CRANIO-VERTEBRAL JUNCTION

DR. GAURAV CHAUHANDR. R. V. PHADKE

17.11.2015

ANATOMICAL TOUR

BONES AND JOINTS

LIGAMENTSC1-OCCIPITAL OCCIPITO-C2 C1-C2

• ANTERIOR ATLANTO - OCCIPITAL MEMBRANE • APICAL LIGAMENT • ANTERIOR ATLANTO-

AXIAL LIGAMENT

• POSTERIOR ATLANTO- OCCIPITAL MEMBRANE • TECTORIAL MEMBRANE

• POSTERIOR ATLANTO-AXIAL LIGAMENT

• LATERAL ATLANTO- OCCIPITAL LIGAMENTS • ALAR LIGAMENT • TRANSVERSE

LIGAMENT

• CRUCIATE LIGAMENT

TRANSVERSE LIGAMENT APICAL LIGAMENTPOSTERIOR ATLANTO

OCCIPITALMEMBRANE

ANTTERIOR ATLANTO OCCIPITALMEMBRANE

CRUCIATE LIGAMENT

TECTORIAL MEMBRANE

EMBRYOLOGY

SCLEROTOME ORIGINS OF CVJ

RADIOGRAPHIC VIEWS

LATERAL VIEWLATERAL VIEW

• ALIGNMENT • ADI• PADI• POSTERIOR VERTEBRAL LINE• ANTERIOR VERTEBRAL LINE• SPINOLAMINAR LINE• PREVERTEBRAL SPACE• CRANIOMETRIC LINES

OBLIQUE VIEWS

OBLIQUE VIEW• VERTEBRAL FORAMINA• FACET JOINTS

OPEN MOUTH VIEWOPEN MOUTH VIEW

• ALIGNMENT OF DENS AND ATLAS • ALIGNMENT OF AXIS AND ATLAS • ATLANTO AXIAL DISTANCE• OVERHANGING ATLAS MARGINS ???• ATLANTO OCCIPITAL JOINT

AXIS ANGLE

AP VIEWAP VIEW

• ALIGNMENT OF TRANSVERSE PROCESS• ALIGNMENT OF SPINOUS PROCESS• PEDICLES• SPRENGEL’S DEFORMITY

DYNAMIC VIEWSDYNAMIC VIEWS

• FLEXION, NEUTRAL AND EXTENSION• CONTRAINDICATED IN UNSTABLE PT• ADI• PADI• SUBLUXATIONS

IMAGING MODALITIES

USG

CT SCAN

MRIMRI

• SOFT TISSUE• SPINAL CORD• BONES

CRANIOMETRY

BASILAR INVAGINATIONBASILAR IMPRESSIONPLATYBASIA

ANGLESLINES

WIDE RANGES

PAUCITY OF LITERATURE

CRANIAL SETTLING

CHAMBERLEIN LINECHAMBERLEIN LINE• SHOULD NOT PROJECT ABOVE• 3 mm PERMITTED• ABOVE 7 mm ABNORMAL

MC GREGORS LINE Mc GREGOR LINE

• DENS SHOULD NOT PROJECT ABOVE• PERMITTED LIMIT IS 6 TO 8 mm

WAKENHEIM’s LINE AND ANGLE

WAKENHEIM’s LINE AND ANGLE• LINE SHOULD FALL TANGENT TO POSTERIOR ASPECT OF TIP OF DENS• IS FALLS POST = POST CRANIOCERVICAL DISSOCIATION AND VICE VERSA• ANGLE IF LESS THAN 150, SUSPECT CORD COMPRESSION• UPTO 150 IN FLEXION, UPTO 180 IN EXTENSION

MCREE LINEMc REE LINE

• DENS SHOULD NOT PROJECT ABOVE• LOWER OCCIPITAL PROTUBERANCE LIE BELOW THIS LINE• LINE THROUGH DENS SHOULD PASS THROUGH ANT 1/3RD• NORMAL 19 to 34 mm• LESS THAN 20 mm = CORD COMPROMISE• MORE THAN 40 mm IN CHIARI

HEIGHT INDEX OF KLAUSHEIGHT INDEX OF KLAUS• < THAN 30 = BASILAR IMPRESSION• 30 to 36 mm (TENDENCY)• AVERAGE 40 – 41 mm

BOOGARD’S LINE AND ANGLE

BOOGARD’S LINE AND ANGLE

AVERAGE MAXIMUM MINIMUM122 135 119

RANAWAT LINE• 15 mm IN MALE• 13 mm IN FEMALE• IF DECREASED THEN BI• CENTRE OF C2 PEDICLE TO LINE JOINING ANT. AND POST. ARCH OF ATLAS

