Review and evolution of occipital fixation devices and techniques

Occipital-cervical (OC) fixation poses distinctive challenges due to unique craniocervical junction (CCJ) anatomy and a complex range of pathology leading to CCJ instability. There has been substantial evolution in modern OC fixation techniques since their introduction in the 1990s, each with implications on rate of fusion, range of motion, and ease of use.

We performed a manual review of OC fixation techniques via a query of the National Library of Medicine MEDLINE database between 10 September and 1 October 2025. Categories of OC fixation included sublaminar wiring and bone graft, pre-integrated and modular plate-based constructs, non-plate-based screw-rod constructs, occipital condyle screws, and C1-occipital transarticular screws.

Patient outcomes are comparable between modern plate-based and non-plate-based fixation systems, thus selection of technique is determined by surgeon preference, ease of use, and patient-specific anatomical considerations. Increasingly, modular plate-based and eyelet screw systems are gaining popularity due to their adaptability to varying anatomy, with poly-axial condylar and transarticular screws representing bail-out options in cases of suboccipital decompression or prior hardware failure due to the risk this technique poses to neurovascular structures. Future innovation may give rise to 3-D printed personalized implants for cases with complex anatomical or pathological considerations.