobulin resistance, coronary artery lesions, and neurological impairment. Conclusions GS is a rare complication of KD with an incidence of 0.6%, predominantly affecting older, female children. The overall outcome of this disorder in KD was satisfactory with conservative therapy. Pediatricians, especially pediatric surgeons, should recognize and be aware of this possible complication of KD to avoid misdiagnosis and overtreatment.

Abstract Background Atlantoaxial subluxation (AAS) is a not rare abnormality between the atlas (C1) and axis (C2). For AAS patients with persistent neck pain and neurologic symptoms, surgical intervention is a good choice. Nevertheless, there were still few reports about the use of intraoperative skull traction and different fixation methods in treatment of AAS. Methods From January 2012 to December 2018, a total of 86 cases were admitted to our hospital and diagnosed as AAS. All the patients received atlantoaxial reduction with the help of intraoperative skull traction and C1-C2 fixation. Clinical and radiological parameters were collected through chart review. Results There were 86 cases included in this study. The mean operative time was 153.9 ± 73.9 min, and the mean amount of intraoperative blood loss was 219.1 ± 195.6 ml. 81 patients underwent posterior reduction, internal fixation and fusion. 5 patients underwent anterior release, followed by posterior internal fixation and fusion. 82 patients got satisfactory postoperative outcomes while complications occurred in 4 patients. Significant neurologic improvement was observed in these patients. Bone fusion was achieved on the midline sagittal reconstructed CT images at the latest follow-up in all these patients except 1 case. All the patients were followed up for 34.84 ± 15.86 months at average (range 12–60 months). The mean ADI value was 7.55 ± 1.67 mm at average preoperatively, and improved to 4.03 ± 1.21 mm postoperatively, and to 4.21 ± 0.99 mm at the latest follow-up. The mean A-A angle was 15.48 ± 9.82 degrees at average preoperatively, and improved to 21.61 ± 10.43 degrees postoperatively, and to 19.73 ± 8.13 degrees at the latest follow-up. The mean A-A height was 35.61 ± 7.66 mm at average preoperatively, and improved to 40.08 ± 8.5 mm postoperatively, and to 38.83 ± 6.97 mm at the latest follow-up. There were complications in 4 patients, including pedicle misplacement, pedicle screw fracture, infection and one death. Conclusion Intraoperative skull traction can effectively facilitate the surgical procedures for ASS caused by different etiologies. Further research will be needed to investigate the safety and effectiveness of this method in the future.

Abstract Background Occipitocervical (OC) fusion is indicated for OC instability and other conditions. Surgical complications include infection, malunion, and instrument failure. Case presentation We described a patient who underwent OC fusion and subsequently developed complication of cerebellar abscess and obstructive hydrocephalus. A 63-year-old male patient had been suffering from long-term neck pain and limb numbness and weakness. Cervical spine examination revealed tight stenosis at C1 level and instability in the C1-C2 joints. A C1 laminectomy with OC fusion was performed, and the patient was discharged. Unfortunately, a few days later, he went to the emergency department and complained of persistent dizziness, vomiting, and unsteady gait. Computed tomography (CT) and magnetic resonance imaging (MRI) images revealed a suspicious cerebellar abscess formation and hydrocephalus. Furthermore, CT images indicated that the left screw was loose, and the diameter of the right screw hole was much larger than the size of the screw. Besides, inappropriate length of the screw penetrated the occipital bone and may cause the disruption of dura mater. The patient underwent external ventricular drainage first, followed by abscess drainage and C1-C2 fixation a few days later. He was discharged without any further neurological deficits or infectious problems. The patient recovered with intact consciousness, full muscle strength, and improved numbness throughout the extremities, with a Nurick grade of 1. A follow-up magnetic resonance imaging at 3 months after surgery revealed near total resolution of the abscess. Inform consent was obtained from this patient. Conclusions Carefully conducting the procedure using the most tailored approach is essential to successful surgery, but this rare complication should always be kept in mind.

Grisel's syndrome is a non-traumatic atlantoaxial (C1-C2) subluxation and one of the causes of torticollis in children. The subluxation occurs in the context of an infection in the ENT ("Ear Nose and Throat") region or following surgery. Diagnosis is based on clinical examination and radiological assessment. Treatment is typically medical and conservative, with surgical interventions reserved for recurrences and late presentations. We discuss here two cases of C1-C2 subluxation. The first case involves a 10-year-old child with subluxation following a rhinopharyngitis. This presentation is the classical manifestation of Grisel's syndrome. Prompt management led to correction of the subluxation using medical treatment and a soft Philadelphia collar. The second case involves a 34-year-old adult who developed posterior headaches after sphenoidotomy surgery. Grisel's syndrome is less common in adults, leading to clinical challenges and delayed diagnosis (> 1 month). Reduction combined with a halo vest treatment failed, and the patient required cervical arthrodesis.

Study design: Technical note. Objectives: To present a novel C-arm-free technique guided by navigation to insert and place a C1 lateral mass screw. Background and Objectives: Atlantoaxial subluxation (AAS) is a relatively common sequelae in patients with rheumatoid arthritis (RA) and upper cervical trauma. If they present with severe symptoms, surgical intervention such as posterior fusion is indicated. The established treatment for AAS is fixation with a C1 lateral mass screw and C2 pedicle screw (modified Goel technique) to achieve bony fusion. However, this technique requires fluoroscopy for C1 screw insertion. To avoid exposing the operating team to radiation, we present here a novel C-arm-free C1 lateral mass screw insertion technique for AAS. Materials and Methods: A 67-year-old man was referred to our hospital with neck pain, quadriparesis, and clumsiness and numbness of both upper and lower limbs. He had undergone C3–6 posterior fusion previously in another hospital. In physical examination, he had severe muscle weakness of bilateral upper limbs and hypoesthesia of all four limbs. He had hyper-reflexia of bilateral lower limbs and pollakiuria. His Japanese orthopedic score was 8 points out of 17. Preoperative radiograms showed AAS with an atlantodental interval (ADI) of 7 mm. MRI indicated retro-odontoid pseudotumor and severe spinal cord compression at the C1–2 level. The patient underwent posterior atlantoaxial fixation under navigation guidance. To prevent epidural bleeding during the insertion and placement of a C1 lateral mass screw, we have here defined a novel screw insertion technique. Results: The surgical time was clocked as 127 min and blood loss was 100 mL. There were no complications per-operatively or in the postoperative period. The patient showed almost full recovery (JOA 16/17) at two months follow-up and a solid bony fusion was noticed in the radiograms at one year follow-up. Conclusions: This novel surgical procedure and C1 lateral mas screw placement technique is a practical and safe method in recent advances of AAS treatment. Procedurally, the technique helps prevent epidural bleeding from the screw entry point and also allows for proper C1 screw insertion under navigation guidance without exposing surgeons and staff to the risk of fluoroscopic radiation.

Rheumatoid arthritis (RA) is a progressive autoimmune inflammatory disease affecting 1% of the population with three times as many women as men. As many as 86% of patients suffering from RA have cervical spine involvement. Synovial inflammation in the cervical spine causes instability and injuries including atlantoaxial subluxation, retroodontoid pannus formation, cranial settling, and subaxial subluxation. While many patients with cervical spine involvement are asymptomatic, symptomatic patients often present with nonspecific symptoms resulting from inflammation and additional secondary symptoms that are due to compression of the brainstem, cranial nerves, vertebral artery, and spinal cord. Radiographs are the imaging modality used most often, while MRI and CT are used for assessment of neural element involvement and surgical planning. Multiple classification systems exist. Early diagnosis and treatment of cervical spine involvement is critical. Surgical management is indicated when patients experience symptoms from cervical involvement that result in biomechanical instability and, or a neurological deficit. Atlantoaxial instability managed with atlantoaxial fusion, retroodontoid pannus with neural element compression is managed with posterior decompression and atlantoaxial fusion or occipitocervical fusion. Cranial settling is managed can be managed with anterior decompression and posterior fusion or with dorsal only approaches. Subaxial subluxation is managed with circumferential fusion or posterior only decompression and fusion. Patients with atlantoaxial instability have better functional and neurologic outcomes. RA patients have higher complication rates and more frequent need for revision surgery than the general population of spine surgery patients. [ABSTRACT FROM AUTHOR]

