Occipital Cervical Fusion

What is Occipital Cervical Fusion?

Occipital cervical fusion or Occipitocervical fusion (OCF) is a surgical procedure employed for the treatment of a variety of craniovertebral junction (CVJ) conditions such as traumatic, inflammatory, neoplastic, degenerative, infective, and congenital.

The occipital bone is a trapezoidal-shaped bone located at the back portion of the cranium (skull) and sits at the highest point of the neck. The cervical spine is the section of the vertebrae that passes through the neck. Occipitocervical fusion stabilizes the junction between the occipital bone and the cervical spine. Fixation devices such as screws and/or bone grafts may be utilized in the portion of the spine to be fused. The main objective of this fusion is to prevent an unstable joint from causing injury to the crucial brain structures at the base of the skull or the spinal cord. 

Anatomy of the Cervical Spine

The spine is made up of 33 small bones called vertebrae and is known as the spinal column or vertebral column. The cervical spine is comprised of the first 7 vertebrae (C1-C7), which support the neck and the head. The vertebrae are protected by spongy vertebral discs that are present in between them and are supported by ligaments that hold them together and surround the underlying spinal cord.

The upper cervical spine comprises of the atlas (C1) and axis (C2), which are different from the rest of the cervical vertebrae. The atlas vertebra articulates with the occiput superiorly at the atlanto-occipital joint and with the axis inferiorly at the atlantoaxial joint. Generally, the atlantoaxial joint is accountable for half of the cervical rotational movements; while the atlanto-occipital joint is responsible for half of the flexion and extension movements of the neck. 

Indications for Occipital Cervical Fusion

Occipital cervical spine fusion may be indicated to stabilize injuries and prevent fracture and spinal cord damage, and to treat misalignment of the vertebrae, herniated discs, arthritis, tumor, deformities, and infection. The most common indications for occipital cervical fusion include:

• Compressive myelopathy – abnormal compression of the spinal cord due to neurological deficits
• Basilar invagination (infolding) - developmental disorder of the craniovertebral junction
• Instability at the occipito-atlantoaxial segment - a joint between the 1st and 2nd cervical vertebrae

Preparation for Occipital Cervical Fusion

Pre-procedure preparation for occipital cervical fusion may involve the following steps:

• A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
• You will be asked if you have allergies to medications, anesthesia, or latex.
• You should inform your doctor of any medications, vitamins, or supplements that you are taking.
• You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
• You should not consume any solids or liquids at least 8 hours prior to surgery.
• You will be instructed to shower with an antibacterial soap the morning of surgery to help lower your risk of infection after surgery.
• Arrange for someone to drive you home after surgery.
• A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Occipital Cervical Fusion

The basic steps involved in the occipital cervical fusion surgery include:

• The procedure is performed through a posterior approach.
• You will be administered general anesthesia and placed in a prone position (face down) on the operating table.
• The head is fixed in position with a special device called Mayfield.
• A vertical incision is made over the occiput bone up to the external occipital protuberance (EOP) in the middle of the neck at the C1-C2 region.
• The neck muscles and soft tissues are retracted and the cervical spine is exposed for the surgery.
• X-ray imaging is employed to identify the affected intervertebral discs (C1 and C2).
• Your surgeon performs the required treatment such as removal of a tumor or posterior arch of C1/C2 causing spinal cord compression or neurological deficit to achieve decompression.
• The surface of the lamina of each vertebra to be fused is shaved off (laminectomy) to stimulate fusion through bone healing.
• In addition, small strips of bone grafts are placed over the spinal column, which aid in fusion of the bones.
• Two titanium metal rods are then fixed to either side of the vertebra with the help of two screws to achieve C1, C2 fixation and fusion with the occiput. This instrumentation stabilizes the cervical spine.
• Confirmatory X-rays may be taken to confirm proper alignment at the occipitocervical junction, posterior occipitocervical fixation and fusion, and bone graft placement.
• Finally, the retracted muscles and soft tissues are placed in their normal positions and the wound is sutured.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after occipital cervical fusion surgery may involve the following:

• You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
• Most patients may need to stay in the hospital for 2 to 3 days before discharge to home.
• You may experience pain, inflammation, and discomfort in the cervical spine area. Pain and anti-inflammatory medications are provided as needed.
• You will be given a cervical collar for neck support, comfort, and pain relief for a couple of weeks.
• Walking and moving around in bed is strongly encouraged to prevent the risk of blood clots.
• Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
• Refrain from smoking and alcohol for a specific period of time as it can negatively affect the healing process.
• Refrain from strenuous activities and lifting anything heavier than 5 pounds until the first follow-up visit. These activities include housework, yard work, gardening, mowing, etc.
• Gentle neck stretches and regular walking is recommended to improve strength and endurance after the first follow-up visit.
• Refrain from driving until you are fully fit and receive your doctor’s consent.
• Most patients can return to their normal daily routines in 3 to 4 weeks after surgery.
• A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Occipital cervical fusion is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

• Infection
• Bleeding
• Blood clots
• Anesthetic reactions
• Hardware failure
• Bone graft migration
• Neurovascular injury
• Persistent pain
• Failure of vertebral fusion