A series of 8 cases operated on for symptomatic basilar impression associated with occipitalization of the atlas is reported (with or without atlantoaxial dislocation). Symptoms of onset (such as the frequent association between nuchal pain and vertigo) are emphasized and analyzed in relation to the pathogenetic mechanism that underlies the multiform symptomatology of the basilar impression. The diagnostic workup for basilar impression foresees X-rays, magnetic resonance imaging and computed tomography. The most important diagnostic problem is that of considering the possible existence of such a pathology in the presence of very common symptoms such as nuchal pain and vertigo. The surgical treatment has certainly been useful both to improve and to stabilize the symptomatology mainly when there is atlantoaxial dislocation. In fact in these cases the symptomatology is more severe and progressive for the alteration of the transverse ligament of the atlas secondary to abnormal mechanical stimuli.