Anesthesia - Surgery is performed in general anesthesia, the patient will be fully asleep.

Patient position - Patients are positioned in the prone (lying on the stomach) position for posterior surgery on the operating table with the use of special padding to protect the face from pressure and for the anterior surgery, requires supine position(face up).

Procedure: A 5-centimeter longitudinal posterior midline incision is made. The level is confirmed with intraoperative fluoroscopy. Retractors are used and muscles are dissected subperiosteally to expose the targeted spinal level. In decompression alone surgery, the whole lamina (complete laminectomy) C1 or foramen magnum decompression by suboccipital bone removal to decompress the cervical spinal cord and brain stem adequately. For fusion surgery, depending upon the pathology C1-C2 fixation or Posterior occipito-cervical screw fixation is done using a screws and rods system. The bone graft will be placed on the sides of the rods and between the affected vertebrae to join them. The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer is closed with strong non-absorbable sutures, while is closed with subcuticular self-absorbable sutures leaving a minimal scar. The total surgery time is approximately 2 hours

Post-Operative Care
After 1-2 hours of monitoring in the recovery room, patients are shifted toward. Oral fluid intake started after 4 hours and gradually switched to a full diet. Most of the patients can stand and walk by the evening or the next morning with good pain tolerance and can be sent home accordingly in 1-2 days.

Home Care
To follow proper techniques of getting in and out of bed and walking independently. The patient should walk and stay active as much as possible and can climb stairs if required. The patient should avoid excessive rotation and extension of neck activities and avoid lifting (more than 2-3 kg).

Brace
usually not required, however one can wear a soft neck collar if the patient finds it comfortable.

Wound Care and follow up
Before leaving the hospital, a waterproof dressing is applied to the surgical wound, and the patient can take shower and will be called on the 5th post-op day for a dressing checkup and change of medication if needed.

Return to work
The patient can resume light work or driving once the pain is tolerable, and depending upon the pre-surgery neurological status in a week to 10 days. While heavy work and sports activity should be avoided for at least 3 months after the surgery.

CVJ surgery is generally considered complicated area surgery and like any other surgery, there are several risks and complications associated with are:

• Operative wound infection
• Hoarseness of voice and difficulty in swallowing
• Dural tear and CSF leakage
• Bleeding
• Risk of cardiovascular and breathing difficulty
• Need of ICU care
• Implant related complication- loose screw, broken implant
• Risk of neurological insult- quadriplegia
• Pseudoarthrosis or non-union
• Nerve root damage
• Bowel/bladder incontinence
• Deep vein thrombosis, which occurs when blood clots form in the leg

CVJ surgery is a critical surgery but very rewarding surgery and can bring a dramatic improvement in the quality of life of patients by improving myelopathy symptoms in approximately 90-95% of patients.