Occipitocervical fusion is a complex operation to stabilise the junction between the skull (occiput) and the upper cervical spine using screws, rods, and bone graft. It is performed for instability at the craniovertebral junction from rheumatoid arthritis, trauma, tumour, or congenital anomaly.
A midline incision is made from the base of the skull to the upper cervical spine. Screws are placed into the occiput (skull bone) and into the C1 lateral masses and/or C2 pedicles. Rods are contoured to the normal occipitocervical alignment and connected to the screws. Bone graft is placed to promote fusion. If there is spinal cord compression, decompression may be performed at the same time. The operation takes two to four hours.
Occipitocervical fusion is recommended for atlantoaxial instability from rheumatoid arthritis (erosion of the odontoid peg and transverse ligament), traumatic occiput-C1 or C1-C2 injuries, tumours of the upper cervical spine, congenital anomalies (os odontoideum, occipitalisation of C1), and basilar invagination.
Rigid cervical orthosis (halo vest or rigid collar) for specific stable injuries. Observation for stable, asymptomatic subluxation. However, craniovertebral instability with myelopathy generally requires surgery.
CT with 3D reconstruction for screw trajectory planning. MRI to assess spinal cord compression. CT angiography to map the vertebral arteries. Assessment of swallowing function (may be affected post-operatively). This is a high-risk procedure performed at specialist centres.
Stabilisation of the craniovertebral junction, preventing further spinal cord compression and potential quadriplegia or death from brainstem compression. Neurological symptoms may stabilise or improve.
Significant loss of head rotation (approximately 50% of total cervical rotation occurs at C1-C2).
From extensive muscle dissection.
Difficulty swallowing, usually temporary, from soft tissue swelling.
The vertebral arteries run through the C1-C2 region. Injury can cause stroke. Risk approximately 2–4%.
Risk of quadriplegia or death from manipulation of the unstable craniovertebral junction. Risk approximately 1–2%.
Particularly C2 pedicle screws.
Failure of fusion.
Approximately 2–3%.
Increased stress on levels below the fusion.
General anaesthesia with fibreoptic intubation (the neck must not be extended during intubation). Neuromonitoring throughout. Meticulous positioning — the unstable spine must be protected.
Rigid cervical collar for six to twelve weeks. Hospital stay three to seven days. Swallowing assessment before eating. Return to desk work at six to eight weeks. Avoid heavy lifting for three months. Full fusion at three to six months. Permanent loss of approximately 50% of head rotation.
X-rays and CT at six weeks, three months, and six months. Long-term monitoring for subaxial degeneration.
The upper cervical spine houses the brainstem and upper spinal cord — the most critical neurological structures. The vertebral arteries also pass through this region. Surgery here requires extreme precision.
Head rotation will be significantly reduced because the C1-C2 joint (which provides 50% of cervical rotation) is fused. Most patients adapt, though driving may require additional mirrors.