Occipito-cervical fusion (OCF) is required when the junction is rendered unstable by a variety of pathological conditions including congenital abnormalities, inflammatory diseases, trauma, tumours and infections. Over the years there has been an evolution of surgical technique as implants have developed to accommodate the challenges of the occipito-cervical junction. These range from onlay bone graft techniques with halo jacket immobilisation to sophisticated instrumentation techniques. Early on, tenuous wire fixation methods were utilised but their use has decreased over time. The most common implant used for oc fusion is a plate and rod construct.