约88%的类风湿性关节炎（RA）患者出现不同程度的颈椎受累。寰枢关节的过度运动（连接枕骨和上颈椎）导致寰枢关节不稳定（AAI）。AAI的稳定通常通过C1横突-C2椎弓根螺钉杆固定术（LC1-PC2固定术）来实现，但在RA患者中，解剖结构常显示破坏性变化，这对技术提出了挑战。本研究旨在分析C1-C2手术的临床结果和手术经验，重点是影像引导手术和增强现实（AR）辅助导航的进展。我们展示了2004年4月至2022年11月对AAI的外科治疗经验。我们对67例AAI患者进行了手术，其中包括21例齿状突创伤性骨折，20例退行性骨关节炎，11例RA炎症性疾病，5例先天性骨折锤骨畸形，2例原因不明，2例运动障碍，2例先前植入物失效，2例骨髓炎，1例强直性脊柱炎和1例肿瘤。自2007年起，我们开始在C型臂透视下进行LC1-PC2固定术。作为脊柱手术进展的一部分，自2011年起，我们使用术前计划到术中导航的手术导航，使用术前计算机断层扫描（CT）为基础的BrainLab影像引导系统。2021年，我们开始使用术中CT扫描和显微镜基于AR导航。CT基于影像引导手术和显微镜基于AR导航可以减轻C1-C2手术的技术复杂性，提高螺钉放置的准确性和整体临床效果，特别是对于AAI伴有RA的患者。© 2023 The Authors. International Journal of Rheumatic Diseases由亚太类风湿病协会和约翰·威立出版澳大利亚有限公司发表。

An 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.We presented our two decades of experience in the surgical management of AAI from April 2004 to November 2022.We 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.The 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.© 2023 The Authors. International Journal of Rheumatic Diseases published by Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.