title: Occipitocervical fusion for rheumatoid arthritis using the inside-outside stabilization technique.
abstract: METHODS
  A retrospective study investigating the clinical outcome of the inside-outside cranial bolt technique for occipitocervical stabilization used to manage rheumatoid arthritis was conducted.
  
  
  OBJECTIVE
  To evaluate the safety and efficacy of the inside-outside technique for occipitocervical stabilization used to manage rheumatoid patients.
  
  
  BACKGROUND
  Achieving occipital cervical fusion for patients with rheumatoid arthritis is a complex and challenging problem. Complications related to placement of occipital screws have been reported.
  
  
  METHODS
  Occipitocervical stabilization was used for atlantoaxial subluxation or basilar invagination in 21 patients with rheumatoid arthritis. The patients were assessed for pre- and postoperative neurologic status (Ranawat classification), neck pain, fusion and alignment, hardware complications, and continued posterior cranial settling. All the patients underwent stabilization using inside-outside occipital screws. The technique involves bilateral fixation of cervical plates to the occiput using inside-outside screws, and to the cervical spine using pars screws at C2 or lateral mass screws at subaxial levels. Bone grafting was accomplished with autologous rib or iliac crest graft.
  
  
  RESULTS
  During the study, 14 women and 7 men with rheumatoid arthritis underwent occipitocervical stabilization and fusion. The average age of the patients was 65 years, and the mean follow-up period was 25.5 months. There were no surgical complications. Neck pain was reduced from an average Ranawat pain score of 2.40 to 0.4 (P < 0.0001). The Ranawat neurologic grade improved in 62% of the patients with preoperative neurologic deficit. Further cranial settling was not observed in any patient. There were no complications from implants and no incidence of instrumentation failure.
  
  
  CONCLUSIONS
  The "inside-outside" technique is safe and effective for stabilizing the occipitocervical junction in rheumatoid patients. It is associated with significant reduction of neck pain, improved neurologic status, and maintenance of alignment and stability.
authors.affiliation: Department of Neurosurgery, Georgetown University, Washington, DC 20007, USA.
authors.forename: Faheem A
authors.initials: FA
authors.lastname: Sandhu
authors.forename: T Glenn
authors.initials: TG
authors.lastname: Pait
authors.forename: Edward
authors.initials: E
authors.lastname: Benzel
authors.forename: Fraser C
authors.initials: FC
authors.lastname: Henderson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000601:surgery*; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009777:Occipital Bone / Q000000981:diagnostic imaging / Q000601:surgery*; D010146:Pain / Q000209:etiology / Q000503:physiopathology; D010147:Pain Measurement / Q000379:methods; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome