AimAn estimated 88% of rheumatoid arthritis (RA) patients experience various degrees of cervical spine involvement. The excessive movement of the atlantoaxial joint, which connects the occiput to the upper cervical spine, results in atlantoaxial instability (AAI). AAI stabilization is usually achieved by C1 lateral mass‐to‐C2 pedicle screw‐rod fixation (LC1–PC2 fixation), which is technically challenging in RA patients who often show destructive changes in anatomical structures. This study aimed to analyze the clinical results and operative experiences of C1–C2 surgery, with emphasis on the advancement of image‐guided surgery and augmented reality (AR) assisted navigation.MethodsWe presented our two decades of experience in the surgical management of AAI from April 2004 to November 2022.ResultsWe have performed surgery on 67 patients with AAI, including 21 traumatic odontoid fractures, 20 degenerative osteoarthritis, 11 inflammatory diseases of RA, 5 congenital anomalies of the os odontoideum, 2 unknown etiologies, 2 movement disorders, 2 previous implant failures, 2 osteomyelitis, 1 ankylosing spondylitis, and 1 tumor. Beginning in 2007, we performed LC1–PC2 fixation under C‐arm fluoroscopy. As part of the progress in spinal surgery, since 2011 we used surgical navigation from presurgical planning to intraoperative navigation, using the preoperative computed tomography (CT) ‐based image‐guided BrainLab navigation system. In 2021, we began using intraoperative CT scan and microscope‐based AR navigation.ConclusionThe technical complexities of C1–C2 surgery can be mitigated by CT‐based image‐guided surgery and microscope‐based AR navigation, to improve accuracy in screw placement and overall clinical outcomes, particularly in RA patients with AAI.

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