Cranio-vertebral junction anatomy and imaging
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Cranio-vertebral junction anatomy and imaging
- 1. CRANIO-VERTEBRALJUNCTION DR. GAURAV CHAUHAN DR. R. V. PHADKE 17.11.2015
- 4. LIGAMENTS C1-OCCIPITAL OCCIPITO-C2 C1-C2 •ANTERIORATLANTO-OCCIPITAL MEMBRANE •APICALLIGAMENT •ANTERIORATLANTO-AXIAL LIGAMENT •POSTERIORATLANTO-OCCIPITAL MEMBRANE •TECTORIALMEMBRANE •POSTERIORATLANTO-AXIAL LIGAMENT •LATERALATLANTO-OCCIPITAL LIGAMENTS •ALARLIGAMENT •TRANSVERSELIGAMENT •CRUCIATE LIGAMENT
- 6. EMBRYOLOGY
- 12. OPEN MOUTHVIEW OPEN MOUTHVIEW •ALIGNMENTOF DENS ANDATLAS •ALIGNMENTOF AXIS ANDATLAS •ATLANTOAXIALDISTANCE •OVERHANGINGATLASMARGINS??? •ATLANTOOCCIPITALJOINTAXIS ANGLE
- 13. AP VIEW AP VIEW •ALIGNMENTOF TRANSVERSEPROCESS •ALIGNMENTOF SPINOUSPROCESS •PEDICLES •SPRENGEL’S DEFORMITY
- 17. USG
- 18. CTSCAN
- 20. CRANIOMETRY
- 21. BASILAR INVAGINATION BASILAR IMPRESSION PLATYBASIA ANGLES LINES WIDE RANGES PAUCITY OF LITERATURE CRANIALSETTLING
- 22. CHAMBERLEIN LINE CHAMBERLEINLINE •SHOULD NOT PROJECT ABOVE •3 mm PERMITTED •ABOVE 7 mmABNORMAL
- 23. MC GREGORSLINE Mc GREGORLINE •DENS SHOULD NOTPROJECTABOVE •PERMITTEDLIMITIS6TO8mm
- 24. WAKENHEIM’s LINE AND ANGLE WAKENHEIM’s LINE AND ANGLE •LINESHOULDFALLTANGENTTO POSTERIORASPECTOFTIPOFDENS •IS FALLSPOST=POSTCRANIOCERVICALDISSOCIATIONANDVICEVERSA •ANGLEIFLESSTHAN 150,SUSPECTCORDCOMPRESSION •UPTO150 IN FLEXION,UPTO180IN EXTENSION
- 25. MCREELINE Mc REELINE •DENS SHOULD NOTPROJECTABOVE • LOWER OCCIPITAL PROTUBERANCE LIE BELOW THISLINE •LINE THROUGH DENS SHOULD PASS THROUGH ANT1/3RD •NORMAL19to 34mm •LESS THAN20mm= CORD COMPROMISE •MORE THAN40mmINCHIARI
- 26. HEIGHT INDEX OF KLAUS HEIGHT INDEXOF KLAUS •< THAN30= BASILARIMPRESSION •30to 36mm(TENDENCY) •AVERAGE40– 41mm
- 27. BOOGARD’SLINE ANDANGLE BOOGARD’S LINE AND ANGLE AVERAGE MAXIMUM MINIMUM 122 135 119
- 28. RANAWAT LINE • 15 mm IN MALE •13 mm IN FEMALE •IF DECREASED THEN BI •CENTRE OFC2 PEDICLE TOLINE JOINING ANT. AND POST.ARCH OFATLAS
- 29. CLARK’S STATION • ANTERIOR ARCH SHOULD LIE IN STATION I •IF ANT ARCH LIES INSTATION II OR III, THENBI
- 30. 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
- 31. DIGASTRIC LINE DIGASTIC LINE •LINEJOINING BILATERALDIGASTRICGROOVES •ATLANTOOCCIPITALJOINTSHOULD BE11+/-4 mm BELOWTHIS LINE
- 32. BIMASTOID LINE BIMASTOID LINE •LINEJOINING BILATERALMASTOIDPROCESSES •TIP OFDENSSHOULDBELESSTHAN 10mm ABOVETHIS LINE