Case series summary: We describe here the surgical management of two pure breed cats with traumatic atlantoaxial subluxation. One cat was ambulatory tetraparetic on presentation and the second was tetraplegic, both with cervical spinal pain and acute onset of paresis with subsequent deterioration. MRI was performed in both cases, demonstrating spinal cord injury. Flexed lateral cervical radiographs were needed to confirm atlantoaxial subluxation in one case. CT was performed for surgical planning and surgical stabilisation was achieved with threaded pins and polymethyl methacrylate (PMMA) cement; odontoidectomy was required in one case. Both cats showed improvement postoperatively, with no complications or deterioration seen. Following surgery, one cat made a complete recovery; however, the second cat retained significant deficits. Relevance and novel information: We present the first report of surgically managed atlantoaxial subluxation of traumatic aetiology in cats, and report its occurrence in two novel breeds for this disease, Ragdoll and Persian. One case required odontoidectomy due to previous fracture and malunion of the odontoid process of the axis; both cases underwent surgical stabilisation of the atlantoaxial joint utilising multiple threaded pins and PMMA cement without transarticular implants – a technique that has not been previously reported in cats. [ABSTRACT FROM AUTHOR]

Study Design Retrospective case series. Purpose To evaluate surgical outcomes and effectiveness of an autogenic rib graft for upper cervical fixation in pediatric patients. Overview of Literature Autogenic bone grafts have long been considered the ‘gold standard’ bone source for posterior cervical fusion in pediatric patients. However, there are some unsolved problems associated with donor-site morbidity and amount of bone grafting. Methods We studied five consecutive pediatric patients who underwent atlantoaxial fixation or occipitocervical fixation (OCF) using an autogenic rib graft with at least 2 years of follow-up (mean age, 9.8 years; mean follow-up period, 73.0 months). Two patients underwent OCF without screw-rod constructs and three patients with screw-rod constructs. Autogenic rib grafts were used in all patients. We evaluated the surgical outcomes including radiographic parameter, bony union, and perioperative complications. Results The atlantoaxial interval (ADI) was corrected from 11.6 to 6.0 mm, and the C1–2 angle was corrected −14.8° to 7.8°. The C2–7 angle was reduced from 31° to 9° spontaneously. Two patients with OCF required revision surgery due to loss of correction. Patients did not experience any complication associated with the donor sites (rib bone grafts). Six months postoperation X-rays clearly showed regeneration of the rib at the donor sites. Bony fusion was achieved in all patients; however, bony fusion occurred more slowly in patients without screw-rod constructs compared with patients with screw-rod constructs. Bone regeneration of the rib was observed in all patients with no complications at the donor site. Conclusions Autogenic rib grafts have advantages of potential bone regeneration, high fusion rate, and low donor-site morbidity. In addition, a screw-rod construct provides better bony fusion in pediatric patients with OCF and atlantoaxial fixation.

Abstract Background Atlantoaxial subluxation (AAS) is characterized by excessive movement at the junction between the atlas (C1) and axis (C2) as a result of either a bony or ligamentous abnormality. Surgical intervention is a therapeutic choice for AAS. In addition to C1 laminectomy (LAM), surgical fixation for subluxation or instability is performed by various techniques. While surgical treatment options for AAS have increased, the outcomes of different surgical techniques remain unclear. Methods The authors conducted a retrospective analysis of the outcomes of 30 consecutive spinal surgeries performed for AAS patients, C1 LAM in 11 cases and C1/2 fixation in 19 cases. We investigated the correlation between the clinical outcomes and the surgical methods. We also examined the factors related to poor outcomes (the recovery rate of the Japanese Orthopedic Association score for cervical myelopathy

The atlantoaxial joint C2 (axis) with the anterior arch of C1 (atlas) allows 50% of cervical lateral rotation. It is responsible for precise and important movements that allow us to perform precise actions, both in normal and working life. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed and the outcome is worse. An early diagnosis and treatment are essential to ensure satisfactory neurological and functional outcomes. The aim of this review is to analyze C1-C2 rotatory subluxation in adults, given its rarity. The time between injury and reduction is key, as it is directly related to prognosis and the severity of the treatment options. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed as a lot of cases are not related to a clear trauma, with a poor prognosis just because of the late diagnosis and the outcome is worse. The correct approach and treatment of atlantoaxial dislocation requires a careful study of the radiological findings to decide the direction and plane of the dislocation, and the search for associated skeletal anomalies.

