Occipital-Cervical Approach and Stabilization

  • A. Karim Ahmed
  • Ian Suk
  • Ali Bydon
  • Nicholas TheodoreEmail author


The spinal column is the most common site for skeletal metastases but involves the cervical spine in only 8–20% of cases. Metastatic disease is more common than primary spinal tumors, and surgery for metastatic spine disease is generally palliative. Due to its junctional location, metastatic disease from the occiput to C2 is more likely to cause instability, compared to the mobile subaxial spine. As such, patients most commonly present with refractory neck pain from mechanical instability. In the setting of cervical spine or craniovertebral junction tumors, the treatment goals for patients undergoing occipital-cervical stabilization are to decompress neural elements, realign the cervical spine, and stabilize the spinal column.


Occipito-cervical fusion OC fusion Craniovertebral junction 


  1. 1.
    Smoker WR. Craniovertebral junction: normal anatomy, craniometry, and congenital anomalies. Radiographics. 1994;14(2):255–77.CrossRefGoogle Scholar
  2. 2.
    Offiah CE, Day E. The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. Insights Imaging. 2017;8(1):29–47.CrossRefGoogle Scholar
  3. 3.
    Schweitzer ME, Hodler J, Cervilla V, Resnick D. Craniovertebral junction: normal anatomy with MR correlation. AJR Am J Roentgenol. 1992;158(5):1087–90.CrossRefGoogle Scholar
  4. 4.
    Lopez AJ, Scheer JK, Ke L, Smith ZA, Dlouhy BJ, Dahdaleh NS. Anatomy and biomechanics of the craniovertebral junction. Neurosurg Focus. 2015;38(4):E2.CrossRefGoogle Scholar
  5. 5.
    Milligram MA, Rand N. Cervical spine anatomy. Spine State of the Art Rev. 2000;14(3):521–32.Google Scholar
  6. 6.
    Bhatia R, Desouza RM, Bull J, Casey AT. Rigid occipitocervical fixation; indications, outcomes, and complications in the modern era. J Neurosurg Spine. 2013;18(4):333–9.CrossRefGoogle Scholar
  7. 7.
    Ciftdemir M, Kaya M, Selcuk E, Yalniz E. Tumors of the spine. World J Orthop. 2016;7(2):109–16.CrossRefGoogle Scholar
  8. 8.
    Jenis IG, Dunn EJ, An HS. Metastatic disease of the cervical spine. A review. Clin Orthop Relat Res. 1999;359:89–103.CrossRefGoogle Scholar
  9. 9.
    Guidetti B, Spallone A. Benign extramedullary tumors of the foramen magnum. Adv Tech Stand Neurosurg. 1988;16:83–120.CrossRefGoogle Scholar
  10. 10.
    Shin H, Barrenechea IJ, Lesser J, Sen C, Perin NI. Occipitocervical fusion after resection of craniovertebral junction tumors. J Neurosurg Spine. 2006;4(2):137–44.CrossRefGoogle Scholar
  11. 11.
    Laufer I, Rubin DG, Lis E, Cox BW, Stufflefield MD, Yamada Y, et al. The NOMS fraeworks: approach to the treatment of spinal metastatic tumors. Oncologist. 2013;18(6):744–51.CrossRefGoogle Scholar
  12. 12.
    Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the spinal oncology study group. Spine. 2010;35(22):E1221–9.CrossRefGoogle Scholar
  13. 13.
    Fehlings MG, David KS, Vialle L, Vialle E, Setzer M, Vrionis FD. Decision making in the surgical treatment of cervical spine metastases. Spine (Phila Pa 1976). 2009;34(22 suppl):S108–17.CrossRefGoogle Scholar
  14. 14.
    Phillips E, Levine AM. Metastatic lesions of the upper cervical spine. Spine (Phila Pa 1976). 1989;14(10):1071–7.CrossRefGoogle Scholar
  15. 15.