- 33. POWER’S RATIO POWER’s RATIO •< THAN1 ALWAYS(NORMAL) •IF MORE THAN 1, SUSPECT ANT ATLANTO OCCIPITALDISSOCIATION
- 34. BULL’S ANGLE BULL’S ANGLE •< THAN10°(POSTERIORANGLE) •ANGLEB/N 10°AND13°(TENDENCYFOR BI ) •IFANGLEMORE THAN 13°(BI) •HARDPALATEPLANE •ATLASPLANE
- 35. ADI ATLANTODENTALINTERSPACE •< THAN5 mmINCHILDREN •< THAN3 mmINADULTS •DECREASED INDJD •INCREASED IN DOWNs, ARTHROPATHIES, TRAUMA,GRIESEL,RA
- 36. RULE OF 12 BAI BDI BAI BDI BAI AND BDI •BAIUPTO12mm •BDI UPTO12mm •IF MORE THAN 12mm , SUSPECT OCCIPITI - CERVICALDISSOCIATION
- 37. BASAL WECHLERANGLE AVERAGE MINIMUM MAXIMUM 137 123 152 BASAL WECHLER ANGLE •NASION,TUBERCULUMSELLA AND BASION • IFMORETHAN 152, PLATYBASIA •IFLESS THAN123,KYPHOTICSKULL •MAYOR MAYNOTBE ASSOCIATEDWITHBI
- 38. POSTERIOR CERVICAL LINE POSTERIORCERVICAL LINE •LINESHOULDBECONTINOUS, SPINOLAMINARJUNCTION JOINING •IF BREAKS,SUSPECTSUBLUXATION
- 39. ATLANTO-OCCIPITAL JOINTAXIS ANGLE ATLANTO-OCCIPITAL JOINT AXIS ANGLE •NORMALLY124to 127DEGREE •IF MORETHAN 180DEGREE,SEVEREOCCIPITALCONDYLARHYPOPLASIA
- 40. BONYANOMALIES
- 43. BASILAR ARTERY COMPRESSION BOWSTRING DEFORMITY
- 45. CONDYLUSTERTIUS
- 48. ANTERIOR ARCH OF ATLAS SPLIT ATLAS
- 49. AXIS ABSENT DENS ABSENT DENS HYPOPLASTICDENS BERGMANN’S OS ODONTOIDEUM OS ODONTOIDEUM
- 54. CHIARI 2 LEMON SIGN BANANASIGN DANGLINGCHOROID PLEXUS + HYDROCEPHALOUS ANTENATAL USG
- 57. WASP WAIST SCOLIOSIS BLOCK VERTEBRAE OPEN SPINABIFIDA SPRENGEL’SDEFORMITY
- 59. DOWN’SSYNDROME
- 60. NORMAL DOWN’S SYNDROME INCREASED ADI NARROW FORAMEN MAGNUM AOI AAI
- 62. ACHONDROPLASIA
- 63. LARGE CRANIAL VAULT SMALL SKULL BASE FLAT NOSE FRONTAL BOSSING NARROWFORAMEN MAGNUM NARROWFORAMEN MAGNUM SMALL CISTERNAMAGNA CERVICOMEDULLARYKINK HIGHUP BRAINSTEM
- 64. MUCOPOLYSACCHARIDOSIS AAI J SHAPED SELLA FORAMEN MAGNUMNARROWING DYSPLASTICCONE SHAPEDDENS
- 65. ACQUIRED LESIONS OF CVJ
- 68. PSORIATIC ARTHRITIS OSTEITIS& ENTHESITISOF DENS BONEFORMATIONAROUNDDENS & AA JOINTAAI ACCESSORYBONE FORMATION FUSIONOFZYGOAPO PHYSEALJOINTS
- 71. SUBLUXATIONS INAS AAD / AAI
- 75. JEFFERSON’S OVERHANGINGLATERALMASSESOFC1 TYPICAL4PART# 2 PART# > THAN 7 mm INCREASEDADI, DECREASEDPADI
- 77. JEFFERSON #
- 78. STEELE’s RULE OF THIRDS
- 79. # IN ARCH OF ATLAS ANTERIOR POSTERIOR MORE COMMON
- 80. RUPTURE OF TRANSVERSELIGAMENT INCREASED ADI INCREASED ADI IN JEFFERSON’S # OVERHANGING ATLAS MARGINS
- 83. MACHEFFECT FRACTURE ??? OPEN MOUTH VIEW TOMOGRAM NO FRACTURE
- 84. MACH EFFECT EXPLAINED !!!