Occipitocervical fusion is an important surgical procedure to treat instability of the upper cervical and craniocervical junction. Fixation to the dense cortical bone of the occiput, contemporaneously typically accomplished with a plate and screws, is known to be strong and durable, but there are many competing methods used to secure an adequate number of fixation points of sufficient strength at the cervical end. Extension of hardware to the midcervical region to acquire additional fixation points, however, results in loss of subaxial motion segments and additional potential morbidity. The C2 vertebra is unique in that its morphology and dimensions permit fixation with longer screws than are typically possible to place in the midcervical lateral masses. Translaminar and pars screw techniques, both commonly used to achieve C2 fixation, are not mutually exclusive, as their respective trajectories are considerably different and engage different portions of the bony anatomy. We describe a novel, 4-point C2 fixation technique for OC fusion that may avoid the need to extend fusion to the subaxial spine. This technical note illustrates how 4-point C2 fixation can be employed in occiptocervical fusion. 4-point fixation of C2 combining translaminar and pars screw placement is technically feasible and may be a suitable strategy to spare subaxial motion segments in OC fusion procedures. Futher investigation may establish its applicability to additional surgical procedures. [ABSTRACT FROM AUTHOR]

A 4-year-old spayed female miniature poodle dog presented with a 1-week history of acute tetraparesis. A neurological examination revealed severe neck pain and non-ambulatory tetraparesis. Computed tomography and magnetic resonance imaging showed hypoplastic dens with moderate compression of the spinal cord at C1–C2. The atlantoaxial subluxation (AAS) was surgically stabilized using ventral pins and polymethylmethacrylate (PMMA) cement. On the second postoperative day, the patient showed significant dyspnea, and aspiration pneumonia was identified on radiography. The patient exhibited dysphagia with abnormal food prehension and an inability to protrude the tongue, with no gag reflex. We tentatively diagnosed the patient with multiple cranial nerve (CN) palsies involving the 9th, 10th, and 12th CNs following surgical ventral stabilization. The protruding cranial part of the implanted PMMA cement, which could mechanically contribute to the corresponding CNs dysfunction, was surgically removed. The symptoms gradually improved, and the patient showed normal tongue movement 1 month after revision surgery. In conclusion, we report herein a canine case of multiple CN palsies following ventral stabilization surgery for AAS. The experience gained from this case suggests an optimized management plan for postoperative neurological complications associated with ventral stabilization.

Introduction: Cervical spine (C-spine) instability is a unique and significant characteristic of rheumatoid arthritis (RA) because its occurrence is not rare and it can cause compressive cervical myelopathy, which may lead to serious neurologic sequelae. This study evaluated the prevalence and risk factors of C-spine instabilities in RA patients with a focus on anti-citrullinated protein antibody (ACPA) and biologic disease-modifying antirheumatic drug (DMARD) therapies. Methods: The presence of C-spine instabilities in 1114 patients with RA was evaluated using C-spine radiographies according to the defined metrics. Multivariable logistic regression analyses were performed to identify independent predictors of C-spine instability. The initiation of biologic DMARDs was assessed via a Kaplan–Meier analysis and compared using log-rank tests. Results: In total, 306 (27.5%) patients presented with C-spine instabilities. The most common type was atlantoaxial subluxation (AAS; n = 199 [17.9%]). Male sex, positivity for rheumatoid factor and ACPA, erosive change in the peripheral joints, and presence of osteoporosis were independently associated with C-spine instabilities (all P < 0.05). In particular, positivity for ACPA was the most powerful risk factor (odds ratio: 2.33 [95% confidence interval: 1.37, 3.96], P = 0.002), and it was closely associated with AAS. Patients with AAS were at a higher risk for early initiation of biologic DMARDs. Conclusions: Positivity for ACPA was a significant risk factor for C-spine instability, and AAS was remarkably correlated to the early initiation of biologic DMARDs, a surrogate index of poor long-term outcomes. Key Points • The presence of antibodies against citrullinated proteins was a strong risk factor for C-spine instability in patients with rheumatoid arthritis. • Atlantoaxial subluxation was significantly associated with early initiation of biologic DMARDs, a surrogate index of poor long-term outcome. [ABSTRACT FROM AUTHOR]

