SPINE Volume 30, Number 5, pp 530 –535 ©2005, Lippincott Williams & Wilkins, Inc. Occipitocervical Fixation: Long-Term Results Harel Deutsch, MD, Regis W. Haid, Jr., MD, Gerald E. Rodts, Jr., MD, and Praveen V. Mummaneni, MD Study Design. The study is a retrospective review of 58 patients who underwent occipitocervical fusion between 1997 and 2001. Objectives. Our objective is to study the clinical results after occipitocervical fixation with long-term follow-up and assess factors contributing to clinical success. Methods. Data from patient charts, operative notes, physician office notes, and imaging studies were incorpo- rated in the study. Myelopathy was assessed using a Nurick scale for preoperative and postoperative evalua- tion. Fusion was assessed using cervical plane films with flexion and extension views. Results. Mean follow-up was 36 months, with all pa- tients having a greater than 1-year follow-up. The most common pathology was congenital cranial settling (41%) followed by trauma (22%) and rheumatoid arthritis (17%). Myelopathy was the most common presentation (62%) followed by pain (28%). A successful fusion occurred in 48 out of 51 patients (94%). Symptoms improved in 86% of patients, whereas 35% improved 1 Nurick grade. Compli- cations occurred in 30% of patients. The cervical wound infection rate was 5%. The rate of adjacent level degen- eration was 7%. The mortality rate was 1.7%. Conclusions. Occipitocervical instrumentation allows for very high fusion rates without the need for halo vest immobilization. All patients with successful fixation have pain resolution. Myelopathy improves in most patients, whereas one-third of patients demonstrate dramatic im- provement. Key words: occipitocervical fixation, cervical pain. Spine 2005;30:530 –535 Occipitocervical fixation is effective in treating several pathologic conditions of the craniocervical junction. Ini- tial operative techniques involved onlay fusion. Onlay fusion is highly effective but requires prolonged immobi- lization in a halo vest. The addition of rigid instrumen- tation provides immediate stability and allows patients to forego the use of a halo vest while achieving higher fusion rates. There have been numerous small studies evaluating the effectiveness of occipitocervical fixation. The articles have generally focused on surgical technique and operative complications. The goal of our study is to evaluate the clinical results with occipitocervical decom- pression and fusion including the long-term complications. Patients and Methods From 1997 to 2001, 58 patients were identified who underwent occipitocervical fusion at Emory University Hospital and Emory-Crawford-Long Hospital by the senior surgeons (R.W.H., G.E.R.). Data from patient charts, operative notes, physician office notes, and imaging studies was reviewed retro- spectively. The Nurick scale was used to assess myelopathy. 1 Occipitocervical fusion was performed only when C1–C2 fu- sion alone was not feasible. Patient mean age was 50 years (range 15–74 years) (Table 1). The female to male ratio was 1:16, although in the rheuma- toid patients, there was a 4:1 ratio. The average follow-up was 36 months (range 12– 86 months). The most common presen- tation was myelopathy. The second most common presentation was pain. The most common pathologic conditions were cra- nial settling followed by trauma (Table 2) (Figure 1). Five pa- tients had failed previous C1–C2 fusion surgery. All surgeries were done with patients positioned prone in a Mayfield head clamp. A midline incision was made with a sub- periosteal exposure of the occiput and cervical spine. Fluoros- copy was used to establish the correct cervical alignment. Lam- inectomies were performed as indicated to address neuronal compression. Occipitocervical fixation was achieved using an Ohio Medical Loop with sublaminar wires (Figure 2), Vertex (Medtronic Sofamor Danek) (Figures 3 and 4), and Summit (DePuy-AcroMed) systems (Table 3). Posterior iliac crest bone graft was harvested in all cases. A combined transoral decom- pression was performed in 25 patients. Patients undergoing a transoral approach were significantly younger (43 years) than patients undergoing only occipitocervical fusion (58 years) (P = 0.006). Transoral patients were also significantly more disabled before surgery with a mean Nurick score of 2 versus a mean Nurick score of 1 for patients undergoing occipitocervi- cal fusion (P = 0.018). Median length of stay was 7 days. Patients undergoing a transoral approach stayed in the hospital a mean of 11 days versus 5.5 days for patients undergoing only occipitocervical fixation (P = 0.03). Patients were managed in a rigid cervical collar after surgery for 3 months. Fusion was assessed using anterior-posterior and lateral radiographs with flexion and extension views. Statistical analysis of patient neurologic outcome was done using a Wilcoxon signed rank test for nonparametric paired data. The Mann-Whitney rank analysis was used to analyze the significance of fusion length and end level degeneration as well as Nurick score changes. Statistical significance was set at 0.05. Statistical analysis was performed using Microsoft Excel with Berek and Carey Data Analysis Addition (Duxbury, CA). Results Clinical Results Improvement in either pain or myelopathy subjective symptoms was reported by 51 of 58 patients (86%) (Ta- From the Department of Neurosurgery, Emory University, Atlanta, Georgia. Acknowledgment date: June 16, 2003. First revision date: October 14, 2003. Acceptance date: October 17, 2003. The device(s)/drug(s) that is/are the subject of this manuscript is/are not FDA-approved for this indication and is/are not commercially avail- able in the United States. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Harel Deutsch, MD, Assistant Professor, Department of Neurosurgery, Rush University, 1725 West Harrison Street #970, Chicago, IL 60612; E-mail: hdeutsch@cinn.org 530