- 85. LEVINE AND EDWARD’S CLASSIFICATION HANGMAN’S #
- 86. THE FAT “C2” SIGN FRACTUREIN BODY OF C2 VERTEBRA
- 87. LESIONS : BENIGN ANDMALIGNANT
- 88. VERTEBRAL ARTERY NORMAL HYPOPLASTIC APLASTIC FENESTRATEDMEDIAL LOOPSTRECHEDLOOP SIGN
- 89. AT THELEVEL OF ENTRYOFVERTEBRAL ARTERYINFTOF ATLAS,MEDIAL EDGE OF FORAMEN TRANSVERSARIUMTOMIDLINE AT THELEVEL OF DENSTIP,SHORTESTDISTANCEOF DENS TOEITHER VERTEBRALARTERIES AT THELEVEL OF POSTERIORARCHOF ATLAS,MEDIAL EDGE OF VERTBRALARTERYTO MIDLINE M3
Editor's Notes
- INTERNAL OCCIPITAL PROTUBERANCE AND SPHENO OCCIPITALK SYNCHONDROSIS.
- LOTS OF ARTICLES AND CHAPTERS ABOUT THE SKULL AND THE CERVICAL SPINE BUT PAUCITY OF LITERATURE ON CVJ 2ND COUNTLESS LINES AND ANGLES AND LINES HAVE BEEN GIVEN WITH WIDE RANGES VARYING BETWEEN AGE AND GENDERS, AND TO MAKE THE MATTER WORSE VARIOUS TERMINOLOGIES HAVE BEEN INTRODUCES. BASILAR INVAGINATION IS THE PRIMARY DEVELOPMENTAL ANOMALY, BASILAR IMPR
- 7 mm abovw not more than this
- 5 mm above not more than this
- ANGLE POST AXIS LINE AND CLIVAL LINE 150 IN FLEXION 180 IN EXTENSION IS DFL LESS THAN 150 , CORD COMPRESSION
- Tip of odntoid below this line Macrae’s Line: Two assessments are then made in relation to this line: the occipital bone and the odontoid process. The inferior margin of the occipital bone should lie at or below this line. In addition a perpendicular line drawn through the odontoid apex should intersect this line in its anterior quarter. When effective saggital diameter is <20 mm, neurological symptoms occur (FM stenosis). Normal diameter is around 40mm. The FM is enlarged to >50 mm in c/o Chiari malformation.
- Average (mm) -- 40-41 Minimum (mm) --- 30 A measurement < 30 mm indicates basilar impression. Values between 30 and 36 mm reflect a tendency toward basilar impression A line is drawn from the tuberculum sellae to the internal occipital protuberance. The vertical distance between this line and the apex of the odontoid is measured. (14) (Fig. 2-9)
- Boogard’s line. The basion should lie below this line Both measurements will be altered in basilar impression Boogard’s line. A line is drawn connecting the nasion to the opisthion. (15) (Fig. 2-10A) Boogard’s angle. (a) A line is drawn between the basion and the opisthion (Macrae’s line). (b) A second line is drawn from the dorsum sellae to the basion along the plane of the clivus. (c) The angle between these two lines is measured.
- 15 MM 13 MM
- Atlanto occipital joint 11 +/-4mm below this line
- Tip of odontoid less than 10 mm above this line
- If more than 1. then ant occipito atlantal dissociation In the normal individual the ratio is always < 1.
- Bull's angle <13° Radiography (Lateral) X-ray computed tomography Magnetic resonance imaging Line drawn between the posterior and anterior arch of C1. Bull's angle is the angle between this line and the hard palate plane.
