To define how pre-operative evaluation guides surgical planning in patients with atlanto-axial subluxation secondary to rheumatoid arthritis and to measure clinical outcome for the same group.

Prospective evaluation of a consecutive cohort of 26 patients undergoing C1/2 fusion over 5 years (2004-2009).

Pre-operative evaluation of posterior atlanto-dens interval (PADI), C1 lateral mass and C2 pedicle dimensions.

Pre- and post-op Ranawat scores and visual analogue scores for neck and C2 pain

C1/2 instability resulted from rheumatoid arthritis (21), trauma (4) and infection (1).

C1 lateral mass mean height 4.4mm, C2 pedicle mean height 5.1mm and mean width 3.4mm (30% width <3mm).

Ranawat scale improved Grade II to Grade I (p=0.07). Neck pain (pre-op mean 5.5, s.d. 2.8; post-op mean 1.6, s.d. 2.1, t<0.05) and C2 pain (pre-op mean 2.1, s.d. 3.3; post-op mean 0.5, s.d. 1.2, t<0.05) improved.

No instrumentation failure. In the rheumatoid group, 17/21 patients had C1 lateral mass and C1/2 transarticular screws. 1 patient had a cranio-cervical fusion and 3 patients had other constructs.

3 patients had C2 numbness. No other neurological deficit.

In a rheumatoid population, pre-operative evaluation often precludes the use of C2 pedicle screws. Rigid fixation with a C1 lateral mass and C1/2 transarticular polyaxial screw-rod system is associated with good clinical outcomes.

Purpose of study: To demonstrate the safety and efficacy 3 and 4-level ACDF with stand-alone (no additional anterior fixation) intervertebral cages.

Methods and results: A consecutive cohort of 19 patients undergoing 3 (n=15) and 4-level (n=4) ACDF with Solis cages over 4 years was studied (mean follow-up 24 months). Outcome measures were clinical (VAS scores for neck and arm pain, myelopathy scores) and radiological (disc height, kyphotic angles, fusion).

Neck pain scores improved from 5.1 pre-operatively (range 0–10, s.d. 4) to 2.8 post-operatively (range 0–10, s.d.5), t=3.7, P< 0.0002.

Arm pain scores improved from 5.3 pre-operatively (range 0–10, s.d. 5) to 2.5 post-operatively (range 0–8, s.d. 3), t=2.8, P< 0.009.

Pre-operative myelopathy scores averaged 10.6 (range 7–16, s.d. 4.7) rising to 12.8 post-operatively (range 10–17, s.d. 3.9). Although there was no statistically significant change in myelopathy scores, no patient experienced a worsening of their myelopathy score after surgery.

There were no operative complications. Radiological follow-up demonstrated early improvement in disc space heights (pre-op 3.1 mm, range 1–6 mm; post-op 5.6 mm, range 4–9 mm) but, at 12 months, two patients demonstrated asymptomatic evidence of cage settling and loss of disc height. There was no incidence of pseudarthrosis. No patient has thus far required further surgery.

Conclusion: Multi-level cervical disc disease can be managed safely and effectively by 3 or 4-level discectomy and fusion with stand-alone intervertebral cages.

Ethics approval: None – audit

Interest Statement: None