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Purpose To describe occipitocervical inclination (OCI), a new parameter that could compensate for defects in existing radiographic parameters, and to define occipitocervical neutral position. Methods Neutral, flexion, and extension lateral cervical spine radiographs of 200 patients (100 male and 100 female patients) judged to be normal were analyzed. The mean age was 45.19 years (range 11–74; 42.84 for male and 47.53 for female patients). For OCI, the angle formed by the line connecting the posterior border of the C4 vertebral body and McGregor’s line was measured. Occipitocervical angle (OCA) and occipitocervical distance (OCD) were measured and compared with OCI. Results OCI on standard, neutral lateral cervical radiographs was 102.51° ± 8.87°. There was no significant gender difference in neutral OCI 102.81° ± 7.93° for male and 102.21° ± 9.74° for female patients ( P  = 0.631). The mean neutral OCA was 38.69° ± 9.23°, and the mean neutral OCD was 22.98 ± 5.10 mm. Pearson’s correlation coefficient for the value of the cervical lordosis angle and that of neutral OCI was r  = 0.274 ( P  < 0.001). Intraclass correlation coefficient values for inter- and intraobserver reliability for OCI were significantly higher than those for OCA ( P  < 0.001) and tended to be higher than those for OCD ( P  = 0.087). Conclusions OCI is a very useful parameter for the determination of neutral position during occipitocervical fusion for patients with altered C0–C2 anatomy.

Purpose The purpose of this study was to evaluate patient-reported outcome measures (PROMS) on dysphagia, health-related quality of life (HRQoL) and return to work after occipitocervical fixation (OCF). Postoperative radiographic measurements were evaluated to identify possible predictors of dysphagia. Methods All individuals (≥ 18 years) who underwent an OCF at the study center or were registered in the Swedish spine registry (Swespine) between 2005 and 2019, and were still alive when the study was conducted, were eligible for inclusion. There was no overlap between the cohorts. Prospectively collected data on dysphagia (Dysphagia Short Questionnaire DSQ), HRQoL (EQ5D-3L) and return to work were used. Radiological and baseline patient data were retrospectively collected. In addition, HRQoL data of a matched sample of individuals was elicited from the Stockholm Public Health Survey 2006. Results In total, 54 individuals were included. At long-term follow-up, 26 individuals (51%) had no dysphagia, and 25 (49%) reported some degree of dysphagia: 11 (22%) had mild dysphagia, and 14 (27%) had moderate to severe dysphagia. On a group level, the OCF sample scored significantly lower EQ VAS and EQ-5D index values compared to the general population (60.0 vs. 80.0, p  = 0.016; 0.43 vs. 0.80, p  < 0.001). Individuals working preoperatively returned to work after surgery. Of those responding, 88% stated that they would undergo the OCF operation if it was offered today. No predictors of dysphagia based on radiographic measurements were identified. Conclusion Occipitocervical fixation results in a high frequency of long-term dysphagia. The HRQoL of OCF patients is significantly reduced compared to matched controls. However, most patients are satisfied with their surgery. No radiographic predictors of long-term dysphagia could be identified. Future prospective and systematic studies with larger samples and more objective outcome measures are needed to elucidate the causes of dysphagia in OCF.

PurposeThere is an increased demand for surgical solutions to treat craniocervical instability. This retrospective study demonstrates the clinical and radiological outcomes of unstable craniocervical junction treated with occipitocervical fusion.Material and methodsThe mean age of 52 females and 48 males was 56.89 years. The clinical and radiological outcomes were assessed, including NDI, VAS, ASIA score, imaging, complications and bony fusion in two used constructs: a modern occipital plate–rod–screw system (n = 59) and previous bilateral contoured titanium reconstruction plates–screws (n = 41).ResultsClinically and on imaging, patients presented with neck pain, myelopathy, radiculopathy, vascular symptoms and craniocervical instability. The mean follow-up was 6.47 years. A solid bony fusion was achieved in 93.81% of the patients. The NDI and the VAS improved significantly from 28.3 and 7.67 at the presentation to 16.2 and 3.47 at the final follow-up. The anterior and posterior atlantodental interval (AADI and PADI), the clivus canal angle (CCA), the occipitoaxial angle (OC2A) and the posterior occipitocervical angle (POCA) improved significantly. Six patients required early revision.ConclusionOccipitocervical fusion can yield excellent results regarding clinical improvement and long-term stability with a high fusion rate. Simple reconstruction plates, though more demanding surgically, achieve similar results. Preserving a neutral patient’s position for fixation avoids postoperative dysphagia and may help prevent adjacent segment disease development.

