Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis

BACKGROUND CONTEXT: 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). PURPOSE: 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. STUDY DESIGN: 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.