CLARK’S STATION• ANTERIOR ARCH SHOULD LIE IN STATION I• IF ANT ARCH LIES IN STATION II OR III, THEN BI

REDLUND JONALL CRITERIA

• MGREGOR LINE AND DISTAL MARGIN OF C2• 34 mm IN MALES AND 29 mm IN FEMALES•IF LESS THAN THAT, THEN BI

DIGASTRIC LINE

DIGASTIC LINE• LINE JOINING BILATERAL DIGASTRIC GROOVES• ATLANTO OCCIPITAL JOINT SHOULD BE 11 +/- 4 mm BELOW THIS LINE

BIMASTOID LINE

BIMASTOID LINE• LINE JOINING BILATERAL MASTOID PROCESSES• TIP OF DENS SHOULD BE LESS THAN 10 mm ABOVE THIS LINE

POWER’S RATIOPOWER’s RATIO

• < THAN 1 ALWAYS (NORMAL)• IF MORE THAN 1, SUSPECT ANT ATLANTO OCCIPITAL DISSOCIATION

BULL’S ANGLEBULL’S ANGLE

• < THAN 10° (POSTERIOR ANGLE)• ANGLE B/N 10° AND 13° (TENDENCY FOR BI )• IF ANGLE MORE THAN 13° (BI)• HARD PALATE PLANE• ATLAS PLANE

ADIATLANTO DENTAL

INTERSPACE• < THAN 5 mm IN CHILDREN• < THAN 3 mm IN ADULTS• DECREASED IN DJD• INCREASED IN DOWNs, ARTHROPATHIES, TRAUMA, GRIESEL, RA

RULE OF 12BAIBDI

BAI

BDI

BAI AND BDI• BAI UPTO 12 mm• BDI UPTO 12 mm• IF MORE THAN 12mm , SUSPECT OCCIPITI -CERVICAL DISSOCIATION

BASAL WECHLER ANGLEAVERA

GEMINIMU

MMAXIM

UM137 123 152BASAL WECHLER ANGLE

• NASION, TUBERCULUM SELLA AND BASION• IF MORE THAN 152 , PLATYBASIA• IF LESS THAN 123, KYPHOTIC SKULL• MAY OR MAY NOT BE ASSOCIATED WITH BI

POSTERIOR CERVICAL LINE

POSTERIOR CERVICAL LINE• LINE SHOULD BE CONTINOUS , SPINO LAMINAR JUNCTION JOINING• IF BREAKS, SUSPECT SUBLUXATION

ATLANTO-OCCIPITAL JOINT AXIS ANGLE

ATLANTO-OCCIPITAL JOINT AXIS ANGLE

• NORMALLY 124 to 127 DEGREE• IF MORE THAN 180 DEGREE, SEVERE OCCIPITAL CONDYLAR HYPOPLASIA

BONY ANOMALIES

ATLANTO OCCIPITAL ASSIMILATION

PARTIAL FUSION

COMPLETE FUSION

COMPLETE FUSION

PLATYBASIABASILAR INVAGINATION

PLATYBASIA

BASILAR INVAGINATION

BASILAR ARTERY COMPRESSION BOW STRING DEFORMITY

BASIOCCIPUT HYPOPLASIA

CONDYLUS TERTIUS

HYPOPLASTIC OCCIPITAL CONDYLE

FLAT ATLANTO OCCIPITAL JOINT AXIS ANGLE

POSTERIOR ATLAS DEFECTS

A

B

C

D

E

ANTERIOR ARCH OF ATLAS

SPLIT ATLAS

AXIS

ABSENT DENS

ABSENT DENS HYPOPLASTIC DENS

BERGMANN’S

OS ODONTOIDEUM

OS ODONTOIDEUM

AXISBERGMANN’S

OS ODONTOIDEUM

HYPOPLASTIC DENS

BIFID DENSI II III

CONGENITAL LESIONS OF CVJ

CHIARI 1

TONSILLAR HERNIATION

FM CROWDING

SYRINX

CHIARI 2

TONSILLAR PLUS BRAINSTEMHERNIATION

MENINGOMYELOCELE

HYDROCEPHALOUS

CHIARI 2

LEMON SIGN

BANANA SIGN

DANGLING CHOROID PLEXUS + HYDROCEPHALOUS

ANTENATAL USG

“KLIPPEL FEIL SYNDROME”