Study Design Retrospective, cross-sectional study. Objectives Occipitocervical fusion is indicated for various conditions. Some techniques require placement of screws in the occipital condyle. The objective of this study was to analyze the morphometric features of the occipital condyle among Arabs. Methods Computed tomography (CT)-based morphometric analysis of occipital condyles of 200 Arab skeletally mature patients (400 condyles) was done. Axial width of at least 8 mm and coronal height of at least 6.5 mm are the cutoff values for feasibility of condylar screw placement. Results The mean age of the patients was 48.0 ± 18.3 years. Males were 53.5% (107) of the sample. The mean axial condylar width and length were 8.5 ± 1.5 mm and 20.3 ± 2.6 mm, respectively, while the mean axial screw angle was 35.9° ± 5.5° from midline. The mean sagittal condylar length and height were 16.1 ± 1.9 mm and 8.8 ± 1.5 mm, respectively. The mean condylar coronal height was 8.2 ± 1.4 mm. Based on axial width and coronal height measurements, 150 (37.5%) condyles could safely fit a 3.5 mm condylar screw. One hundred and four (55.9% female condyles) condyles cannot fit a screw in females, while 46 (21.5% male condyles) condyles cannot fit a screw in males. Conclusions Condylar screw for occipitocervical fusion is feasible for the majority of Arabs in our sample; however, this applies to slightly less than half of the female condyles. Detailed preoperative radiological planning is critical to avoid complications related to occipital condyle screw placement.

Background Occipitocervical fusion (OCF) is a procedure performed for multiple upper cervical pathologies. A common postprocedural complication of OCF is dysphagia, which has been linked to the narrowing of the pharyngeal space due to fixation in a hyper-flexed angle. Postoperative dysphagia is linked to reduced quality of life, prolonged hospital stay, aspiration pneumonia, and increased mortality. This has led to investigations of the association between sagittal radiographic angles and dysphagia following OCF. Methods A systematic review of the literature was performed to explore the current evidence regarding cervical sagittal radiographic measurements and dysphagia following OCF. A search strategy was carried out using the PubMed, Embase, and Web of Science databases from their dates of inception until August 2022. Only original English-language studies were considered. Moreover, studies had to include the correlation between dysphagia and at least one radiographic measurement in the sagittal plane. Results The search and subsequent selection process yielded eight studies that were included in the final review, totaling 329 patients in whom dysphagia had been assessed and graded. The dysphagia score by Bazaz et al. ( Spine 27, 22:2453–2458, 2002) was used most often. The pooled incidence of dysphagia, in the early postoperative period, was estimated at 26.4%. At long-term follow-up (range: 17–72 months), about one-third of patients experienced resolution of symptoms, which resulted in a long-term post-OCF dysphagia incidence of 16.5%. Across the studies included, six different radiographic parameters were used to derive several measures which were repeatedly and significantly associated with the occurrence of dysphagia. Conclusions The high incidence of postoperative dysphagia following OCF warrants close monitoring of patients, especially in the short-term postoperative period. These patients may be assessed through standardized tools where the one by Bazaz et al. was the most commonly used. Moreover, there are several radiographic measurements that can be used to predict the occurrence of dysphagia. These findings may serve as a basis for strategies to prevent the occurrence of dysphagia after OCF.