- A decreased space is to be expected with advancing age because of degenerative joint disease of the atlantodental joint. abnormally widened space with reduction in the neural canal size is seen in Trauma, occipitalization, Down’s syndrome, pharyngeal infections (Grisel’s disease), and inflammatory arthropathies (e.g., ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, and Reiter’s syndrome) ATLANTODENTAL INTERSPACE. A. Normal Adult Interspace. The interspace measures < 3 mm (arrows). B. Abnormal Interspace. On flexion a patient with rheumatoid arthritis exhibits anterior translation of the atlas by 5 mm (arrows). C. Normal Childhood Interspace. The interspace measures < 5 mm (arrows). D. CT Scan, Abnormal Interspace. In this patient with rheumatoid arthritis, the atlantodental interspace is increased (arrowheads). Note the erosion at the posterior surface of the odontoid at the site of synovial tissue beneath the transverse ligament
- If more than 12 mm, the occipito cervical dissociation is present
- 125 to 143 degree,
- Posterior Cervical Line: If the drawn curve is discontinuous at any level, then an anterior or posterior displacement may be present. This line is especially useful for detecting subtle odontoid fractures and atlantoaxial subluxation (anterior), which otherwise may be easily overlooked. A disruption in the middle to lower cervical spine may also be a sign of anterolisthesis, retrolisthesis, or frank dislocation
- Atlanto-occipital joint axis angle 124 to 12 degree. If more than 180, severe occipital condyle hypoplasia
- CLIVUS CANAL ANGLE LESS THAN 150, SHORTENING OF CLIVUS, VIOLATION OF CHAMBERLEIN LINE
- ATLANTOOCCIPITAL JOINT AXIS ANGLE NRMAL 124 TO 127 DEGREE THEY GET FLAT IN HYPOPLASTIC OCCIPITAL CONDYLE
- 4%, IN BIOPSY SPECIMEN, RARE
- 0.2% ,,,RARER THAN POST ARCH
- BERGMAN OSSICLE 12 YEARS. RERMINAL OSSICLE TO THE REMAINDER OF THE DENS. OS ODONTOIDEUM....INDEPENDENT OSSEOUS STRUCTURE LYING CEPHALAD TO THE BODUY OF THE AXIS, IN POSITION OF THE DENS. SMOOTH XCORTICATED MARGINS AND HYPERTROPHIC ANT ARCH OF THE ATLS.
- ASSOCIATED WITH BI, PLATYBASIA AND ATLANTO OCCIPITAL FUSION
- NOT ASSOCIATED WITH BI, PLATYBASIA AND ATLANTO OCCIPITAL FUSION
- LEMON: INDENTATION OF FRONTAL BONE CHIARI 1 BANANA: CONTENT OF POST FOSSA DISPLACED DOWNWARDS, CISTERNA MAGNA IS OBLITERATED, AND CEREBELLUM WRAPS AROUND BRAINSTEM AS A BANANA.
- The radiographic Rigault classification 3,7: grade I: superomedial angle lower than T2 but above T4 transverse process grade II: superomedial angle located between C5 and T2 transverse process grade III: superomedial angle above C5 transverse process
- AOI, AAI in downs syndrome due to ligament laxity, altered bone shapes
- Posterior atlantodental interval (PADI) measured from the posterior border of the dens to the anterior border of the posterior tubercle. • This index may be more important because it more directly assesses the spinal canal width. • Normal range 19 –32 mm in male & 19 –30mm in females. • Below 19mm, neurological manifestations occur. The tectorial membrane and alar ligaments pr ,,,, Atlanto-occipital dissociation (AOD) injuries a,,,, basion-dens interval (BDI) >10 mm in adults 3 basion-axial interval (BAI) >12 mm in adults Powers ratio >1 (insensitive to a vertical distraction injury or posterior dissociation) atlantodental interval (ADI) >3 mm in adult males >2.5 mm in adult females Normal values are < 12mm on plain radiographs and <8.5mm on CT 1 BDI AND BAI Powers ratio is a measurement of the relationship of the foramen magnum to theatlas, used in the diagnosis of atlanto-occipital dissociation injuries. The ratio, AB/CD, is measured as the ratio of the distance in the median (midsagittal) plane between the: basion (A) and the posterior spinolaminar line of the atlas (B) and, opisthion (C) and the anterior arch of the atlas (D) Normal values are <1 on plain radiographs 1 and <0.9 on CT 2. If this ratio is >1, then the anterior atlanto-occipital dissociation should be suspected.
