Occipito–cervical instability and compression at the cervico–medullary junction provides a big surgical challenge. We present 5 cases of cervico–medullary compression operated with posterior decompression and fixation along with bone grafting taken from iliac crest. Three cases had occipto–cervical congenital anomalies associated with atlanto–axial instability, one was associated with dens erosion with rheumatoid arthritis and one had odontoid fracture. Four of them showed significant canal compromise associated with neurological deficit. In 3 cases we used hartshill–ramsford loop and sub–laminar wires, in one cortical bone graft with sub–laminar wires and in one screws with contoured rods was used. All the cases showed post–operative neurological improvement and 3 patients were able to walk without support. No instance of construct failure, broken wire or laminar fracture was seen.