PurposeOdontoidectomy for ventral compressive pathology may result in O-C1 and/or C1-2 instability. Same-stage endonasal C1-2 spinal fusion has been advocated to eliminate risks associated with separate-stage posterior approaches. While endonasal methods for C1 instrumentation and C1-2 trans-articular stabilization exist, no hypothetical construct for endonasal occipital instrumentation has been validated. We provide an anatomic description of anterior occipital condyle (AOC) screw endonasal placement as proof-of-concept for endonasal craniocervical stabilization.MethodsEight adult, injected cadaveric heads were studied for placing 16 AOC screws endonasally. Thin-cut CT was used for registration. After turning a standard inferior U-shaped nasopharyngeal flap endonasally, 4 mm × 22 mm AOC screws were placed with a 0° driver using neuronavigation. Post-placement CT scans were obtained to determine: site-of-entry, measured from the endonasal projection of the medial O-C1 joint; screw angulation in sagittal and axial planes, proximity to critical structures.ResultsAverage site-of-entry was 6.88 mm lateral and 9.74 mm rostral to the medial O-C1 joint. Average angulation in the sagittal plane was 0.16° inferior to the palatal line. Average angulation in the axial plane was 23.97° lateral to midline. Average minimum screw distances from the jugular bulb and hypoglossal canal were 4.80 mm and 1.55 mm.ConclusionEndonasal placement of AOC screws is feasible using a 0° driver. Our measurements provide useful parameters to guide optimal placement. Given proximity of hypoglossal canal and jugular bulb, neuronavigation is recommended. Biomechanical studies will ultimately be necessary to evaluate the strength of AOC screws with plate-screw constructs utilizing endonasal C1 lateral mass or C1-2 trans-articular screws as inferior fixation points.

PurposeThe pathological changes of basilar invagination (BI) and atlantoaxial dislocation (AAD) include vertical and horizontal dislocations. Current surgical techniques have difficulty in accurately controlling the degree of reduction in these two directions and often require preoperative traction, which increases patients’ pain, hospital stay, and medical cost. This study aimed to introduce a novel technique for accurately reducing horizontal and vertical dislocation without preoperative traction and report the radiological and clinical outcomes.MethodsFrom 2010 to 2020, patients with BI and AAD underwent posterior two-step distraction and reduction (TSDR) and occipitocervical fixation. Radiological examination was used to evaluate the reduction degree (RD) and compression. Japanese Orthopedic Association (JOA) score was used to evaluate clinical outcome.ResultsA total of 55 patients with BI and AAD underwent TSDR and occipitocervical fusion. The clinical symptoms of 98.2% of them improved. JOA score increased significantly after the operation. Appropriate (50% ≤ RD < 80%) or satisfactory (RD ≥ 80%) horizontal reduction was achieved in 92.7% of patients, and 90.9% obtained appropriate or satisfactory vertical reduction. Thirty-one patients did not undergo preoperative skull traction. There was no significant difference in radiological outcomes or JOA scores between the traction and non-traction groups. However, the length of hospital stay in the traction group was longer than that in the non-traction group.ConclusionTSDR enables horizontal and vertical reduction. It is a safe, simple, and effective technique for patients with BI and AAD. Despite the absence of preoperative skull traction, the degree of reduction and clinical outcomes were satisfactory.

Background Due to the high stresses placed on the upper cervical spinal region, achieving firm fixation and solid bony fusion is essential for good surgical outcomes. However, few reports have addressed bony fusion in procedures involving this region. The present investigation evaluated bony union in fusion procedures for surgical treatment of the upper cervical spinal region and searched for factors associated with fusion failure. Methods The medical data of 84 consecutive patients (38 male and 46 female; mean age: 68.7 years) who underwent upper cervical spinal fusion surgery were retrospectively examined. The surgical techniques used were occipitocervical (O-C) fusion in 45 patients and atlantoaxial fusion with trans-articular screws in 39 patients. To determine the incidence of bony union, the cohort was divided into O-C fusion and atlantoaxial fusion groups and examined for the presence of delayed bony union. Logistic regression models were employed to analyze the prevalence, characteristics, and risk factors of delayed bony union. Results Overall, 20.2% of upper cervical spinal fusion surgery patients experienced delayed bony union. In comparisons of the O-C fusion and atlantoaxial fusion groups, we observed no remarkable differences for age, gender, or steroid use, although rheumatoid arthritis was significantly more common in the O-C fusion group ( p < 0.001). Bony fusion rates tended to be higher in the O-C fusion group (86.6%) than in the atlantoaxial fusion group (71.7%). Multivariate analysis identified atlantoaxial fusion to be more strongly associated with delayed bony union (odds ratio: 2.6). Conclusion Approximately 20% of patients undergoing upper cervical spinal fusion surgery experienced delayed bony union. With an odds ratio of 2.6, atlantoaxial fusion was strongly related to this complication.

