Surgical treatment for atlantooccipital osteoarthritis: a case report of two patients

Patient-rated outcome after atlantoaxial (C1-C2) fusion: more than a decade of evaluation of 2-year outcomes in 126 patients

INTRODUCTION

Various surgical techniques have been introduced for atlantoaxial (C1-C2) fusion, the most common being Magerl's (transarticular) or the Harms/Goel screw fixation. Common indications include degenerative osteoarthritis (OA), trauma or rheumatoid arthritis (RA). Only few, small studies have evaluated patient-reported outcomes after C1-C2 fusion. We investigated 2-year outcomes in a large series of consecutive patients undergoing isolated C1-C2 fusion.

METHODS

We analysed prospectively collected data (2005-2016) from our Spine outcomes database, collected within the framework of EUROSPINE's Spine Tango Registry. It included 126 patients (34 (27%) men, 92 (73%) women; mean (SD) age 67 ± 19 y) who had undergone first-time isolated C1-C2 fusion (61% Magerl, 39% Harms(-Goel)) at least 2 years ago for OA (83 (66%)), RA (20 (16%)), fracture (15 (12%)) or other (8 (6%)). Patients completed the multidimensional Core Outcome Measures Index (COMI; 0-10) and various single item outcomes.

RESULTS

Questionnaires were returned by 118/126 (94%) patients, 2 years post-operative. Mean COMI scores showed a significant reduction from baseline: 6.9 ± 2.4 to 2.7 ± 2.5 (p < 0.0001). Overall, 75% patients achieved the MCIC of ≥ 2.2 points reduction in COMI and 88% reported a good global outcome. 91% patients were satisfied/very satisfied with their care. Self-reported complications were declared by 16% patients and further surgery at the same segment, by 2.5%.

CONCLUSION

In this large series with almost complete follow-up, C1-C2 fusion showed extremely good results. Despite the complexity of the intervention, outcomes surpassed those typically reported for simple procedures such as ACDF and lumbar discectomy, suggesting reservations about the procedure should perhaps be reviewed.

ABCs of the degenerative spine

Degenerative changes in the spine have high medical and socioeconomic significance. Imaging of the degenerative spine is a frequent challenge in radiology. The pathogenesis of this degenerative process represents a biomechanically related continuum of alterations, which can be identified with different imaging modalities. The aim of this article is to review radiological findings involving the intervertebral discs, end plates, bone marrow changes, facet joints and the spinal canal in relation to the pathogenesis of degenerative changes in the spine. Findings are described in association with the clinical symptoms they may cause, with a brief review of the possible treatment options. The article provides an illustrated review on the topic for radiology residents.

TEACHING POINTS

• The adjacent vertebrae, intervertebral disc, ligaments and facet joints constitute a spinal unit. • Degenerative change is a response to insults, such as mechanical or metabolic injury. • Spine degeneration is a biomechanically related continuum of alterations evolving over time.

Joint arthropathy at the cranio-vertebral junction. Scintigraphic patterns on bone SPECT/CT

Osteoarthritic degeneration at the cranio-vertebral junction (CVJ) is an underrecognized source of suboccipital and neck pain, limited range of motion and cervicogenic headaches. Correlation of radiographic findings with clinical symptoms is often difficult. Limited evidence currently exists to support the use of bone single-photon emission computed tomography/computed tomography (SPECT/CT) in this subgroup of patients. The aim of this study was to describe the scintigraphic patterns of joint arthropathy at the CVJ on bone SPECT/CT in patients with suboccipital/neck pain and cervicogenic headache. Patients with more than 3 months of suboccipital/neck pain/cervicogenic headache and abnormal SPECT/CT findings at the CVJ were included. Patients with known/suspected malignancy, trauma, infectious processes and previous surgery at the CVJ were excluded. Neck disability index (NDI), visual analogue scale (VAS) and treatment were recorded for each patient. Patterns of osteoblastic activity at the CVJ on bone SPECT/CT were described and correlated with arthritic changes on conventional scans. Eighteen patients were included (10 females, mean age 68). Mean NDI score was 22. Mean VAS was 7.5. On bone SPECT/CT, it was found that 13 patients had high osteoblastic activity unilaterally at the atlanto-axial joint (AAJ); two patients at the atlanto-dental joint (ADJ), one at the occipito-atlantal joint (OAJ), one at both OAJ and ADJ and one at the level of C2 pars/pedicle unilaterally. Metabolic activity on SPECT/CT was associated with severe degenerative changes on CT scans. The ability of hybrid bone SPECT/CT to precisely localize osteoblastic activity at the CVJ may provide significant improvement in the diagnosis and treatment of patients with suboccipital/neck pain and joint arthropathy at the CVJ. Further clinical studies are needed to establish the real clinical impact of bone SPECT/CT in the treatment of patients with suboccipital neck pain.

Feasibility of Ultrasound Guided Atlanto-occipital Joint Injection

Objective

To evaluate the feasibility of ultrasound guided atlanto-occipital joint injection.

Method

Six atlanto-occipital joints of three cadavers were examined. Cadavers were placed in prone position with their head slightly rotated towards the contra-lateral side. The atlanto-occipital joint was initially identified with a longitudinal ultrasound scan at the midline between occipital protuberance and mastoid process. Contrast media 0.5cc was injected into the atlanto-occipital joint using an in-plane needle approach under ultrasound guide. The location of the needle tip and spreading pattern of the contrast was confirmed by fluoroscopic evaluation.

Results

After ultrasound guided atlanto-occipital joint injection, spreading of the contrast media into the joint was seen in all the injected joints in the anterior-posterior fluoroscopic view.

Conclusion

The ultrasound guided atlanto-occipital injection is feasible. The ultrasound guided injection by Doppler examination can provide a safer approach to the atlanto-occipital joint.