The document discusses the anatomy, classification, and imaging of cervical vertebral anomalies. It describes the following key points:
1. The cervical vertebrae have complex articulations and ligaments that allow flexion, extension, and rotation. Common anomalies involve bony fusions or ligamentous laxity.
2. Anomalies are classified as congenital bony anomalies, soft tissue anomalies like Chiari malformation, or developmental/acquired issues. Atlantoaxial instability and basilar invagination are frequently discussed anomalies.
3. Imaging plays an important role in evaluation. Measurements like Chamberlain's line and Atlanto-dens interval on radiographs help characterize anomalies and risk of cord compression.
This document provides an overview of the anatomy, classification, and clinical features of craniovertebral junction anomalies. It begins by describing the normal anatomy of the occiput-C1-C2 articulations and ligaments. It then discusses various congenital and acquired bony and soft tissue anomalies that can affect the craniovertebral junction, including occipitalization, basilar invagination, atlantoaxial instability, and dens dysplasia. The document also outlines methods for evaluating craniovertebral junction anomalies using radiography, CT, MRI, and craniometric measurements. It concludes by describing clinical signs and symptoms as well as treatments for different types of craniovertebral junction abnormalities.
1) The document discusses injuries at the occipitocervical junction, including classifications of various injuries such as atlanto-occipital dissociation, transverse ligament injuries, rotatory C1-C2 subluxations, and fractures of the occipital condyle, C1, and C2.
2) Evaluation involves imaging such as CT, which is more sensitive than radiographs, to assess injuries and instability based on measurements. Management depends on the specific injury but may include immobilization in a collar, halo vest, or surgery such as occipitocervical fusion.
3) Occipitocervical fusion techniques are described, including use of rods, cables,
This document discusses the anatomy, imaging, classification, and treatment of various cervical vertebral anomalies. It begins with an overview of the normal anatomy of the atlantoaxial joint and landmarks seen on imaging. It then discusses various congenital and acquired bony and soft tissue anomalies that can occur in this region, including platybasia, basilar invagination, occipitalization of the atlas, and atlantoaxial dislocation. Imaging criteria and classifications for these conditions are provided. Common associated findings like Chiari malformation and syringomyelia are also mentioned. The document concludes with sections on clinical presentation and evaluation of these cervical vertebral anomalies.
CRANIOVERTEBRAL JUNCTION ANATOMY, CRANIOMETRY, ANAMOLIES AND RADIOLOGY dr sum...SUMIT KUMAR
The craniovertebral junction (CVJ) refers anatomically to the occiput, atlas, axis, and their articulations and ligaments. It is a complex region forming the transition between the skull and upper cervical spine.
The document describes the normal anatomy of the CVJ bones including the occiput, atlas, and axis. It discusses the important ligaments including the occipitoatlantoaxial ligaments. Key radiological measurements and lines used to evaluate the CVJ are presented, along with classification of various congenital and acquired CVJ anomalies and their imaging appearance. Basilar invagination, basilar impression, and platybasia are distinguished.
Craniovertebral juction 1 by dr mohammad mushtaqdrmushtaq22
This document discusses abnormalities of the craniovertebral junction (CVJ). It begins by defining the anatomical structures that make up the CVJ. It then covers the embryology and normal anatomy, including range of motion measurements. Radiological assessment criteria are outlined. Various congenital and acquired disorders are described such as basilar invagination and atlantoaxial subluxation. Specific conditions involving the occiput, atlas, and odontoid are also detailed.
CVJ.Ghty.24thoct2010.ppt sms medical collegedineshdandia
This document discusses imaging of the cranio-vertebral junction. It begins by describing the key anatomical structures in the CV junction, including the occiput, atlas, axis, and their ligaments. It then covers the embryology and normal anatomy and biomechanics of the atlantoaxial joint. The document discusses various imaging modalities for evaluating the CV junction, including plain radiographs, CT, MRI, and angiography. It also outlines common congenital and acquired disorders of the CV junction, including basilar invagination, atlantoaxial subluxation, and atlantoaxial rotatory fixation. Key diagnostic measurements and classifications of abnormalities are provided.
The craniovertebral junction consists of the occiput, atlas, axis, and connecting ligaments. It is a transition zone between the mobile cranium and spinal column. Common anomalies include occipitalization of the atlas, basilar invagination, atlantoaxial dislocation, and platybasia. Radiological assessment involves measurements of angles and distances on plain radiographs and CT/MRI to evaluate for abnormalities. Key measurements include the Chamberlain's line, McGregor's line, and posterior atlantodental interval.
