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C1-C2 facet arthropathy


Introduction

Atlanto-axial (C1-C2) facet joint arthropathy is an underdiagnosed condition closely associated with the development of refractory occipital pain. Prevalence increases with age, ranging from 5% in the sixth decade to 18% in the ninth decade of life. Moreover, the atlanto-axial (CI-C2) facet joints are a common site of involvement in patients with inflammatory arthropathies, such as rheumatoid arthritis. Older adult women are the most commonly affected. Secondary occipital neuralgia in the setting of C1-C2 facet joint arthropathy is a well-known phenomenon; however, there are numerous possible causes of nonspecific chronic suboccipital pain (infections, trauma, neoplasms, congenital malformations), and therefore, the diagnosis is challenging and often neglected. Headache, occipital pain, retro-auricular pain, and neck pain (usually unilateral) account for the most common symptoms associated with atlanto-axial facet arthropathy. Additionally, rotation restriction toward the affected side is noted in most patients. Cervicogenic headache has been implicated in 15% to 20% of chronic headaches cases. Atlanto-axial arthropathy is rarely asymptomatic. The pathophysiology of pain associated to C1-C2 arthropathy may be explained by the origination of aberrant axonal discharges (neuralgia) or nerve compression (radiculopathy). Radiological diagnosis requires the confirmation of arthritis and vertical collapse of the facet joint on the side of neuralgia. Alleviation of pain is the mainstay of treatment, and therefore pain reduction is the core determinant of a positive long outcome. The primary indication for surgical intervention is C1-C2 osteoarthritis with unremitting pain after failed nonsurgical management. Currently, posterior transarticular atlanto-axial fusion has proved to be an effective treatment to relieve intractable pain with a low rate of complications. In this chapter, we present the case of a patient with persistent cervical pain localized on her left side.

Example Case

  • Chief complaint: neck pain

  • History of present illness: This is a 62-year-old female patient with a history of persistent neck pain localized on the left side. The pain is exacerbated with head turning. The patient does not report additional symptoms or arm pain. She has a history of previous surgical intervention of the cervical spine ( Fig. 18.1 ).

    Fig. 18.1, Preoperative imaging of the cervical spine. (A) Preoperative lateral x-rays demonstrating previous anterior cervical discectomy and fusion, multilevel osseous foraminal narrowing secondary to facet, and uncovertebral joint hypertrophy. (B) Coronal reconstruction of computed tomography demonstrating severe arthrosis of the left C1-C2 facet joint, with vertical collapse of the joint on the side of pain (left), and no fusion is noted.

  • Medications: aspirin

  • Allergies: no known drug allergies

  • Past medical and surgical history: anterior cervical discectomy and fusion

  • Family history: none

  • Social history: smoker

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch

  • Sigurd Berven, MD

  • Department of Orthopaedic Surgery

  • UC San Francisco

  • San Francisco, California, United States

  • Alvaro Camparo, MD

  • Ramiro Barrera, MD

  • Neurosurgery

  • Hospital Padilla at Tucuman

  • Universidad Nacional de Tucuman

  • Tucuman, Argentina

  • Praveen Mummaneni, MD

  • Brenton Pennicooke, MD

  • Neurosurgery

  • University of California at San Francisco

  • San Francisco, California, United States

  • Baron Zarate Kalfopulos, MD

  • Orthopaedic Surgery

  • Instituto Nacional de Rehabilitacion

  • Medica Sur

  • Mexico City, Mexico

Preoperative
Additional tests requested

  • SPECT

  • C1-2 facet injection

  • Neuromodulation trial

  • MRI C-spine

  • Dynamic cervical x-ray

  • CT Cervical angiography

  • MRI C-spine

  • CT C-spine angiography

  • MRI C-spine

  • CT-guided C2 nerve block and ESI

  • SPECT/CT C-spine

  • MRI C-spine

  • EMG upper extremities

Surgical approach selected If persistent pain despite nonoperative optimal care including neuromodulation, posterior C1-2 fusion C1-3 posterior fusion Avoid surgery because of smoker, but if responded to nerve block and had to, left C1-2 hemi-laminotomy for left C2 neurectomy Avoid surgery because of smoker, but if responded to nerve block and had to, posterior C1-2 fusion with Gallie fusion
Goal of surgery Stabilization of C1-2 segment Deformity reduction, fusion Relieve occipital pain Relieve occipital pain
Perioperative
Positioning Prone, in Mayfield pins Prone, in Mayfield pins Prone on Jackson table, in Mayfield pins Prone on a mask
Surgical equipment

  • O-arm

  • Surgical navigation

Fluoroscopy

  • IOM (MEP/SSEP/EMG)

