Occipitocervical posterior fusion itself is an uncommon cause of severe dysphagia. But occipitocervical malalignment after posterior fusion can be a cause of severe dysphagia. A 46-year-old man was referred to the department of rehabilitation medicine because of swallowing difficulty. He complained of severe dysphagia immediately after the occipitocervical posterior fusion. From the lateral view of video-fluoroscopic swallowing study (VFSS), we could conclude that the mechanical cricopharyngeal relaxation failure was a direct cause of his dysphagia and this was due to malalignment of the occipitocervical fixation. His occipitoaxial angle was fixed in hyperflexed position and this lead to the severe dysphagia and even dyspnea. After the revision operation, his dysphagia and dyspnea symptom was dramatically resolved. The occipitoaxial angle can be a useful index, which measure the anatomic relation of the occiput and the cervical vertebrae on sagittal plane, on evaluation of the swallowing function in the patient who had occipitocervical posterior fusion. (J Korean Acad Rehab Med 2010; 34: 247-251)
