Background

Occipitocervical fusion (OCF) is a widely utilized procedure for stabilizing the craniocervical junction in cases of trauma, congenital malformation, inflammatory disease, and other causes of upper cervical instability. Although the transition from early wiring techniques to modern screw-rod systems has improved biomechanical stability and fusion rates, OCF continues to present unique physiological challenges due to the complexity of the occiput–C2 relationship. Recent studies published between 2020 and 2025 provide crucial insight into evolving surgical techniques and the spectrum of postoperative complications that accompany this procedure.

A contemporary clinical series by Faraj et al. (2025) demonstrated excellent radiographic and clinical outcomes associated with modern rigid instrumentation. In their cohort of 45 patients treated with screw-rod constructs, the authors reported a 100% fusion rate, substantial reduction in neck pain, and improvement in myelopathic symptoms, with no vascular injuries or catastrophic hardware failures. Their findings indicate that when performed with meticulous preoperative planning, neuromonitoring, and precise anatomical screw placement, OCF can achieve high levels of procedural safety. These results reflect advances in surgical technology and technique that have significantly reduced some of the historical morbidity associated with occipitocervical stabilization.

Despite these advances, comparative data suggest that OCF still carries a higher overall morbidity burden than other upper cervical fusion strategies. Uotani et al. (2025) conducted a multicenter retrospective study comparing outcomes between OCF and atlantoaxial (AA) fusion in 90 patients treated over a 12-year period. They found that patients undergoing OCF experienced significantly more postoperative complications—39.5% compared to 11.5% in the AA group—and a markedly higher rate of revision surgery (23.7% vs. 3.8%). Although operative times were longer for OCF, blood loss was similar between cohorts. The authors concluded that AA fusion should be preferred whenever anatomically feasible, noting that OCF is often reserved for irreducible atlantoaxial dislocations, os odontoideum, or cases with anatomical anomalies that preclude C1–2 fixation. Their work highlights that the greater mechanical complexity of OCF continues to manifest as higher postoperative risk even in the era of improved instrumentation.

Airway complications represent another critical dimension of postoperative risk in OCF. In a systematic review of 429 patients, Khan et al. (2025) identified serious respiratory or airway adverse events (RAEs) in 11.7% of cases. These included respiratory failure, delayed extubation, and upper-airway obstruction, with failed extubation occurring in 58% of affected individuals and failed reintubation in 61%. Notably, nearly one-third of these patients ultimately required tracheostomy. Congenital etiologies were overrepresented among those experiencing RAEs, and pediatric patients demonstrated higher rates of persistent airway compromise compared with adults. Khan and colleagues emphasized the need for standardized airway protocols, preoperative risk stratification, and coordinated postoperative monitoring—particularly because airway collapse or edema may be precipitated or worsened by the mechanical realignment achieved during OCF. Although serious RAEs remain relatively infrequent, their lethality and the high rate of reintubation failure underscore their importance in perioperative planning.

Beyond airway compromise, dysphagia is one of the most common and functionally significant complications associated with OCF. Chen et al. (2025), in a retrospective analysis of 43 patients, found that 39.5% developed postoperative dysphagia and 25.6% exhibited persistent symptoms at one year. Using detailed radiographic measurements, the authors demonstrated that reductions in the pharyngeal inlet angle (PIA) strongly predicted postoperative dysphagia, with a threshold of approximately an 8° decrease associated with substantially higher risk. Changes in occipitocervical angles and narrowing of the oropharyngeal airway space were also implicated. Chen and colleagues interpreted dysphagia as a multifactorial phenomenon arising from both static structural realignment of the craniocervical junction and dynamic alterations in airway mechanics during swallowing. Their findings support growing consensus that optimal sagittal alignment—particularly maintenance of physiological O–C2 orientation—is essential to minimizing postoperative swallowing dysfunction. Persistent dysphagia after OCF can significantly impair nutritional intake, quality of life, and may require prolonged rehabilitative therapy.

Taken together, these recent studies demonstrate that although OCF is highly effective at achieving fusion and neurological improvement when performed with modern techniques, it remains associated with meaningful risks. The discrepancy between low complication rates in single-center series (e.g., Faraj et al., 2025) and higher complication and revision rates in multicenter analyses (e.g., Uotani et al., 2025) suggests that institutional experience, patient selection, and surgical expertise strongly influence outcomes. Furthermore, airway compromise and dysphagia—highlighted by Khan et al. (2025) and Chen et al. (2025)—remain significant contributors to postoperative morbidity and require structured perioperative management.

The evidence collectively reinforces several clinical imperatives: the need for meticulous preoperative planning of sagittal alignment, especially minimizing reductions in PIA; consideration of AA fusion whenever anatomically appropriate; proactive airway evaluation and extubation planning in high-risk populations; and continued refinement of surgical protocols that minimize soft-tissue disruption. As research advances, prospective multicenter studies incorporating dynamic swallowing assessment, long-term hardware surveillance, and standardized perioperative airway pathways will be essential to further reduce the morbidity burden of OCF and enhance patient safety.

References

Faraj, M., et al. (2025). Advancements in occipitocervical fusion: Biomechanical and clinical outcomes. Surgical Neurology International. https://surgicalneurologyint.com/wp-content/uploads/2025/02/13384/SNI-16-46.pdf

Khan, M., et al. (2025). Occipitocervical fusion and serious airway adverse events: A systematic review. Journal of Clinical Neuroscience. https://www.sciencedirect.com/science/article/pii/S0967586825002115

Uotani, K., et al. (2025). More postoperative complications and revision surgery after occipitocervical fusion than after atlantoaxial fusion: A retrospective multicenter cohort study. Asian Spine Journal. https://www.asianspinejournal.org/upload/pdf/asj-2024-0374.pdf

Chen, Y., et al. (2025). Risk factors and prognosis analysis of dysphagia after occipitocervical fusion: A retrospective study of 43 cases. Journal of Orthopaedic Surgery and Research. https://josr-online.biomedcentral.com/articles/10.1186/s13018-025-05516-6

Key Takeaways

• Modern OCF is biomechanically reliable, with studies reporting 100% fusion rates and strong neurological improvement when performed with contemporary screw-rod systems.

• OCF has significantly higher complication and revision rates than atlantoaxial fusion, making AA fusion the preferred option whenever anatomically possible.

• Serious airway complications occur in ~12% of OCF cases, with high rates of failed extubation and frequent need for tracheostomy—especially in pediatric and congenital-instability patients.

• Postoperative dysphagia is common, affecting nearly 40% of patients and often persisting beyond 1 year.

• Sagittal alignment changes—particularly reductions in pharyngeal inlet angle—are the strongest predictors of dysphagia, underscoring the need for careful intraoperative positioning.

• OCF outcomes are highly sensitive to surgical technique, alignment preservation, and institution-level expertise.

• Overall, OCF should be performed selectively, with meticulous planning and enhanced airway precautions to minimize complications.

Prepared by: Aritro Ray, InsightLab (InclusiVibe Foundation)
Inquiries: research@inclusivibe.org

How to cite
InclusiVibe Foundation, InsightLab. Technical Brief No. X: Complications Of Occipitocervical Fusion Surgery. Version 1.1, Published 2025-12-10 (Updated 2025-12-15).

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