This document discusses the craniovertebral junction (CVJ), which refers anatomically to the occiput, atlas, and axis vertebrae and their articulations. It describes the anatomy, embryology, biomechanics, imaging modalities including conventional radiography and MRI, and various measurements used to evaluate the CVJ. Common congenital and acquired abnormalities are also discussed, including basilar invagination, platybasia, assimilation of the atlas, and atlantoaxial instability. Imaging plays an important role in identifying bony and soft tissue anomalies, instability, and spinal canal compromise or cord compression.
This document provides an overview of the anatomy, classification, and clinical features of craniovertebral junction anomalies. It begins by describing the normal anatomy of the occiput-C1-C2 articulations and ligaments. It then discusses various congenital and acquired bony and soft tissue anomalies that can affect the craniovertebral junction, including occipitalization, basilar invagination, atlantoaxial instability, and dens dysplasia. The document also outlines methods for evaluating craniovertebral junction anomalies using radiography, CT, MRI, and craniometric measurements. It concludes by describing clinical signs and symptoms as well as treatments for different types of craniovertebral junction abnormalities.
1) The document discusses injuries at the occipitocervical junction, including classifications of various injuries such as atlanto-occipital dissociation, transverse ligament injuries, rotatory C1-C2 subluxations, and fractures of the occipital condyle, C1, and C2.
2) Evaluation involves imaging such as CT, which is more sensitive than radiographs, to assess injuries and instability based on measurements. Management depends on the specific injury but may include immobilization in a collar, halo vest, or surgery such as occipitocervical fusion.
3) Occipitocervical fusion techniques are described, including use of rods, cables,
This document discusses the anatomy, imaging, classification, and treatment of various cervical vertebral anomalies. It begins with an overview of the normal anatomy of the atlantoaxial joint and landmarks seen on imaging. It then discusses various congenital and acquired bony and soft tissue anomalies that can occur in this region, including platybasia, basilar invagination, occipitalization of the atlas, and atlantoaxial dislocation. Imaging criteria and classifications for these conditions are provided. Common associated findings like Chiari malformation and syringomyelia are also mentioned. The document concludes with sections on clinical presentation and evaluation of these cervical vertebral anomalies.
CRANIOVERTEBRAL JUNCTION ANATOMY, CRANIOMETRY, ANAMOLIES AND RADIOLOGY dr sum...SUMIT KUMAR
The craniovertebral junction (CVJ) refers anatomically to the occiput, atlas, axis, and their articulations and ligaments. It is a complex region forming the transition between the skull and upper cervical spine.
The document describes the normal anatomy of the CVJ bones including the occiput, atlas, and axis. It discusses the important ligaments including the occipitoatlantoaxial ligaments. Key radiological measurements and lines used to evaluate the CVJ are presented, along with classification of various congenital and acquired CVJ anomalies and their imaging appearance. Basilar invagination, basilar impression, and platybasia are distinguished.
Craniovertebral juction 1 by dr mohammad mushtaqdrmushtaq22
This document discusses abnormalities of the craniovertebral junction (CVJ). It begins by defining the anatomical structures that make up the CVJ. It then covers the embryology and normal anatomy, including range of motion measurements. Radiological assessment criteria are outlined. Various congenital and acquired disorders are described such as basilar invagination and atlantoaxial subluxation. Specific conditions involving the occiput, atlas, and odontoid are also detailed.
CVJ.Ghty.24thoct2010.ppt sms medical collegedineshdandia
This document discusses imaging of the cranio-vertebral junction. It begins by describing the key anatomical structures in the CV junction, including the occiput, atlas, axis, and their ligaments. It then covers the embryology and normal anatomy and biomechanics of the atlantoaxial joint. The document discusses various imaging modalities for evaluating the CV junction, including plain radiographs, CT, MRI, and angiography. It also outlines common congenital and acquired disorders of the CV junction, including basilar invagination, atlantoaxial subluxation, and atlantoaxial rotatory fixation. Key diagnostic measurements and classifications of abnormalities are provided.
The craniovertebral junction consists of the occiput, atlas, axis, and connecting ligaments. It is a transition zone between the mobile cranium and spinal column. Common anomalies include occipitalization of the atlas, basilar invagination, atlantoaxial dislocation, and platybasia. Radiological assessment involves measurements of angles and distances on plain radiographs and CT/MRI to evaluate for abnormalities. Key measurements include the Chamberlain's line, McGregor's line, and posterior atlantodental interval.
This document discusses the craniovertebral junction (CVJ), which refers anatomically to the occiput, atlas, and axis vertebrae and their articulations. It describes the anatomy, embryology, biomechanics, imaging modalities including conventional radiography and MRI, and various measurements used to evaluate the CVJ. Common congenital and acquired abnormalities are also discussed, including basilar invagination, platybasia, assimilation of the atlas, and atlantoaxial instability. Imaging plays an important role in identifying bony and soft tissue anomalies, instability, and spinal canal compromise or cord compression.
This document discusses evaluation and management of craniocervical dissociation and atlantoaxial injuries. It covers anatomy of the craniocervical junction, mechanisms of injury, classification systems, diagnosis using imaging, and treatment considerations including traction, fusion techniques. Key points are stability from skull to axis ligaments, most common injury is hyperextension with lateral flexion, and treatment depends on injury type and may involve traction or anterior-posterior fusion.
This document discusses osteonecrosis, also known as avascular necrosis or bone infarction. It causes bone death due to loss of blood supply. Common sites are the femoral head, humeral head, and distal femur. Symptoms depend on location and cause, and may include pain, reduced range of motion, and muscle atrophy. Causes include trauma, corticosteroid use, alcoholism, and idiopathic factors. Diagnosis involves x-rays, MRI, and bone scans. MRI provides sensitive detection and staging using Mitchell classification. Treatment depends on severity but may include decompression, osteotomy, or hip replacement in advanced cases.
The craniovertebral junction refers to the occiput, atlas, and axis vertebrae and their articulations and ligaments. It is a complex anatomical region forming the transition between the skull and cervical spine. Common craniovertebral junction anomalies include occipitalization of the atlas, basilar invagination, atlantoaxial dislocation, and dens dysplasia. These anomalies can be developmental, post-traumatic, or acquired. Imaging studies including X-rays, CT, MRI are used to classify and evaluate the anomalies. Treatment may involve surgery such as fusion if the anomaly causes spinal cord compression.
1. Spinal cord injuries are commonly caused by motor vehicle accidents, falls, and sports. The cervical spine is most frequently injured.
2. Initial evaluation involves stabilizing the patient with a cervical collar and assessing for neurological deficits. Imaging such as X-rays and CT/MRI are used to classify fractures and guide treatment.
3. Treatment depends on the fracture type but may involve halo immobilization, surgery to stabilize fractures or decompress the spinal cord, or bracing for stable injuries. The goal is to restore spinal alignment and prevent further neurological injury.
This document discusses the anatomy, classification, treatment, and complications of proximal femoral fractures. It begins by covering the anatomy of the proximal femur and blood supply. It then discusses the AO classification system and Garden classification for femoral neck fractures. Treatment options are presented for different fracture types, including internal fixation and hemiarthroplasty. Complications of various treatments like nonunion and avascular necrosis are also summarized. Studies comparing treatments like screw fixation versus hemiarthroplasty in elderly patients are reviewed.
Evaluation of Spinal Injury & Emergency ManagementAtif Shahzad
This document provides information on spinal injuries, including:
- Traumatic spinal cord injuries result in 12,000 new cases per year in the US. Most injuries occur in men aged 16-30 from vehicle crashes, falls, or sports.
- Injuries are categorized by location (cervical, thoracic, lumbar), stability (stable or unstable), and neurological status (complete or incomplete paralysis).
- Initial treatment follows ATLS protocols to stabilize the spine and assess airway, breathing, circulation, disability, and exposure. Advanced imaging can further evaluate bone and neurological injuries.
The document discusses injuries to the acromioclavicular (AC) joint and sternoclavicular (SC) joint. It describes the anatomy, mechanisms of injury, clinical evaluation, classification systems, treatment approaches, and potential complications for each joint. AC joint injuries are more common and typically result from direct trauma, while SC joint injuries are rare but can cause serious issues due to nearby vital structures. Treatment involves rest, immobilization, and sometimes surgery depending on the severity of the injury.
Congenital anomalies and Normal skeletal variants- Cervical spineSanal Kumar
The document discusses several congenital anomalies and normal variants of the cervical spine, including:
- Platybasia, which is flattening of the skull base angle. It can occur alone or with skeletal dysplasias. Most cases are asymptomatic.
- Basilar invagination, where the upper cervical vertebrae are positioned too far superiorly in relation to the skull base. It can be primary/congenital or secondary due to bone disease. Symptoms typically begin in the third to fourth decade of life.
- Occipitalization of the atlas, the most common craniocervical junction anomaly, is failure of segmentation of the atlas from the occiput.
This document discusses imaging of the cranio-vertebral junction. It begins by defining the cranio-vertebral junction and its key anatomical parts. It then discusses various imaging modalities for evaluating the CV junction, including plain radiographs, CT, MRI, and angiography. Specific abnormalities that can be seen include basilar invagination, atlantoaxial subluxation, occipital anomalies, and os odontoideum. Measurement lines and angles used in evaluation are also defined.
Supracondylar fractures of the humerus are the most common elbow injuries in children, accounting for about 60% of cases, and involve the area just above the elbow. These fractures are classified into 3 types - Type I is nondisplaced, Type II is displaced with an intact posterior cortex, and Type III is completely displaced with no cortical contact. Treatment involves closed or open reduction and pin fixation or casting depending on the fracture type and stability.
Atlantoaxial injuries can cause serious neurologic problems if not properly treated. Rotatory subluxation of C1 on C2 is the most common type and results from trauma or infection that disrupts the transverse atlantal ligament. Anterior subluxation involves displacement of C1 forward on C2 due to ligament disruption or odontoid process abnormalities. Fractures of C1 and C2 can also occur from trauma and require evaluation to assess stability and neurologic involvement. Treatment depends on the specific injury but may involve traction, immobilization, or fusion surgery to prevent further neurologic damage.
Spinal cord injuries are commonly caused by motor vehicle accidents, falls, and sports. The cervical spine is most commonly injured, especially between C5-C6. Plain films and advanced imaging can help evaluate injuries. Flexion injuries risk paralysis and require stabilization to prevent further injury. Compression fractures are generally stable with rest, while burst fractures may require surgery if unstable.
This document discusses scoliosis, defined as a lateral curvature of the spine greater than 10 degrees. It covers the causes of scoliosis including idiopathic, congenital, post-traumatic, and those associated with various medical conditions. The patterns and types of scoliosis like infantile, juvenile, adolescent, and congenital are described. Clinical and radiological findings, treatment options like observation, bracing, and surgery, and examples of scoliosis cases are summarized.
This document discusses fractures that require special attention due to their location or potential to be overlooked. It identifies two main groups - fractures of the ribs, scapula, Lisfranc joint, cervicothoracic junction, and posterior spinal elements, and fractures of the scaphoid, radial head, and femoral neck. It emphasizes the importance of optimal imaging like CT scans to detect these fractures, and provides guidance on imaging techniques and views needed to properly evaluate common fracture sites.
Common lower limb injuries include fractures, dislocations, and subluxations of bones or joints. Posterior hip dislocations are the most common type of hip dislocation, often caused by an axial load on the flexed and adducted hip. They are diagnosed via x-ray and treated initially with closed reduction and immobilization. Complications can include avascular necrosis, stiffness, and late onset osteoarthritis. Femoral neck fractures are also common in the elderly and are classified using the Garden system to determine appropriate treatment.
This document discusses the anatomy, landmarks, measurements, common anomalies, syndromes, and injuries of the craniovertebral junction. It begins with a brief description of the craniovertebral junction's development and components. It then outlines several key anatomical landmarks and measurements used to evaluate the region on imaging. The remainder of the document details various congenital anomalies, developmental abnormalities, syndromes, and acquired conditions that can affect the craniovertebral junction.
The document provides an overview of the anatomy and pathologies of the craniovertebral junction (CVJ). It begins with the normal anatomy and embryological development of the CVJ. It then discusses the most common congenital malformations including assimilation, platybasia, basilar invagination, and abnormalities of the occiput, atlas, and axis. Finally, it reviews acquired disorders, associated syndromes like Chiari malformations and Klippel-Feil syndrome, and imaging techniques for evaluating the CVJ.
A 35-year-old male patient previously underwent intestinal obstruction surgery and was given a bowel diversion. He has now returned to the emergency department. The patient's prior procedure and current condition need to be identified to determine the appropriate management approach and understand the potential indications and complications.
This document summarizes primary and secondary liver malignancies, their management, and principles of liver resection. It covers hepatocellular carcinoma (HCC), the most common primary liver cancer, risk factors, presentation, diagnosis, staging, and treatment options. Intrahepatic cholangiocarcinoma and metastatic tumors to the liver are also discussed. Surgical resection is the main curative treatment for early-stage HCC and intrahepatic cholangiocarcinoma when possible.
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This document discusses evaluation and management of craniocervical dissociation and atlantoaxial injuries. It covers anatomy of the craniocervical junction, mechanisms of injury, classification systems, diagnosis using imaging, and treatment considerations including traction, fusion techniques. Key points are stability from skull to axis ligaments, most common injury is hyperextension with lateral flexion, and treatment depends on injury type and may involve traction or anterior-posterior fusion.
This document discusses osteonecrosis, also known as avascular necrosis or bone infarction. It causes bone death due to loss of blood supply. Common sites are the femoral head, humeral head, and distal femur. Symptoms depend on location and cause, and may include pain, reduced range of motion, and muscle atrophy. Causes include trauma, corticosteroid use, alcoholism, and idiopathic factors. Diagnosis involves x-rays, MRI, and bone scans. MRI provides sensitive detection and staging using Mitchell classification. Treatment depends on severity but may include decompression, osteotomy, or hip replacement in advanced cases.
The craniovertebral junction refers to the occiput, atlas, and axis vertebrae and their articulations and ligaments. It is a complex anatomical region forming the transition between the skull and cervical spine. Common craniovertebral junction anomalies include occipitalization of the atlas, basilar invagination, atlantoaxial dislocation, and dens dysplasia. These anomalies can be developmental, post-traumatic, or acquired. Imaging studies including X-rays, CT, MRI are used to classify and evaluate the anomalies. Treatment may involve surgery such as fusion if the anomaly causes spinal cord compression.
1. Spinal cord injuries are commonly caused by motor vehicle accidents, falls, and sports. The cervical spine is most frequently injured.
2. Initial evaluation involves stabilizing the patient with a cervical collar and assessing for neurological deficits. Imaging such as X-rays and CT/MRI are used to classify fractures and guide treatment.
3. Treatment depends on the fracture type but may involve halo immobilization, surgery to stabilize fractures or decompress the spinal cord, or bracing for stable injuries. The goal is to restore spinal alignment and prevent further neurological injury.
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This document provides information on spinal injuries, including:
- Traumatic spinal cord injuries result in 12,000 new cases per year in the US. Most injuries occur in men aged 16-30 from vehicle crashes, falls, or sports.
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The document discusses injuries to the acromioclavicular (AC) joint and sternoclavicular (SC) joint. It describes the anatomy, mechanisms of injury, clinical evaluation, classification systems, treatment approaches, and potential complications for each joint. AC joint injuries are more common and typically result from direct trauma, while SC joint injuries are rare but can cause serious issues due to nearby vital structures. Treatment involves rest, immobilization, and sometimes surgery depending on the severity of the injury.
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The document discusses several congenital anomalies and normal variants of the cervical spine, including:
- Platybasia, which is flattening of the skull base angle. It can occur alone or with skeletal dysplasias. Most cases are asymptomatic.
- Basilar invagination, where the upper cervical vertebrae are positioned too far superiorly in relation to the skull base. It can be primary/congenital or secondary due to bone disease. Symptoms typically begin in the third to fourth decade of life.
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This document discusses imaging of the cranio-vertebral junction. It begins by defining the cranio-vertebral junction and its key anatomical parts. It then discusses various imaging modalities for evaluating the CV junction, including plain radiographs, CT, MRI, and angiography. Specific abnormalities that can be seen include basilar invagination, atlantoaxial subluxation, occipital anomalies, and os odontoideum. Measurement lines and angles used in evaluation are also defined.
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Microstomia, characterized by an abnormally small oral aperture, presents significant challenges in prosthodontic treatment, including limited access for examination, difficulties in impression making, and challenges with prosthesis insertion and removal. To manage these issues, customized impression techniques using sectional trays and elastomeric materials are employed. Prostheses may be designed in segments or with flexible materials to facilitate handling. Minimally invasive procedures and the use of digital technologies can enhance patient comfort. Education and training for patients on prosthesis care and maintenance are crucial for compliance. Regular follow-up and a multidisciplinary approach, involving collaboration with other specialists, ensure comprehensive care and improved quality of life for microstomia patients.
The Importance of Black Women Understanding the Chemicals in Their Personal C...bkling
Certain chemicals, such as phthalates and parabens, can disrupt the body's hormones and have significant effects on health. According to data, hormone-related health issues such as uterine fibroids, infertility, early puberty and more aggressive forms of breast and endometrial cancers disproportionately affect Black women. Our guest speaker, Jasmine A. McDonald, PhD, an Assistant Professor in the Department of Epidemiology at Columbia University in New York City, discusses the scientific reasons why Black women should pay attention to specific chemicals in their personal care products, like hair care, and ways to minimize their exposure.
2. ANATOMY OF CVJ (ARTICULAR)
Occiput & atlas
⚫ Upper surfaces of C1 lateral masses is cup-like or
concavewhich fit into the ball & socketconfiguration
with occipital condyle.( flexion 10*, extension 25*).
Atlas & axis – 4 synovial joints
⚫2 median –front & back of dens (Pivotvariety)
⚫2 lateral –b/w opposing articular facets (Planevariety)
⚫Each joint has itsowncapsule & synovial cavity.
⚫Rotation is upto 90* & approx ½ occursat the A-A
joint.
3. ANATOMY OF CVJ(LIGAMENTOUS)
Principal stabilizing ligaments of C1 -
⚫-Transverse atlantal ligament
⚫-Alar ligaments
Secondary stabilizing ligaments of CVJ are moreelastic &
weaker than the primary ligaments.
⚫-Apical ligament
⚫-Anterior & posteriorA-O membranes
⚫-Tectorial membrane
⚫-Ligamentum flavum
⚫-Capsular ligaments
4.
5. NEURAL
Structures related are –
⚫Caudal brainstem (Medulla)
⚫Fourth ventricle
⚫Rostral partof spinal cord
⚫Lower cranial (9,10,11 ,12) & uppercervical
nerves (C1,C2, and C3 nerveswith both rami).
⚫In cerebellum, only the tonsils, biventral lobules
& the lower partof thevermis (nodule, uvula &
pyramid)
6. Classification of CV Anomalies
I. Bony Anomalies
A. MajorAnomalies
1. Platybasia
2.Occipitalizationof
atlas
3. Basilar Invagination
4. Dens Dysplasia
5.Atlanto- axial
dislocation
B. MinorAnomalies
1. Dysplasiaof Atlas
2. Dysplasia of
occipital condyles,
clivus, etc.
I. Soft Tissue anomalies
1. Arnold-Chiari Malformation
2. Syringomyelia/ Syringobulbia
9. Clinical features
A. Cervical symptomsand signs- pain suboccipital region
radiating vertex, stiffness in 85%
B. Myelopathic Features- long tract involvement and
wasting
C. CN involvement- IX, X,XI,XI in 20%
D. Vascular - in 15% Transient Attack of V-B insufficiency
E. Sensory symptomof post. column involvement.
F. Cerebellar symptoms/signs- Nystagmus, Ataxia,
intention tremor, dysarthria
G. Featuresof Raised ICT- usually seen in Pateints Having
basilar impresssionand/orACM
10. INVESTIGATIONS
⚫ X Rays
-Antero-posteriorview
-Lateral view
-Open mouth view fordens
⚫ Stress X-Rays (neutral, flexion, extention)
⚫ CT Scan and 3D reconstruction
⚫ MRI conventional and dynamic
⚫ Myelogram & Ventriculogram
⚫ Angiography
11. CRANIOMETRY:
⚫Craniometryof the CVJ uses a series of lines, planes &
angles todefine the normal anatomic relationshipsof the
CVJ.
⚫These measurementscan be taken on plain X rays,3D CT or
on MRI.
⚫No single measurement is helpful.
⚫disadvantage --anatomicstructuresand planesvarywithin
a normal range.
12. Lines and angles used in radiologic diagnosis of C.V
anomalies.
Parameter Normal range limits
A. PLATYBASIA
B. BASILAR INVAGINATION
C. ATLANTO-AXIAL DISLOCATION *
• Basal angle
• Boogard’s angle
• Bull’s angle
< 150 degree
< 136 degree
< 13 degree
< onethird of odontoidabove this line
< 5 mm
odontoid lies below this
> 35 mm
> 22mm.
• Chamberlain’s line
• Mcgregor’s line
• Mcrae line
• Klausheightindex
• Atlanto-temporo
mandibular index
• Atlanto-odontoid space upto 3 mm inadults
upto 5 mm inchildren
13. Chamberlain’s line
⚫ From tipof hard palate toposterior
tipof Foramen Magnum
(opisthion).
⚫ It helps to recognise basilar
invaginationwhich is said to be
present if the tipof thedens is >3
mm abovethis line
14. Mc Gregor’s line (basal line)
⚫ Line drawn from posterior
tip of Hard palate to lowest
partof Occiput
⚫ Odontoid tip >5mm above =
Basilar Invagination
⚫ Position changed with
flexion and extension so not
used.
⚫ Should be used when lowest
part of occipital bone is not
Foramen Magnum.
