Craniocervical fixation

Last revised by Rohit Sharma on 22 Oct 2022

Craniocervical fixation, instrumentation or occipitocervical fusion refer to surgical fixation techniques with the goal to stabilize the craniocervical junction.

Craniocervical fixation is indicated in the setting of craniocervical instability including 2,3:

Contraindications occipitocervical fixation include:

  • extensive occipital destruction

  • active local infection

A relative contraindication is an aberrant or unilateral vertebral artery with an increased operative risk of injury.

The surgical procedure usually involves a posterior approach and application of various interfaces including occipital-plate-screw-rod, occipital-wire-rod-screw or occipital-hook-clamp-rod-screw systems 1-3:

  • an incision from the inion to the caudal vertebral body and splitting of the occipital muscles

  • dissection of the occipital and paraspinal muscles away from the spinous processes and laminae

  • occipital plate fixation close but caudal to the external occipital protuberance

  • alternatively burr hole drilling with wire or hook placement

  • variably occipital condyle screw placement

  • posterior cervical screw fixation

    • atlas lateral mass screw insertion

    • axis pars screw, pedicle screw or laminar screw insertion

  • occipitocervical alignement and rod contouring

  • rod insertion and occipital fixation with plate-screw, rod-wire or rod-clamp interface

  • variably decortication and bone graft placement

An alternative approach is an atlantooccipital condyle screw placement with a screw trajectory from the midpoint of the atlas lateral masses to the midpoint of the occipital condyles at a 10-20° medial angulation 1,2.

Complications of craniocervical fixation techniques include complications of spinal surgery and the following 1-4:

Plain radiographs can assess implant position and vertebral alignment.

In addition to the exact position of implants, CT might detect upper cervical and intracranial complications and characterize bony fusion.

MRI can be used to evaluate the spinal canal and posterior cranial fossa in the setting of suspected complications 1.

The postoperative radiological report should include a description of the following features:

Occipitocervical fusion leads to reduced mobility in the atlantooccipital and atlantoaxial joints with restriction in inclination, reclination and cervical rotatory capacity.

An occipitocervical fusion with fibular only bone graft was already described by Forrester in 1927 1,2. Several different bone graft techniques with and without wiring have been described later 1.

A rod-wire technique has been described by Sonntag and Dickmann 1993 and an inverted hook-clamp system was introduced by Faure in 1998 1,2. Rod-screw systems extending to the occiput have been described in the late 90s of the last millennium 1-4.

Transarcticular atlantooccipital condyle screw fixation has been introduced by LF Gonzalez and colleagues in 2003 1,5.

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