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Odontoid upward migration in rheumatoid arthritis

An analysis of 45 patients with “cranial settling”

Arnold H. Menezes, John C. VanGilder, Charles R. Clark and George El-Khoury

. This view was shared by several others at that time. 9, 44 In a subsequent study of the 76 patients 5 years later, Mathews 35 found that 16 had died and six were lost to follow-up review. Of the remaining 54 patients, 18 showed an increase in the vertical subluxation of the odontoid process into the foramen magnum. Mathews interpreted this finding as a descent of the skull on the eroded lateral atlantal masses with occipito-atlanto-axial instability. The term “cranial settling” had its origin from this interpretation. Rheumatoid arthritis is a systemic disease

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Kost Elisevich, Suzanne Fontaine and Gilles Bertrand

✓ Cranial settling and basilar invagination with medullospinal compression is believed to have resulted in the production of a syrinx in a case of Paget's disease of the cranium. This mechanism of compression at the craniovertebral junction resembles the development of syringomyelia in Chiari malformations presenting in adult life.

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Arnold H. Menezes and John C. VanGilder

-transpalatine clivus-odontoid resection, 1977–1987 Pathology No. of Cases primary basilar invagination 39 rheumatoid irreducible cranial settling 14 basilar invagination after malunion, odontoid-clival dislocation 4 upward migration of nonfused odontoid fracture (C1–C2 posterior fusion) 3 dystopic os odontoideum 5 granulation mass 3 cancer, pyrophosphate mass 1 osteoblastoma at C-1 1 chordoma lower clivus 1 chondroma at clivus-C-1 1 Investigative Studies

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Stephen M. Papadopoulos, Curtis A. Dickman and Volker K. H. Sonntag

intermittently given a variety of nonsteroidal anti-inflammatory agents. Radiographic Findings Five patients had a combination of atlantoaxial instability and cranial settling with irreducible anterior subluxation that required a transoral resection of the odontoid and associated pannus. This procedure was typically followed by a C1–2 fusion approximately 7 to 10 days later. In the remaining 12 patients, the degree of subluxation, as measured from the atlanto-odontoid interval on lateral cervical spine x-ray films in flexion and extension, ranged from 6 to 14 mm ( Fig

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Conrad T. E. Pappas and Harold L. Rekate

, Hibri N: Abnormalities of the craniovertebral junction with cervico-medullary compression: a rational approach to surgical treatment in children. Childs Brain 7: 15–30, 1980 8. Menezes AH , VanGilder JC , Clark CR , et al : Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with “cranial settling.” J Neurosurg 63 : 500 – 509 , 1985 Menezes AH, VanGilder JC, Clark CR, et al: Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with “cranial settling.” J Neurosurg 63

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Curtis A. Dickman, Jacqueline Locantro and Richard G. Fessler

presented with signs and symptoms of spinal-cord or brain-stem dysfunction (mean duration of symptoms 8 months). Pathology included rheumatoid arthritis with irreducible cranial settling in 11 cases, congenital osseous malformations of the craniovertebral junction in 11, and other causes in five ( Table 1 ). TABLE 1 Pathology in 27 patients treated with transoral odontoid resection Pathology No. of Cases rheumatoid arthritis 11 congenital osseous malformations 11  Klippel-Feil syndrome 2  Chiari malformation 4

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Vincent C. Traynelis, Timothy Ryken, Robert L. Rodnitzky and Arnold H. Menezes

cranial settling due to erosion of the lateral masses of the atlas vertebra. She had excruciating posterior cervical headaches which were relieved with manual cervical traction. A dorsal occipitocervical fusion was proposed once the “cranial settling” was reduced. In preparation for this, both sternocleidomastoid muscles and the right trapezius muscle were injected with botulinum toxin. A total of 130 U was injected without complication (40 U into each sternocleidomastoid muscle and 50 U into the right trapezius muscle). This resulted in a decrease of her torticollis

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Ossama Al-Mefty, Luis A. B. Borba, Nobuo Aoki, Edgardo Angtuaco and T. Glenn Pait

reviewed the records of 45 patients with rheumatoid arthritis and “cranial settling.” Among these, 36 patients had an acceptable reduction of the basilar invagination and underwent posterior occipitocervical fusion. Nine patients had irreducible ventral compression of the cervicomedullary junction by the invaginated odontoid process and granulation tissue. In these patients, transoral resection of the odontoid process and granulation tissue was followed by posterior occipital—C-2 fusion. In eight of the patients in that series, a significant amount of rheumatoid

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Vijendra K. Jain, Piyush Mittal, Deepu Banerji, Sanjay Behari, Rajesh Acharya and Devendra K. Chhabra

cranial settling.” J Neurosurg 63 : 500 – 509 , 1985 Menezes AH, Van Gilder JC, Clark CR, et al: Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with “cranial settling.” J Neurosurg 63: 500–509, 1985 31. Menezes AH , Van Gilder JC , Graf CJ , et al : Cranio-cervical abnormalities. A comprehensive surgical approach. J Neurosurg 53 : 444 – 455 , 1980 Menezes AH, Van Gilder JC, Graf CJ, et al: Cranio-cervical abnormalities. A comprehensive surgical approach. J Neurosurg 53

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Adrian T. H. Casey, H. Alan Crockard, J. Martin Bland, John Stevens, Ronald Moskovich and Andrew Ransford

guide to surgical intervention, 5, 6, 15, 19, 22, 29, 34 has not been shown to exert an effect on the severity of myelopathy or the surgical outcome in this subgroup. This contrasts with the finding in this study that the degree of vertical translocation and the cord area that correlate with disability (HAQ Stanford score) also act as prognostic factors. The reasons behind this apparent failure of the ADI measure can be seen in its correlation with the degree of vertical translocation, in which the ADI decreases as the degree of cranial settling progressively