- relatively large cranial vault with small skull base prominent forehead with depressed nasal bridge narrowed foramen magnum cervico medullary kink relative elevation of the brainstem resulting in a large suprasellar cistern and vertically-oriented straight sinus communicating hydrocephalus (due to venous obstruction at sigmoid sinus)
- LARGE SUPRASELLAR CISTERN SMALL CISTERNA MAGNA FRONTAL BOSSING LARGE CALVARIA SMALL BASE OF SKULL NARROW FORAMEN MAGNUM VERTICAL STRAIGHT SINUS (27 TO 52) AND 55 TO 72 CERVICIOMEDUULLARY KINKING HIGH UP BRAINSTEM ENLARGED HEAD CIRCUMFERENCE OBLITERATION OF SUBARACHNOID SPACE
- AAI J SHAPED SELLA F MAGNUM NARROWING DYSPLASTIC CONE SHAPED DENS
- RA EROSION OF DENS DECREASED FACET JOIMT INCREASED ADI on flexion PANNUAS AROUND DENS INCREASED ADI IMPINGEMENT OF CERVICOMEDULLARY JUNCTION
- DENS EROSION AAI ERANAVAT INVAGINATION BASE DENS EROSION LATERAL SUBLUXATION
- VOULUMINOUS NEW BONE FORMATION FUSION OF ZYGO APOPHYSEAL JOINTS ANTERIOR TO C4 7 AAI OATEITIS AND ENTHESISTIS OF DENS BONE FORMATION AROUND ATLANTO AXIAL REGION AND DENS
- DECREASED ADI SCLEROSIS SCLEROSIS SIGNAL LOSS STIR OSTEOPHTES
- DENS EROSION CALCIFIED PSEUDOMASS OF URATE CRYSTAL BEHIND DENS’ CAN CAUSE SPINAL CORD COMPRESSION CAN CAUSE SUBLUXATION DUAL ENERGY CT SHOWING URATE CYRYSTAL
- type I fracture (~15%) impaction fracture of the occipital condyle due to axial compression stable injury type II fracture (~50%) basilar skull fracture that extends to involve the occipital condyle due to direct blow to the skull stable injury type III fracture (~35%) avulsion injury of condyle in region of alar ligament attachment due to forced contralateral bending and rotation potentially unstable injury
- IN RA AND DOWNS IN CHILDREN BECAUSE OF MORE HORIZONTAL OCCIPITAL CONDYLE FLEXION INJURY ME ANTERIOR SUBLUXATION HYPEREXTENSION INJURY ME POST SUBLUXATION CAN BE LONGITUDINAL DUISTRATCION POWERS RATION IF MORE THAN 1 === ANTERIOR SUBLUXATION WAKENHEIM NLINE IF FALLS POSTERIORLY TO DENS THEN POST SUBLUCATION ATLAS OCCIPUT DISTANCE SHOULD BE LESS THAN 5 MM ALWAYS
- The Jefferson fracture most commonly occurs as the result of axial loading on the head through the occiput, leading to a burst-type fracture of C1.
- Steele's Rule of Thirds: - canal of atlas is about 3 cm in its AP diameter; - spinal cord, odontoid process, and free space for cord are each about 1 cm in diameter; - anterior displacement of the atlas that exceeds one centimeter may jeopardize the adjacent segment of the spinal cord;
- ANTERIOR ARCH FRACTURE ONLY 2 PERCENT, ASSOCIATED WITH DENS FRACTURE POSTERIOR ARCH FRCTURE IS MORE COMMON, ASS WITH HTYPEREXTENSION
- TRANSVERSE LIGAMENT INJURY DENS SHIFTS POSTERIORLY AND COMPRESSES THE SPINAL CORDD
- Hangman fracture (also known as traumatic spondylolisthesis of axis) is a fracture which involves the pars interarticularis of C2 on both sides, and is a result of hyperextension and distraction. lassification type I: fracture with <3 mm antero-posterior deviation no angular deviation type II: fracture with >3 mm antero-posterior deviation significant angular deviation disruption of posterior longitudinal ligament type IIa: the fracture line is horizontal/oblique (instead of vertical) significant angular deviation without anterior translation type III: type I with bilateral facet joint dislocation
- Aneurysmal bone cyst of the axis This rapidly growing, expansile, multilocular lesion replacing the body of the axis proved histol METS: LUNG, BREAST, PROSTATE
- Vertebral artery (VA) injury may occur in approximately 4.1% patients during surgery at the craniovertebral junction (CVJ
- M1: TIP OD ODONTOID AND HARD PALATE LEVEL , DISTANCE OF VERTEBRAL ARTERY AND DENS M2: AT THE LEVEL OF THE ENTRY OF VA INTO THE FT OF THE ATLAS: MEDIAL EDGE OF FORAMEN TRANSVERSARIUM AND MIDLINE M3: AXIAL PLANE AT THE LEVEL OF POST ARCH OF ATLAS: MEDIAL EDGE OF VA AND MIDLINE