Immediate postoperative regression of retroodontoid pannus after lateral mass reconstruction in a patient with rheumatoid disease of the craniovertebral junction

Case report

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The authors report the case of a 35-year-old man who had polyarthritic affliction with rheumatoid disease. He presented with complaints of quadriparesis that had progressed over the course of 2 years. Investigations revealed telltale evidence of rheumatoid disease of the craniovertebral junction with retroodontoid pannus, basilar invagination, and “fixed” atlantoaxial dislocation. The patient underwent lateral mass reconstruction with distraction of the facets and impaction of a spiked metal spacer and bone graft within the joint. Investigations done in the immediate postoperative phase showed complete disappearance of retroodontoid pannus in addition to reduction of basilar invagination and atlantoaxial dislocation. He had remarkable and sustained relief from symptoms. The authors also review the pathogenesis and treatment of retroodontoid pannus.

Abbreviation used in this paper:CVJ = craniovertebral junction.

Article Information

Address correspondence to: Atul Goel, M.Ch., Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Parel, Mumbai 400 012, India. email:

© AANS, except where prohibited by US copyright law.



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    Preoperative images. A: A CT scan showing atlantoaxial dislocation and mild basilar invagination. B: Sagittal T2-weighted MR image showing retroodontoid pannus, a lax posterior spinal ligament, and evidence of cord compression. C: Sagittal T1-weighted MR image showing the retroodontoid pannus and cord compression.

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    Postoperative images. A: A CT scan showing reduction in the atlantoaxial dislocation and basilar invagination. B: Sagittal reconstructed CT scan showing the spacer impacted within the atlantoaxial joint. C: Coronal reconstructed CT scan showing the spacers within both the atlantoaxial joints. D: Sagittal T2-weighted MR image showing complete regression of the retroodontoid pannus and the stretched normal posterior spinal ligament. Craniospinal realignment can be observed. E: Sagittal T1-weighted MR image showing the regression of the pannus.



Casey ATCrockard HAGeddes JFStevens J: Vertical translocation: the enigma of the disappearing atlantodens interval in patients with myelopathy and rheumatoid arthritis. Part I Clinical, radiological, and neuropathological features. J Neurosurg 87:8568621997


Eleraky MAMasferrer RSonntag VK: Posterior atlantoaxial facet screw fixation in rheumatoid arthritis. J Neurosurg 89:8121998


Goel A: Atlantoaxial joint jamming as a treatment for atlantoaxial dislocation: a preliminary report. J Neurosurg Spine 7:90942007


Goel A: Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine 1:2812862004


Goel APareikh SSharma P: Atlantoaxial joint distraction for treatment of basilar invagination secondary to rheumatoid arthritis. Neurol India 53:2382402005


Goel ASharma P: Craniovertebral realignment for basilar invagination and atlantoaxial dislocation secondary to rheumatoid arthritis. Neurol India 52:3383412004


Grob D: Atlantoaxial immobilization in rheumatoid arthritis: a prophylactic procedure?. Eur Spine J 9:4044092000


Grob DWursch RGrauer WSturzenegger JDvorak J: Atlantoaxial fusion and retrodental pannus in rheumatoid arthritis. Spine 22:158015831997


Halla JTHardin JG Jr: The spectrum of atlantoaxial facet joint involvement in rheumatoid arthritis. Arthritis Rheum 33:3253291990


Henderson FCGeddes JFCrockard HA: Neuropathology of the brainstem and and spinal cord in end-stage rheumatoid arthritis: Implications for treatment. Ann Rheum Dis 52:6296371993


Kawaida HSakou TMorizono Y: Vertical settling in rheumatoid arthritis: diagnostic value of Ranawat and RedlundJohnell methods. Clin Orthop 239:1281351989


Menezes AHVanGilder JCClark CRel-Khoury G: Odontoid upward migration in rheumatoid arthritis: an analysis of 45 patients with “cranial settling. J Neurosurg 63:5005091985


Moskovich RCrockard HAShott SRansford AO: Occipitocervical stabilization for myelopathy in patients with rheumatoid arthritis. Implications of not bone-grafting. J Bone Joint Surg Am 82:3493652000


Nguyen HVLudwig SCSilber JGelb DEAnderson PAFrank L: Rheumatoid arthritis of the cervical spine. Spine J 4:3293342004


Ranawat CSO'Leary PPellicci PTsairis PMarchisello PDorr L: Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg Am 61:100310101979


Riew KDHilibrand ASPalumbo MASethi NBohlman HH: Diagnosing basilar invagination in the rheumatoid patient. The reliability of radiographic criteria. J Bone Joint Surg Am 83:1942002001


Sunahara NMatsunaga SMori TIjiri KSakou T: Clinical course of conservatively managed rheumatoid arthritis patients with myelopathy. Spine 22:260326081997


Toussaint PDesenclos CPeltier JLe Gars D: [Transarticular atlantoaxial screw fixation for treatment of C1–C2 instability.]. Neurochirurgie 49:5195262003. (Fr)


Vale FLOliver MCahill DW: Rigid occipitocervical fusion. J Neurosurg 91:2 Suppl1441501999




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