  • Surgical navigation

  • Intraoperative CT

  • IOM

  • Fluoroscopy

Medications None NSAIDs None Tranexamic acid
Anatomical considerations Vertebral artery, internal carotid artery, greater occipital nerve, spinal cord Vertebral artery, C1-2 venous plexus, C2 nerves Vertebral artery, spinal cord C2 nerve roots, vertebral artery, thecal sac, C1-2 spinous process, C1 lateral mass, C2 pedicle
Complications feared with approach chosen Instability, vertebral artery injury, spinal cord injury Vertebral artery injury, C2 neuropathy Spinal cord injury Vertebral artery injury, durotomy, C1 lateral mass fracture, injury to C2 nerve root, venous plexus bleeding
Intraoperative
Anesthesia General General General General
Exposure C1-2 C1-3 C1-3 C1-3
Levels decompressed None None C1-2 None
Levels fused C1-2 C1-3 None C1-2
Surgical narrative Position prone with Mayfield pins, visualize C1-2 with fluoroscopy, posterior midline C1-2 incision, subperiosteal exposure of C1-C2, cauterization of venous plexus behind C1 with bipolar, ligation of greater occipital nerve, Harms technique for posterior fixation at C1-2 with polyaxial C1 lateral mass screws and C2 pedicle screws, obtain local bone from underside of C1 ring/spinous process and lamina of C2, fusion using local bone and demineralized bone matrix, layered closure Position prone with Mayfield pins, verify level with fluoroscopy, vertical midline skin incision from 2 cm superior to C1 to C4, subcutaneous tissue and muscle dissection, subperiosteal dissection of C1-3, place short thread screws in the lateral mass of C1 using high-speed drill and fluoroscopy, place C2 pars and C3 lateral mass screws using high-speed drill and fluoroscopy, placement of rods and close the system, placement of autologous bone graft, closure with drain Position prone with Mayfield pins, lateral x-ray to plan incision, midline posterior incision, expose C1-3, attach navigation array, intraoperative CT and register with navigation system, left C1 inferior laminotomy and left C2 superior laminotomy to access left C1-2 foramen, identify and ligate and section C2 nerve root proximal to ganglion bilaterally, irrigate, layered closure Position prone. 12–12 cm midline incision from C1-3, expose posterior arch of C1 (only 10 mm on each side)/C2 lamina until lateral mass, respect muscular insertions on C1 and C2 spinous processes, place C2 pedicle screws (25–30 degree cephalic and 30–35 degree medial angle) and C1 lateral mass (15 degree cephalic and 5–10 degree medial) screws, connect screws with rods and transverse connector, pass sublaminar wire beneath arch of C1 and around spinous process of C2 with cadaveric allograft between C2 spinous process and C1 posterior arch, decorticate C2 lamina/lateral mass/inferior edge of C1 posterior arch and apply demineralized bone matrix, layered closure
Complication avoidance Ligation of greater occipital nerve, Harms technique for C1-2 screws Screws under fluoroscopy, limiting levels of fusion Surgical navigation, neurectomy Limit exposure of C1 arch to 10 mm on each side, respect muscular insertions on C1 and C2 spinous processes, use transverse connector, avoid sublaminar C2 wire to avoid neural or dural injury
Postoperative
Admission Floor ICU Floor Floor
Postoperative complications feared Pseudoarthrosis, persistent pain, infection Pseudarthrosis, neck pain, implant malposition, screw back out Occipital neuralgia, C1-2 instability Vertebral artery injury, wound infection, CSF leak, adjacent segment degeneration
Anticipated length of stay 2 days 3 days 3 days 3 days
Follow-up testing C-spine AP/lateral x-ray prior to discharge, 4 weeks, 8–10 weeks, 6 months, 1 year, 2 years after surgery

  • C-spine x-ray after surgery, 1 month after surgery

  • CT C-spine 3 months after surgery

C-spine AP and lateral x-ray, 6 weeks, 3 months, 6 months, 1 year, 2 years after surgery

  • C-spine x-ray 6 weeks, every 3 months for first year after surgery

  • CT C-spine 12 months after surgery

Bracing Cervical hard collar for 4 weeks Philadelphia collar for 4 weeks Miami J for 6 weeks None
Follow-up visits 4 weeks, 8–10 weeks, 6 months, 1 year, 2 years after surgery 7 days, 1 month, 3 months after surgery 3 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years after surgery 2 weeks, 6 weeks, every 3 months for first year after surgery
AP , Anteroposterior; CSF , cerebrospinal fluid; CT , computed tomography; EMG , electromyography; ESI , epidural spinal injections; ICU , intensive care unit; IOM , intraoperative monitoring; MEP , motor evoked potential; MIS , minimally invasive surgery; NSAIDs , nonsteroidal antiinflammatory drugs; SPECT , single-photon emission computed tomography; SSEP , somatosensory evoked potential.

Differential diagnosis

  • ▪

    Cervical muscle strain

  • ▪

    Adjacent segment disease

  • ▪

    Junctional instability

  • ▪

    Occipital neuralgia

  • ▪

    Facet arthropathy

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