Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: analysis of the management of 108 cases

Clinical article

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The authors retrospectively analyzed a series of 108 patients in whom was diagnosed atlantoaxial instability due to degenerative osteoarthritis of the atlantoaxial joints. The management issues in such cases are discussed.


One hundred eight patients with osteoarthritis of the atlantoaxial joints and resultant craniovertebral instability—diagnosed on the basis of presenting clinical features, radiological imaging, and direct observation of the joint status during surgery—were retrospectively analyzed. Between 1990 and 2008, these patients were treated with a C1–2 lateral mass plate and screw method of atlantoaxial fixation and joint distraction using bone graft with or without the assistance of metal spacers.


Patient ages ranged from 48 to 84 years (average 63 years). There was a history of mild to moderate head and/or neck trauma 2 months to 11 years prior to diagnosis in 40% of the cases. All patients had symptoms of neck pain, and 82% of the patients had progressive myelopathy. A reduction in the height of the atlantoaxial lateral mass complex (100%), mobile atlantoaxial dislocation (100%), basilar invagination (68%), and periodontoid degenerative tissue mass (90%) were the more frequently encountered radiological features. Two patients died in the immediate postoperative period. At an average follow-up of 64 months, all surviving patients remarkably improved to varying degrees in their neurological condition.


Atlantoaxial joint arthritis frequently leads to craniovertebral instability and cord compression. Treatment by joint distraction and lateral mass fixation can be an optimum form of treatment.

Article Information

Address correspondence to: Atul Goel, M.Ch., Department of Neurosurgery, King Edward VII Memorial Hospital and Seth G. S. Medical College, Parel, Mumbai-400012, India. email:

© AANS, except where prohibited by US copyright law.



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    Images obtained in a 65-year-old man. A: Preoperative CT scan with the head of the patient in flexion showing atlantoaxial dislocation and basilar invagination. Periodontoid degenerative tissue, osteophyte-like ossification in the regions of the apical ligament and the atlantodental joint, and degenerative changes in the cervical spine are seen. B: Preoperative CT scan with the head in extended position showing reduction in the dislocation. C: Three-dimensional CT scan showing ossification near the apical ligament at the site of its attachment to the clivus. D: Postoperative CT scan showing complete reduction in both atlantoaxial dislocation and basilar invagination. E: Postoperative radiograph showing fixation with plate and screws and bone graft.

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    Images obtained in a 58-year-old woman. A: Preoperative radiograph with the head in the flexed position showing marked atlantoaxial dislocation. B: Preoperative radiograph with the head in extension showing partial reduction in the dislocation. C: Preoperative CT scan showing the dislocation as well as degenerative changes in the dens and cervical spine. D: A T1-weighted MR image showing the dislocation. Preodontoid degenerative tissue can be seen. E: Postoperative CT scan showing fixation in an incompletely reduced position. F: Postoperative sagittal CT scan through the lateral masses. A metal spacer is seen in the distracted joint, as is the fixation with plate and screws. G: Coronal image showing spacers in both the atlantoaxial joints and screws in the facets of atlas and axis. H: Postoperative radiograph showing the plate and screw fixation. Note the metal spacers.

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    Images obtained in 57-year-old man. Upper: Preoperative CT scan showing extensive degenerative changes in the periodontoid region and facets. Lower: Coronal image showing degenerative changes in the lateral masses. Reduction of joint space height and osteophyte formation in the facets can be observed.

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    Images of a 65-year-old male. Left: A CT scan showing reduced atlantoaxial joint space and osteophyte formation in the joint-adjoining bones of the facets of atlas and axis. Right: Coronal CT scan showing reduced joint space and degenerative changes.

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    Image obtained in a 68-year-old man. Coronal CT scan showing degenerative changes in the joints. The arthritic changes are more pronounced in the right-sided joint.

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    Images obtained in a 70-year-old man. Upper: A CT scan showing degenerative periodontoid changes. Calcification of the anterior occipitoatlantal membrane can be seen. Lower: Coronal image showing degenerative changes in the atlantoaxial joints. Osteophytes can be seen in the facets of atlas and axis.

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    Images obtained in a 67-year-old man. Upper: Preoperative CT scan showing extensive periodontoid degenerative changes. Atlantoaxial dislocation and basilar invagination can be seen. Lower: Postoperative scan showing reduction and fixation in the region.

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    Image obtained in a 68-year-old man. Sagittal T2-weighted MR image showing degenerative periodontoid changes. Elevation of the posterior longitudinal ligament/tectorial membrane is clearly visible.

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    Image obtained in a 49-year-old woman demonstrating periodontoid degenerative change.

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    Images obtained in a 54-year-old man. A: A T1-weighted MR image showing a retroodontoid ligamentous degenerative tumor-like mass. The posterior longitudinal ligament/tectorial membrane is elevated posteriorly by the mass. B: A T2-weighted MR image showing the retroodontoid hypointense mass. Signal intensity changes in the cord are visible. C: Lateral radiograph with the head in the flexed position showing atlantoaxial dislocation. D: Radiograph with the head in the extension position showing incomplete reduction of the dislocation. E: Postoperative image showing plate and screw fixation of the atlantoaxial joints.



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