Occipitocervical Stabilization

  • Robert F. Heary
  • Nitin Agarwal


The occipitocervical junction, also known as the craniocervical or craniovertebral junction (CVJ), consists of the two joints (the atlanto-occipital and atlantoaxial), the spinal cord, and several neurovascular elements supplying the head and neck. Proper alignment of the occipitocervical junction relies upon several osseous and ligamentous complexes contributing to the aforementioned joints. The interplay of these elements affords stability for this complex anatomical location that functionally allows rotation, flexion, and extension of the cranium in relation to the cervical spine. Historically, in the early 1900s, disruption of the aforementioned structural components, leading to CVJ instability, was not considered amenable to surgical intervention. Over time, treatment strategies have evolved with initial interventions involving only decompression and subsequent strategies also incorporating fusions with stabilization. However, since the first description of an occipitocervical fusion (OCF), by Forrester in 1927, multiple methods of CVJ fixation have been described enabling deformity correction to maintain proper spinal alignment. While OCF is certainly an effective method to address pathology of the occipitocervical junction, given its important role in mobility, posterior fixation must ensure proper sagittal alignment. As such, this chapter discusses the relevant perioperative considerations to attempt to achieve the ideal posture following fixation.


Occipitocervical stabilization Occipitocervical junction CVJ Occipitocervical fusion OCF 


  1. 1.
    Tubbs RS, Hallock JD, Radcliff V, et al. Ligaments of the craniocervical junction. J Neurosurg Spine. 2011;14(6):697–709.CrossRefGoogle Scholar
  2. 2.
    Martinez-Del-Campo E, Turner JD, Kalb S, et al. Occipitocervical fixation: a single surgeon’s experience with 120 patients. Neurosurgery. 2016;79(4):549–60.CrossRefGoogle Scholar
  3. 3.
    Lopez AJ, Scheer JK, Leibl KE, Smith ZA, Dlouhy BJ, Dahdaleh NS. Anatomy and biomechanics of the craniovertebral junction. Neurosurg Focus. 2015;38(4):E2.CrossRefGoogle Scholar
  4. 4.
    Vender JR, Rekito AJ, Harrison SJ, McDonnell DE. The evolution of posterior cervical and occipitocervical fusion and instrumentation. Neurosurg Focus. 2004;16(1):E9.PubMedGoogle Scholar
  5. 5.
    Theodore N, Aarabi B, Dhall SS, et al. The diagnosis and management of traumatic atlanto-occipital dislocation injuries. Neurosurgery. 2013;72 Suppl 2(suppl_3):114–26.CrossRefGoogle Scholar
  6. 6.
    Winegar CD, Lawrence JP, Friel BC, et al. A systematic review of occipital cervical fusion: techniques and outcomes. J Neurosurg Spine. 2010;13(1):5–16.CrossRefGoogle Scholar
  7. 7.
    Glaser JA, Whitehill R, Stamp WG, Jane JA. Complications associated with the halo-vest. A review of 245 cases. J Neurosurg. 1986;65(6):762–9.CrossRefGoogle Scholar
  8. 8.
    Lall R, Patel NJ, Resnick DK. A review of complications associated with craniocervical fusion surgery. Neurosurgery. 2010;67(5):1396–403.CrossRefGoogle Scholar
  9. 9.
    Paramore CG, Dickman CA, Sonntag VKH. The anatomical suitability of the C1–2 complex for transarticular screw fixation. J Neurosurg. 1996;85(2):221–4.CrossRefGoogle Scholar
  10. 10.
    Wright NM. Posterior C2 fixation using bilateral, crossing C2 laminar screws: case series and technical note. J Spinal Disord Tech. 2004;17(2):158–62.CrossRefGoogle Scholar
  11. 11.
    Uchino A, Saito N, Watadani T, et al. Vertebral artery variations at the C1-2 level diagnosed by magnetic resonance angiography. Neuroradiology. 2012;54(1):19–23.CrossRefGoogle Scholar
  12. 12.
    Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine. 2005;30(18):2024–9.CrossRefGoogle Scholar
  13. 13.
    Tang JA, Scheer JK, Smith JS, et al. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery. 2012;71(3):662–9; discussion 669.CrossRefGoogle Scholar
  14. 14.
    Scheer JK, Tang JA, Smith JS, et al. Cervical spine alignment, sagittal deformity, and clinical implications. J Neurosurg Spine. 2013;19(2):141–59.CrossRefGoogle Scholar
  15. 15.
    Matsunaga S, Onishi T, Sakou T. Significance of occipitoaxial angle in subaxial lesion after occipitocervical fusion. Spine. 2001;26(2):161–5.CrossRefGoogle Scholar
  16. 16.
    Abumi K, Ito M, Sudo H. Reconstruction of the subaxial cervical spine using pedicle screw instrumentation. Spine. 2012;37(5):E349–56.CrossRefGoogle Scholar
  17. 17.
    Kuntz C, Levin LS, Ondra SL, Shaffrey CI, Morgan CJ. Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature. J Neurosurg Spine. 2007;6(2):104–12.CrossRefGoogle Scholar
  18. 18.
    Fehlings MG, Errico T, Cooper P, Benjamin V, DiBartolo T. Occipitocervical fusion with a five-millimeter malleable rod and segmental fixation. Neurosurgery. 1993;32(2):198–207; discussion 207–198.CrossRefGoogle Scholar
  19. 19.
    Deutsch H, Haid RW Jr, Rodts GE Jr, Mummaneni PV. Occipitocervical fixation: long-term results. Spine. 2005;30(5):530–5.CrossRefGoogle Scholar
  20. 20.
    Cheung JP, Luk KD. Complications of anterior and posterior cervical spine surgery. Asian Spine J. 2016;10(2):385–400.CrossRefGoogle Scholar
  21. 21.
    He B, Yan L, Xu Z, Chang Z, Hao D. The causes and treatment strategies for the postoperative complications of occipitocervical fusion: a 316 cases retrospective analysis. Eur Spine J. 2014;23(8):1720–4.CrossRefGoogle Scholar
  22. 22.
    Barnes M, Liew S. The incidence of infection after posterior cervical spine surgery: a 10 year review. Global Spine J. 2012;2(1):3–6.CrossRefGoogle Scholar
  23. 23.
    Fineberg SJ, Ahmadinia K, Oglesby M, Patel AA, Singh K. Hospital outcomes and complications of anterior and posterior cervical fusion with bone morphogenetic protein. Spine. 2013;38(15):1304–9.CrossRefGoogle Scholar
  24. 24.
    Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine. 2010;35(22):E1221–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Neurological SurgeryRutgers New Jersey Medical SchoolNewarkUSA
  2. 2.Department of Neurological SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA

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