Change in the Location of a Pseudotumor Around the C2 Odontoid Process from Posterior to Anterior to the Odontoid Process in the Natural Course: A Case with “Antero-Odontoid Pseudotumor” or “Peri-Odontoid Pseudotumor”

TL;DR

A patient with rheumatoid arthritis developed a pseudotumor that moved from behind to in front of the odontoid process over time, revealing a rare progression pattern.

Contribution

This case report documents the first known instance of a pseudotumor shifting from posterior to anterior around the odontoid process.

Findings

The pseudotumor initially appeared retro-odontoid but later became antero-odontoid.

The movement was linked to joint immobilization and ligament rupture due to advanced rheumatoid arthritis.

Such progression is rare, as most retro-odontoid pseudotumors are surgically treated before this stage.

Abstract

Background: A pseudotumor adjacent to the odontoid has been reported to be a non-neoplastic mass that is mainly associated with atlantoaxial instability. Methods: Case report. Results: A 72-year-old woman presented to our clinic with a chief complaint of bilateral fine motor dysfunction and gait disturbance. She had rheumatoid arthritis as a comorbidity. Physical examination revealed bilateral hand fine motor dysfunction and signs of myelopathy, including hyperreflexia of the deep tendon reflexes in the lower extremities. Magnetic resonance imaging (MRI) showed a retro-odontoid pseudotumor. Surgery was proposed to the patient, but she did not wish to undergo surgery at this time. At a follow-up visit approximately one year after the initial visit, she complained of the progression of the bilateral hand fine motor dysfunction and gait disturbance. MRI demonstrated a pseudotumor in the space anterior to the odontoid process, indicating that the localization of the pseudotumor around the odontoid process changed from the posterior space to the anterior space in its natural course. Conclusions: The speculated sequential mechanism of the change in the location of the pseudotumor from the posterior space to anterior space to the odontoid process in the natural course is as follows: As the rheumatoid arthritis progressed, the C1-2 joint was immobilized in the dislocated position, and as a result, the retro-odontoid pseudotumor disappeared due to immobilization of the C1-2 joint. Following the disappearance of the retro-odontoid pseudotumor, the odontoid process shifted backward owing to rupture of the transverse annular ligament. Consequently, a new space appeared in front of the odontoid process. Subsequently, damage to the apical and alar ligaments resulted in pseudotumor formation in the new space. Considering our case, the formation of an antero-odontoid pseudotumor occurs only in limited cases, with extreme progression of the pathology. Most cases of retro-odontoid pseudotumors are treated by surgery before such a progression; therefore, we consider that such a case has not yet been reported in the literature.

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