Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Occipitocervical Fusion

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with [craniocervical instability / basilar invagination / occipitocervical trauma / RA cranial settling / tumor] planned for occipitocervical (occiput–C2/below) instrumented fusion.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

🧭 Operative approach: Far-lateral / craniocervical approach — detailed corridor setup, step-by-step technique & figures

Neurosurgical Atlas · AO Spine / Surgery Reference · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Occipitocervical Fusion — Figure 1 Figure 1. Illustrations of the MCD, OCA, and OCD on one lateral radiograph. The MCD is the shortest distance (BD) from the midpoint (point B) of the two apices of the mandible angles (points A and… Source: Evaluation of occipitocervical neutral position using lateral radiographs — Journal of Orthopaedic Surgery and Research 2014; CC BY.

Occipitocervical Fusion — Figure 2 Figure 2. The MCDs were less affected when the head was slightly rotated. The figure shows the head in neutral position (a). The head turned right (b), and the head turned left (c). Source: Evaluation of occipitocervical neutral position using lateral radiographs — Journal of Orthopaedic Surgery and Research 2014; CC BY.

Occipitocervical Fusion — Figure 3 Figure 3. A preoperative and postoperative radiograph. (a) Preoperative radiograph of a patient with chronic atlantoaxial dislocation secondary to occipitalization showed a decreased MCD and OCA…. Source: Evaluation of occipitocervical neutral position using lateral radiographs — Journal of Orthopaedic Surgery and Research 2014; CC BY.

Occipitocervical Fusion — Fig. 1 Fig. 1. Spinous process screw as a third anchor point in C2 for occipitocervical fixation. a Anteroposterior view. b Lateral view Source: Outcomes of occipitocervical fixation using a spinous process screw in C2 as a third anchor point for occipitocervical fixation: a case presentation — BMC Musculoskeletal Disorders 2020; CC BY.

Occipitocervical Fusion — Fig. 2 Fig. 2. A 35-year-old man with occipitocervical deformity was treated with posterior occipitocervical fixation and fusion. a–c Occipital screws, C2 bilateral pedicle screws, a C2 spinous process… Source: Outcomes of occipitocervical fixation using a spinous process screw in C2 as a third anchor point for occipitocervical fixation: a case presentation — BMC Musculoskeletal Disorders 2020; CC BY.

Occipitocervical Fusion — Fig. 3 Fig. 3. a–d Clinical photographs show the good cervical function of the patient in various positions at the 24-month follow-up visit Source: Outcomes of occipitocervical fixation using a spinous process screw in C2 as a third anchor point for occipitocervical fixation: a case presentation — BMC Musculoskeletal Disorders 2020; CC BY.

Occipitocervical Fusion — Figure 1 Figure 1. MRI demonstrated a mass (arrows) in the occipitocervical subcutaneous tissue with uneven signal intensity on (Figure 1(a)) sagittal T2-weighted, (Figure 1(b)) T2-weighted fat suppressed,… Source: Occipitocervical Hemolymphangioma in an Adult with Neck Pain and Stiffness: Case Report and Literature Review — Case Reports in Medicine 2017; CC BY.

Occipitocervical Fusion — Figure 2 Figure 2. Histological analysis of specimen (hematoxylin and eosin stain; magnification ×100) showed abnormal lymphatic (black arrowheads) and blood vessels (black stars) with polycystic spaces. Source: Occipitocervical Hemolymphangioma in an Adult with Neck Pain and Stiffness: Case Report and Literature Review — Case Reports in Medicine 2017; CC BY.