BLOCK VERTEBRAE

ATLANTO OCCIPITAL ASSIMILATION

ATLANTO OCCIPITAL ASSIMILATION

BLOCK VERTEBRAE

WASP WAIST

SCOLIOSIS

BLOCK VERTEBRAE

OPEN SPINA BIFIDA

SPRENGEL’S DEFORMITY

SPRENGEL’S DEFORMITY

SYRINX

HEMIVERTEBRA

CHIARI MALFORMATION

OMOVERTEBRAL BAR

DOWN’S SYNDROME

NORMAL

DOWN’S SYNDROME

INCREASED ADI

NARROW FORAMEN MAGNUM

AOI

AAI

BDI

BAIPADI

POWER’R RATIO

ACHONDROPLASIA

LARGE CRANIAL VAULTSMALL SKULL BASEFLAT NOSEFRONTAL BOSSING

NARROW FORAMEN MAGNUM

NARROW FORAMEN MAGNUMSMALL CISTERNA MAGNACERVICOMEDULLARY KINKHIGH UP BRAIN STEM

MUCOPOLYSACCHARIDOSIS

AAI

J SHAPED SELLA

FORAMEN MAGNUM NARROWING

DYSPLASTIC CONE SHAPED DENS

ACQUIRED LESIONS OF CVJ

RHEUMATOID

ARTHRITISDENS EROSION

DECREASED FACET JOINT SPACE PANNUS AROUND DENS

AADBONY EROSIONLATERAL TRANSLATION

DENS EROSION AADDECREASED PADI BASILAR

INVAGINATION

DENS EROSION AXIS EROSION

PSORIATIC ARTHRITIS

OSTEITIS & ENTHESITIS OF DENS

BONE FORMATION AROUND DENS & AA JOINTAAI

ACCESSORY BONE FORMATIONFUSION OF ZYGOAPOPHYSEAL JOINTS

DEGENERATIVE JOINT DISEASE

OSTEOPHYTOSIS

OSTEOPHYTOSIS

DECREASED ADI

SCLEROSIS

GOUT

DENS EROSION

CALCIFIED PSEUDOMASS

DUAL ENERGY CTCALCIUM = BLUEURATE = GREEN

SUBLUXATIONS IN AS

AAD / AAI

TRAUMATIC LESIONS

OF CVJ

OCCIPITAL CONDYLE #“ANDERSON’S”

I

II

III

ATLANTO OCCIPITAL INSTABILITY

ANTERIOR SUBLUXATION

↑ed BDI

POSTERIOR SUBLUXATION

JEFFERSON’S

OVERHANGING LATERAL MASSES OF C1TYPICAL 4 PART #

2 PART #

> THAN 7 mm

INCREASED ADI, DECREASED PADI

JEFFERSON’S FRACTURE

JEFFERSON #

STEELE’s RULE OF THIRDS

# IN ARCH OF ATLAS

ANTERIOR

POSTERIORMORE COMMON

RUPTURE OF TRANSVERSE LIGAMENT

INCREASED ADI

INCREASED ADI INJEFFERSON’S #

OVERHANGING ATLAS MARGINS

DICKMAN CLASSIFICATION

ANDERSON AND D’ALONZO CLASSIFICATIONODONTOID #

III

III

MACH EFFECT

FRACTURE ??? OPEN MOUTH VIEW

TOMOGRAMNO FRACTURE

MACH EFFECT EXPLAINED !!!

LEVINE AND EDWARD’S CLASSIFICATION

HANGMAN’S #

THE FAT “C2” SIGNFRACTURE IN BODY OF C2

VERTEBRA

LESIONS : BENIGN AND MALIGNANT

VERTEBRAL ARTERYNORMAL HYPOPLASTIC APLASTIC

FENESTRATEDMEDIAL LOOPSTRECHED LOOP SIGN

AT THE LEVEL OF ENTRY OF VERTEBRAL ARTERY IN FT OF ATLAS, MEDIAL EDGE OF FORAMEN TRANSVERSARIUM TO MIDLINE

AT THE LEVEL OF DENS TIP, SHORTEST DISTANCE OF DENS TO EITHER VERTEBRAL ARTERIES

AT THE LEVEL OF POSTERIOR ARCH OF ATLAS, MEDIAL EDGE OF VERTBRAL ARTERY TO MIDLINE

M3