Background Patients with hypermobile Ehlers-Danlos Syndrome (hEDS) are at risk of developing craniocervical instability (CCI). Iatrogenic causes of CCI in hEDS are underreported. We describe a case series of hEDS patients who developed CCI from routine neck hyperextension during common procedures (e.g., intubation for anesthesia, dental work). Methods We conducted a retrospective case series of 8 adults (≥ 18 years old) with hEDS (2017 diagnostic criteria) who had no preoperative CCI symptoms but developed new CCI symptoms after a surgical procedure that persisted for at least 5 years. Cases were identified from patients seen at a single tertiary center between January 1, 2024, and July 31, 2025. Data collected included symptom onset, symptom types, procedure details (including neck positioning), imaging findings, and clinical outcomes. A structured literature review was performed using PubMed, Scopus, and Web of Science (through November 2025) for reports of CCI in EDS, including terms “Ehlers-Danlos syndrome,” “craniocervical instability,” “atlantoaxial instability,” “occipitocervical fusion,” “upper cervical instability,” “neck hyperextension,” and “ligamentous laxity.” Results All 8 patients were female (mean age 26.3 ± 6.0 years). Three patients underwent dental extractions, two had laparoscopic appendectomy, one had laparoscopic cholecystectomy, one had turbinate reduction, and one had upper endoscopy. Four cases involved prolonged neck hyperextension without intubation, whereas the remaining four involved neck hyperextension with intubation. Common presenting CCI symptoms included occipital headache, dizziness, tinnitus, neck instability (with crepitus/clunking), “brain fog” (cognitive dysfunction), and dysautonomia. Symptom onset ranged from the day of surgery (postoperative day 0) to 4 weeks postoperatively, with 5 patients (62.5%) developing symptoms in the first post-operative week. All patients were evaluated by neurosurgeons. CCI was confirmed by imaging (MRI in 7 cases, CT in 1 case). Literature review revealed no previous literature documenting CCI triggered by intubation or dental positioning in this population. Conclusions This case series provides the first evidence that hEDS patients without preexisting CCI can develop CCI due to routine perioperative neck hyperextension. Even minor neck hyperextension during common procedures (such as intubation or dental work) may precipitate symptomatic CCI in this population. Heightened perioperative caution, including gentle airway management and neutral neck positioning (with adjuncts like cervical collars when appropriate), is warranted to prevent long-term neurologic sequelae.

Objective Condylar screw fixation is a rescue technique and an alternative to the conventional configuration of occipitocervical fusion. Condylar screws are utilized when previous surgical bone removal along the supraocciput has occurred which makes anchoring of a traditional barplate technically difficult or impossible. However, the challenging dissection of C0-1 necessary for condylar screw fixation and the concerns about possible complications have, thus far, prevented the acquisition of large surgical series utilizing occipital condylar screws. In the largest case series to date, this paper aims to evaluate the safety profile and complications of condylar screw fixation for occipitocervical fusion.MethodsA retrospective safety and complication-based analysis of occipitocervical fusion via condylar screws fixation was performed.ResultsA total of 250 patients underwent occipitocervical fusions using 500 condylar screws between September 2012 and September 2018. No condylar screw pullouts, or vertebral artery impingements were observed in this series. The sacrifice of condylar veins during the dissection at C0-1 did not cause any venous stroke. Hypotrophic condyles were found in 36.4% (91 of the 250) cases and did not prevent the insertion of condylar screws. Two transient hypoglossal deficits occurred at the beginning of this surgical series and were followed by recovery a few months later. Corrective strategies were effective in preventing further hypoglossal injuries.ConclusionsThis surgical series suggests that the use of condylar screws fixation is a relatively safe and reliable option for OC fusion in both adult and pediatric patients. Methodical dissection of anatomical landmarks, intraoperative imaging, and neurophysiologic monitoring allowed the safe execution of the largest series of condylar screws reported to date. Separate contributions will follow in the future to provide details about the long-term clinical outcome of this series.