The evolution of occipitocervical fixation and new rigid universal screw-rod construct technology has allowed secure anchorage at each level of the occipitocervical junction with the elimination of rigid external orthoses. Rigid occipitocervical instrumentation constructs have achieved higher fusion rates and less postoperative immobilization-associated complications. Outcomes have improved compared with former nonrigid instrumentation techniques; however, with advances of rigid occipitocervical stabilization capability have come new challenges, risks, and operative techniques. A thorough understanding of the relevant cervical bony and soft tissue anatomy is essential for safe implantation and a successful outcome.