    Zuckerman SL, Kreines F, Powers A, Iorgulescu JB, Elder B, Bilsky MH, et al. Stabilization of tumor-associated craniovertebral junction instability: indications, operative variables, and outcomes. Neurosurgery. 2017;81(2):251–8.CrossRefGoogle Scholar
  16. 16.
    Bilsky MH, Shannon FJ, Sheppard S, Prabhu V, Boland PJ. Diagnosis and management of a metastatic tumor in the atlantoaxial spine. Spine (Phila Pa). 2002;29:246–53.Google Scholar
  17. 17.
    Kukreja S, Ambekar S, Sin AH, Nanda A. Occipitocervical fusion surgery: review of operative techniques and results. J Neurol Surg B Skull Base. 2015;76(5):331–9.CrossRefGoogle Scholar
  18. 18.
    Zou J, Yuan C, Zhu R, Zhang Z, Jiang W, Yang H. Effect of occipitocervical fusion with screw-rod system for upper cervical spine tumor. BMC Surg. 2014;14:30.CrossRefGoogle Scholar
  19. 19.
    Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Sci. 2014;4(1):50–6.CrossRefGoogle Scholar
  20. 20.
    Mazur MD, Sivakumar W, Riva-Cambrin J, Jones J, Brockmeyer DL. Avoiding early complications and reoperation during occipitocervical fusion in pediatric patients. J Neurosurg Pediatr. 2014;14(5):465–75.CrossRefGoogle Scholar
  21. 21.
    Maulucci CM, Ghobrial GM, Sharan AD, Harrop JS, Jallo JI, Vaccaro AR, Prasad SK. Correlation of posterior occipitocervical angle and surgical outcomes for occipitocervical fusion. Evid Based Spine Care J. 2014;5(2):163–5.CrossRefGoogle Scholar
  22. 22.
    Nuwer MR. Spinal cord monitoring. Muscle Nerve. 1999;22(12):1620–30.CrossRefGoogle Scholar
  23. 23.
    Luksanapruksa P, Buchowski JM, Wright NM, Valone FH 3rd, Peters C, Bumpass DB. Outcomes and effectiveness of posterior occipital fusion for suboccipital spinal metastases. J Neurosurg Spine. 2017;26(5):554–9.CrossRefGoogle Scholar
  24. 24.
    Lu JJ. Cervical laminectomy: technique. Neurosurgery. 2007;60(1 Supp1 1):S149–53.PubMedGoogle Scholar
  25. 25.
    Yeom JS, Buchowski JM, Park JW, Chang BS, Lee CK, Riew KD. Lateral fluoroscopic guide to prevent occipitocervical and atlantoaxial joint violation during C1 lateral mass screw placement. Spine J. 2009;9(7):574–9.CrossRefGoogle Scholar
  26. 26.
    Eldin MM, Hassan ASA. Free hand technique of cervical lateral mass screw fixation. J Craniovertebr Junction Spine. 2017;8(2):113–8.CrossRefGoogle Scholar
  27. 27.
    Mohamed E, Ihab Z, Moaz A, Ayman N, Haitham AE. Lateral mass fixation in subaxial cervical spine: anatomic review. Global Spine J. 2012;2(1):39–46.CrossRefGoogle Scholar
  28. 28.
    Hwang SW, Gressot LV, Chern JJ, Relyea K, Jea A. Complications of occipital screw placement for occipitocervical fusion in children. J Neurosurg Pediatr. 2012;9(6):586–93.CrossRefGoogle Scholar
  29. 29.
    Deutsch H, Haid RW Jr, Rodts GE Jr, Mummaneni PV. Occipitocervical fixation: long-term results. Spine (Phila Pa 1976). 2005;30(5):530–5.CrossRefGoogle Scholar
  30. 30.
    Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma. 1989;3(3):192–5.CrossRefGoogle Scholar
  31. 31.
    Cheung JP, Luk KD. Complications of anterior and posterior cervical spine surgery. Asian Spine J. 2016;10(2):385–400.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • A. Karim Ahmed
    • 1
  • Ian Suk
    • 1
  • Ali Bydon
    • 1
  • Nicholas Theodore
    • 1
    Email author
  1. 1.Department of NeurosurgeryThe Johns Hopkins HospitalBaltimoreUSA

Personalised recommendations