Unicortical purchase at and above the superior nuchal line is warranted with a low risk of intracranial venous penetration. Internal fixation devices developed in response to occipital bone variability should be considered with respect to occipital bone thickness distributions. Attention to cervical morphologic characteristics should result in higher success rates in occipitocervical arthrodesis.

Unicortical screw fixation at occipital protuberance offers acceptable pullout strength without the potential complications of bicortical screws or wire fixation.