15. Wackenheim’s clivus canal line
⚫ Linedrawnalong clivus into
cervical spinal canal
⚫ Odontoid is ventral and tangential
tothis line
⚫ If not –suggestAAD or BI
16. Mc rae’s line ( foramen magnum line)
⚫ Joinsanteriorand posterioredges of Foramen magnum
⚫Tipof odontoid is below this line.
⚫When sagittal diameterof canal <20mm, in patientof >8
yrof age neurological symptoms occur – Foramen
Magnum Stenosis
17. Welcher’s Basal Angle
⚫Nasion to tuberculum sella
⚫Tuberculum sellae to the basion
along planeof theclivus
⚫Normal – 1240 - 142
⚫> 1400 = platybasia
⚫< 1300 is seen in achondroplasia
19. Boogard ‘s Angle
⚫1s
t
line between Dorsum sellae to Basion & Mc
Rae’s line.
⚫Average - 1220
⚫> 1350
⚫Basillar impression
20. Atlantooccipital joint Axis Angle
(Schmidt – Fischer angle)
⚫Range between 124- 127.
⚫Wider in occipital condyle hypoplasia.
O
C2
AA JT
AO JT
C1 C1
21. FISHGOLD’S DIGASTRIC LINE( Biventerline)
Connects the digastric grooves ( fossae for digastric
muscleson undersurface of skull just medial to mastoid
process)
Tipof theodontoid process and atlanto-occipital joint
normally project 11 mm and 12 mm below this line
respectively.
Basilar invagination is presentwhen atlanto-occipital
joint projects at orabove this line.
23. HEIGHT INDEX OF KLAUS
⚫Distance between tipof dens
and tuberculum cruciate
line( line drawn from
tuberculum sella to internal
occipital protruberence)
⚫40-41mm normal
⚫In basilar invagination <30
mm
24. 1.nasion
2.tuberculum sella
3.basion (anterior
margin of the
foramen magnum)
4.opisthion
(posterior margin of
the foramen
magnum)
5.posteriorpole of
the hard
palate
6.anteriorarchof
theatlas
7. posteriorarchof
theatlas
8. odontoid process
29. Occipitalization of atlas/assimilation
⚫50% of all cvj anomaly in india.
⚫Failureof segmentation btw last
occipital and first spinal
sclerotome.
⚫ Gradual orsudden onset by trauma
⚫No movement btw OA –leads
increases stress at AA joint –get
instability
⚫Associated –with basilar
invagination, occipital vertebra, KF
syndrome
31. ⚫ Incidence - 1.4 to 2.5 per 1000 children. Itaffects both sexes
equally.
⚫ Neurological symptoms usuallyoccur in third and fourth
decades and vary depending on the area of spinal cord
impingement.
⚫ Clinical Findings
⚫ Low hairlines
⚫ Torticollis
⚫ Short necks
⚫ Restricted neck movement.
⚫ Dull, aching pain in the posteriorocciput and the neck
⚫ Episodic neck stiffness
32.
33. TOPOGRAPHIC FORMS (WACKENHEIM):
⚫Type I: Occipitalization (subtotal) with BI.
⚫Type II: Occipitalization(subtotal) with BI & fusion of 2nd &
3rd cervical vertebrae.
⚫Type III: occipitalization (Total orsubtotal) with BI &
maldevelopment of the transverse ligament. may be
associated with various malformations like C2-C3 fusion,
hemivertebra, dens aplasia, tertiarycondyle, etc
⚫Symptomsaredue to-absence of a freeatlas- TL fails to
develop which causes posterior displacement of axis &
compression of the spinal cord
34. BASILAR INVAGINATION
⚫Basilar invagination implies that the floor of the skull
is indented by the upper cervical spine, & hence the tip
of odontoidis more cephalad protruding into the FM.
⚫Two types : primary invagination, which is
developmental and more common, and secondary
invagination, which is acquired.
⚫Primary invagination can be associated with occipito
atlantal fusion, hypoplasia of the atlas, a bifid
posterior arch of the atlas, odontoid anomalies.
36. ⚫BI isassociated with high incidence of vertebral artery
anomalies.
Topographic typesof BI :
⚫Anterior BI : hypoplasiaof the basilarprocess of the
occipital bone.
⚫BI of theoccipital condyles (Paramedian BI)–Condylar
hypoplasia
⚫BI in the lateral condylararea.
⚫Posterior BI: posterior margin of the FM is invaginated.
⚫Unilateral BI.
⚫Generalised BI
37. SIGNS / SYMPTOMS
Usuallyoccur in 2nd or 3rd decade.