History of Present Illness

Imaging Review

CT craniocervical (thin-cut + CTA)

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Goals

Position

Key Surgical Steps

  1. Posterior midline incision (inion to lower cervical), expose occiput, C1, C2, and subaxial levels as needed
  2. Occipital fixation: midline keel plate/screws into the thick occipital bone (or condylar screws) — occipital screws engage thick midline keel (bicortical risk: dural sinuses)
  3. C2 fixation: pedicle/pars/translaminar screws (VA-dependent per CTA)
  4. ± C1 lateral mass screws, subaxial lateral mass/pedicle screws (if extending below C2)
  5. Decompression if needed: foramen magnum/C1 laminectomy (dorsal compression); for irreducible ventral compression, staged anterior (endonasal/transoral) odontoidectomy
  6. Contour occipitocervical rods connecting occipital plate to cervical screws in correct alignment
  7. Reduce/secure, confirm alignment and cervicomedullary decompression
  8. Decorticate occiput/cervical elements, bone graft (autograft/allograft) for fusion
  9. Hemostasis, layered watertight closure (CSF leak risk if decompression)

Critical Anatomy & Structures at Risk

  1. Vertebral arteries (C1-C2, screw trajectories) — catastrophic; CTA planning
  2. Cervicomedullary junction / spinal cord / brainstem — narrow margin, manipulation
  3. Dural venous sinuses (occipital bicortical screws — transverse/sigmoid/torcula)
  4. Lower cranial nerves, alignment (malalignment → dysphagia, gaze, myelopathy)
  5. Dura (decompression — CSF leak)

Equipment

Monitoring

Anesthesia

Potential Complications

  1. Vertebral artery / neurological injury (cervicomedullary)
  2. Malalignment (dysphagia, gaze, myelopathy — fuse in neutral)
  3. Dural sinus injury (occipital screws), CSF leak
  4. Hardware failure/pseudarthrosis, wound issues (RA/immunosuppressed), occipital screw pullout
  5. Lower CN dysfunction, respiratory issues

Operative Note Template

Preoperative Diagnosis: Craniocervical instability [/ basilar invagination / occipitocervical dislocation / RA cranial settling]

Postoperative Diagnosis: Same

Procedure: Occipitocervical instrumented fusion (occiput–C_) [with foramen magnum/C1 decompression]

Surgeon / Assistant: Anesthesia: General endotracheal (awake fiberoptic intubation) EBL / Fluids / Blood products: [crossmatched] Adjuncts: Neuronavigation/fluoroscopy (CTA-reviewed VA anatomy), high-speed drill; SSEP/MEP/EMG Implants: Occipital plate/keel screws, C2 [pedicle/pars] and cervical screws, contoured rods, bone graft Complications: None

Indications: [Age]yo [M/F] with craniocervical instability/compression from [etiology] and [myelopathy/bulbar symptoms]. Occipitocervical fusion [± decompression] was indicated. Risks (VA injury, malalignment, lower CN, CSF leak) discussed.

Description of Procedure: After consent and time-out, awake fiberoptic intubation was performed and the patient positioned prone in Mayfield with neutral craniocervical alignment confirmed fluoroscopically before fixation (malalignment causes dysphagia/myelopathy/gaze problems); neuromonitoring baselines confirmed. A posterior midline exposure of the occiput, C1, and C2 [and subaxial levels] was performed.

Occipital fixation was achieved with a midline keel plate/screws; C2 [pedicle/pars] screws were placed per CTA-verified VA anatomy [with C1 lateral mass/subaxial screws as needed]. [A foramen magnum/C1 decompression was performed for dorsal compression.] Contoured occipitocervical rods were secured in neutral alignment, and the decorticated surfaces grafted for arthrodesis. Alignment and hardware were confirmed; neuromonitoring remained stable.

A watertight closure [if decompression] was performed in layers with a drain. The patient was transferred to the ICU with lower-CN/respiratory monitoring and a swallow evaluation planned.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Occipitocervical Fusion:

Common Pimp Questions

Use these to pressure-test preparation for Occipitocervical Fusion:

  1. What neurologic level and root are responsible for the presenting deficit?
  2. What is the decompression target and how will you know it is adequately decompressed?
  3. What instability, deformity, bone-quality, or fusion variable changes the construct?
  4. What vascular, visceral, dural, or neural structure is the main structure at risk?
  5. What postop brace, drain, mobilization, MAP, antibiotic, and DVT plan should be ordered?

Attending Preference Variables

Items that commonly vary by surgeon or institution: