Posterior occiput-cervical fixation for metastasis to upper cervical spine Tarush Rustagi, Hazem Mashaly, Ehud Mendel Journal of Craniovertebral Junction and Spine 2019 10(2):119-126 Background: Metastasis to craniocervical area may result in instability manifesting as disabling pain, cranial nerve dysfunction, paralysis, or even death. Stabilization is required to prevent complications. Nonoperative treatment modalities are ineffective in providing stability and adequate pain relief. We present our experience of diagnosis, presentation, and surgical management for metastatic tumors to the upper cervical spine (UCS). Methods: Single-center single-surgeon database of consecutively operated posterior occiput-cervical fusion for metastasis to UCS was reviewed from 2007 to 2016. Demographics, clinical, and surgical data were collected through chart review. Pain scores based on Visual Analog Scale (VAS) and other radiological data were noted. Kaplan–Meier curve was used for survival analysis. Clinical outcomes and complications were recorded. Results: A total of 29 patients (17 females/12 males) had the mean age of 56.7 ± 13.5 (24–82). Predominant metastasis included from the breast in 9 (31.03%) cases, followed by renal in 5, melanoma in 4, and 3 each from lung and colon. Axis was involved in 24 cases (C2 body in 21, pedicle in 8 cases). Atlas was involved in 9 cases (lateral mass in 8 cases and arch in 3 cases) and occiput was involved in three cases. Average Spinal Instability Neoplastic Score was 10 ± 2.3 (7–14). Mild cord compression was seen in 7 cases. Fusion extended from occiput to C4 fusion (n = 23), C5 (n = 5), and C6 (n = 1). Average blood loss was 364.8 ± 252.1 ml and operative time was 235 ± 51.9 min. Average length of stay was 7 ± 2.8 days (3–15). VAS improved from 8.3 ± 1.5 to 1 ± 1.1 (P < 0.001). C2 angulation corrected from 2.1° ±5.3° (0°–17°) to 0.5° ±1.2° (P = 0.045). Three patients each developed cardiopulmonary complications and deep infection. The average survival was 14.5 ± 15.1 (0.15–50) months. Conclusion: C2 body is the most common site of metastasis. Occiput-cervical fusion for unstable upper cervical metastasis offers a good palliative treatment for pain relief and improved quality of life.