Background: The non traumatic, post inflammatory atlantoaxial rotatory instability, also known as Grisel's syndrome is a relatively rare condition usually affecting children. Adult cases are rare and even less frequently reported with separate case reports describing a single patient. Although antibiotic treatment and close neurological monitoring seem to be the gold standard of care, there is no general consensus on the optimal timing and extent of the surgical treatment. Case Description: We present a case of C1-C2 spondylitis, secondary to retropharyngeal abscess, without atlantoaxial instability on initial evaluation that progressed to C1-C2 subluxation with rapidly developing myelopathy 3 months after optimal antibiotic therapy and complete clinical and biochemical remission. Conclusion: Grisel's syndrome is a rare condition in adults with secondary instability in spite of successful antibacterial treatment, which requires decompression and delayed surgical fixation in our case. [ABSTRACT FROM AUTHOR]

Atlantoaxial dislocations (AAD) are a diverse set of C1-C2 rotatory subluxations that include the inferior and superior axial facet articulations. C1-C2 segments are both covered by cranial-cervical ligaments, indicating that AAD would damage both joints. Whenever the posterior elements are missing or impaired, lateral mass screw fixation has replaced alternative posterior cervical fixation procedures as the preferred treatment for securing the sub-axial cervical spine. An increase in muscle tone, hyperreflexia, pathological reflexes, digit/hand clumsiness, and gait deviations caused by spinal cord compression at the cervical level are the most common clinical features. A 23-year-old female patient came with the chief complaint of weakness, tingling sensation, and numbness in both upper and lower limbs along with imbalance while walking. She had a history of falls which was managed conservatively. As the symptoms progressed, an MRI, a CT scan, and an X-ray of the neck were done to rule out the level of injury which revealed AAD, and the patient was operated on for C1-C2 lateral mass fixation. Post-operatively, the patient was referred to the physiotherapy department for further management. The patient's quality of life and daily functioning were positively affected after undergoing early intervention as measured by the Functional Independence Measure, Neck Disability Index, Berg Balance Scale, and Dynamic Gait Index., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Kapre et al.)

Critical central airway obstruction has always been a dreaded complication to which interventional pulmonologist commonly encounters. There have been various modalities which are used for the management and palliation, which includes mechanical coring, laser, cryoextraction, electrocautery and airway stenting. Rigid bronchoscopy with or without jet ventilation has been corner stone of therapeutics and palliation of central airway obstruction. There are only a few conditions where it is not possible to use rigid bronchoscopy. Here we report a case of metastatic tracheal tumour which presented with critical airway obstruction in a patient who had atlantoaxial instability (AAI) due to rheumatoid arthritis. Here we used endobronchial ultrasound scope (EBUS) via esophageal route, i.e. EUS-B guided approach for sampling of the tracheal tumour, and intratumoral chemotherapy was instilled in multiple sessions, which resulted in shrinking of tumour, thus relieving the critical airway obstruction. This is the first report of using EUS-B approach for intratumoral chemotherapy for tracheal tumors. Bronchoscopic intratumoral chemotherapy therapy (BITC) in tracheal tumors is also one of the options but has not been explored much and there has been a dearth of literature for it.

Abstract Background The Magerl and Goel-Harms techniques have been reported to produce excellent treatment outcomes in cases of atlantoaxial subluxation, but they also carry a risk of vertebral artery injuries. In order to completely prevent such injuries, we developed a surgical procedure, involving bone grafting between the C1 posterior arch and C2 lamina with clamp- or hook-and-rod-based fixation combined with the insertion of an interference screw into the posterior atlantoaxial joint. Methods This was a retrospective single-center study. The subjects were 58 patients in whom atlantoaxial subluxation was treated with the abovementioned procedure after 1995 (33 patients with rheumatoid arthritis (RA group) and 25 patients without rheumatoid arthritis (non-RA group)). The clinical outcomes and imaging findings of anterior subluxation at ≥ 2 years after surgery were compared between the RA and non-RA groups. Results No vertebral artery injuries occurred during surgery. Seven and two patients died during the follow-up period in the RA and non-RA groups, respectively, but none of these deaths were associated with surgery. At ≥ 2 years after surgery, the visual analogue scale score, Japanese Orthopaedic Association score, and Ranawat classification had significantly improved in both groups (p