Occipitocervical Fusion

Occipitocervical fusion joins the base of your skull to the top bones of your neck so they heal together as one solid piece. It is done when this junction has become unstable and could put your spinal cord at risk. It is a planned operation, and careful scans beforehand are what keep it safe.

Reviewed by Dr. Kshitij Chaudhary — Last reviewed October 2026

What is occipitocervical fusion?

The occiput is the bone at the base of your skull. Just below it sit C1 and C2, the top two bones of your neck. Together they form the craniovertebral junction, the hinge that lets you nod and turn your head. Your spinal cord, brainstem and the arteries that feed the back of the brain (the vertebral arteries) all pass through this area.

In an occipitocervical (OC) fusion, the surgeon fixes two small metal rod to the back of your skull. These rods link to the screws in the top bones of your neck. The screws give rigid fixation of the neck. Bone graft is added, and over the next few months the skull and upper neck get glued together as one. This is called a occipitocervical (skull-to-neck) fusion.

Who needs this surgery?

You may need it when the skull-neck junction is loose, broken or badly worn, and there is a risk to the spinal cord. Common reasons:

• An injury (trauma) that has torn the ligaments or broken the bones at the top of the neck
• Rheumatoid arthritis or other arthritis that has loosened the joints
• Basilar invagination, where the top of the neck bone pushes up towards the skull opening
• A tumour in these bones
• An infection, including tuberculosis
• A previous operation that left the area unstable, or a fusion that did not heal
• Congenital defects

Not everyone with a problem here needs an operation. If you have been told you need this surgery and want to be sure, you can send your MRI for a second opinion.

Are there options other than surgery?

Sometimes. A firm collar can hold the neck steady while it heals, and this may be enough for a stable injury. Surgery with a plate, screws and rods gives rigid fixation and is usually advised when the area is unstable, when the spinal cord is under pressure, or when a collar alone will not be enough. Dr. Chaudhary will go through which of these applies to you.

How is it different from a C1-C2 fusion?

A C1-C2 Fusion locks only the top two neck bones and leaves the joint between the skull and C1 free. An occipitocervical fusion includes the skull. It is chosen when the problem involves the skull-C1 joint, or when C1 and C2 cannot be used as safe anchors on their own. Depending on the problem, the fusion may also run further down the neck.

What tests do I need first?

• X-rays, sometimes taken bending forward and back when this is safe, to see how much the junction moves
• A thin-slice CT scan with 3D pictures, to see the skull base and top of the neck in detail and plan the screws
• A CT angiogram to map the path of your vertebral arteries, because it decides which screw positions are safe
• An MRI to see the spinal cord and ligaments

What happens on the day of surgery?

• Anaesthesia. You have a general anaesthetic. The anaesthetist and the surgical team decide together how best to place the breathing tube so your neck stays protected.
• Position. You lie face down. Your head is held steady in a head holder, with your neck in a neutral position, and live X-ray checks the alignment.
• Monitoring. Nerve monitoring may be used during surgery, along with X-ray guidance and sometimes computer navigation.
• The cut. One cut runs down the middle of the back of your head and neck. The muscles are gently lifted off the bone.
• Plate and screws. The plate sits on the back of the skull. Its screws go into the thick ridge of bone in the middle, where the hold is strongest. Screws are also placed in the neck bones (C1/C2), and rods join them all together. If the bones are out of line, the surgeon realigns them before locking the rods.
• Bone graft. Graft is laid over roughened bone so the skull and neck grow together. It is usually taken through a small cut over your hip bone (the iliac crest).
• Closing. The wound is closed in layers. A small drain is sometimes left in for about a day, and a firm collar is fitted.

What are the risks?

All surgery carries risks, and this one is delicate because of what lies close by. Your CT angiogram and careful planning are there to keep these low.

• Injury to the vertebral artery. This is uncommon, but it is the most serious risk and the main reason for scanning the arteries beforehand.
• Bleeding from the veins around the upper neck nerves, or from the large blood channels inside the skull. The surgeon plans the skull screws to stay clear of these.
• A leak of spinal fluid if a skull screw goes through the inner layer of bone. This can be repaired.
• Pain or numbness at the back of the head from irritation of a nerve near the screw.
• Infection, or the bones not fusing fully.
• Rarely, injury to the spinal cord or nerves.

Dr. Chaudhary will explain how these apply to you before you decide.

How long will I stay in hospital?

Most people walk within a day and stay in hospital for 2 to 3 days, provided there was no weakness or other nerve problem before surgery. If the operation is done because the spinal cord is under pressure (myelopathy), the stay is sometimes longer.

What is recovery like?

• You will wear a firm neck collar for about 4 to 6 weeks.
• A neck wound at the back can be sore for some days. Painkillers and local anaesthetic around the wound help.
• You will have regular X-rays to check stability and healing.
• A CT scan is sometimes done at about 3 months to confirm fusion, if the X-rays leave any doubt.
• Recovery can take longer if you had weakness or other nerve symptoms before surgery.

Will I lose neck movement?

Yes, some. The skull-neck junction gives you much of your nodding and about half of your head-turning. After the fusion, these movements at the top of the neck are lost, and the rest of your neck takes up some of the work over time. Most people manage everyday tasks well, though looking up and turning sharply can feel different.

Questions to ask your surgeon

• Why do I need the skull included, rather than a C1-C2 fusion alone?
• How far down my neck will the fusion go?
• What do my scans show about my arteries?
• Where will the bone graft come from?
• How long will I need the collar?
• How much neck movement will I lose?

👨‍⚕️

About Dr. Kshitij Chaudhary

This page was written by Dr. Kshitij Chaudhary, a fellowship-trained spine surgeon at P.D. Hinduja Hospital, Mumbai, trained in complex spine surgery at Harvard Medical School (Beth Israel Deaconess) and the Twin Cities Spine Center, Minneapolis. 🏃🏾About Dr. Chaudhary