⚫ Short neck(78%),torticollis (68%)
⚫ Associated ACM & syringomyelia(25 to 35%).
⚫ Motor & sensorydisturbances (85%).
⚫ Lowercranial nerves involvement
⚫ Headache & pain in the napeof neck (greateroccipital N)
⚫ Raised ICP due to posteriorencroachmentwhich causes
blockageof aqueductof sylvius.
⚫ Compression of cerebellum & vestibularapparatus leading to
vertical or lateral nystagmus(65%) .
⚫ Vertebral artery insufficiencys/s.
38.
39. Atlantoaxial Instability
⚫Atlantoaxial instability (AAI) is characterized byexcessive
movement at the junction between the atlas (C1) and axis
(C2) as a result of eithera bony or ligamentous
abnormality.
⚫Neurologic symptomscan occurwhen the spinal cord or
adjacent nerve roots are involved.
Incidence of AAD –
⚫57% of all CVJ anomalies.
⚫8.3% of all causesof cervical compression
40. ⚫GREENBERG’S CLASSIFICATION :
Incompetence of theodontoid process –
Congenital
Traumatic -# of odontoid
Infections
Tumor –1o/ 2o
Adults (RA &
Incompetence of theTAL –
Congenital
Traumatic
Inflammatory –Children (pharynx nasopharynx)
ankylosing spondylitis)
41. WADIA CLASSIFICATION :
⚫Group I: AAD with occipitalizationof atlas & fusion of C2
& C3.
⚫Group II: odontoid incompetence due to its
maldevelopment with no occipitalizationof atlas.
⚫Group III: odontoid dislocation but no maldevelopment of
dens oroccipitalizationof atlas.
42. Non-traumatic conditions associated with increase in
theatlantoaxial distance:
⚫Down syndrome -Due to laxityof the transverse ligament
⚫Grisel syndrome –Atlantoaxial subluxation associated with
inflammation of adjacent soft tissues of the neck
⚫Rheumatoid arthritis-From laxityof the ligamentsand
destruction of thearticularcartilage
⚫Osteogenesis imperfecta
⚫Neurofibromatosis
⚫Morquiosyndrome -Secondary toodontoid hypoplasiaor
aplasia
⚫Other arthridities (Psoriasis, Lupus)
43. Anterior Atlanto-Dental Interval (AADI)
⚫ AAS is + when >3 mm in adults & >5mm in children
⚫ Measured from posteroinferior margin of antarch of C1 to
theant surfaceof odontoid
⚫ AADI 3-6 mm trans lig. damage
⚫ AADI >6mm alar lig. damagealso
44. PosteriorAtlanto-Dental Interval (PADI) :
⚫ Distance b/w posterior
surface of odontoid &
anterior marginof post
ring of C1
⚫ Considered better method
as it directly measures the
spinal canal
⚫ Normal : 17-29 mm at C1
⚫ PADI <14mm : predicts
cord compression
45. RISK FACTORS FOR CORD
COMPRESSION IN AAS-
⚫AADI > 9 mm
⚫PADI < 14 mm
⚫Basilar Invagination,
especially if associated
with AAS of anydegree
48. Fielding and Hawkinsclassification:
⚫Type I- is simple rotatorydisplacement with an intact
transverse ligament.
⚫Type II- injuries involve anteriordisplacement of C1 on C2
of 3-5 mm with one lateral mass serving as a pivot point
and adeficiency of the transverse ligament.
⚫Type III -injuries involve greater than 5 mm of anterior
displacement.
⚫Type IV-injuries involve the posteriordisplacement of C1
on C2.
⚫Both Type III and IV are highly unstable injuries.
49. TREATMENT-
⚫Type I injuries (stablesubluxations) –Collar.
⚫Type II injuries may be potentiallyunstable.
⚫Type III and IV rotatorydisplacements thatare
unstableare treated surgicallywith a reduction and C1-
2 fusion.
⚫Techniques of fusion vary from sublaminar wiring
techniques like Brooks or Gallie, Halifax clamp, or
transarticularscrew of Magerl.
50. DENS DYSPLASIA
⚫Type 1 (Os odontoideum)
separateodontoid process
⚫ Type 2 (Ossiculum terminale)
failure of fusion of apical
segmentwith its base
⚫Type 3 – Agenesis of odontoid
base & apical segment lies
separately.
⚫Type 4 – Agenesis of odontoid
apical segment
⚫Type 5 –Total agenesis of
odontoid process.
51. OS ODONTOIDEUM
⚫At birth odontoid base is separate
from the body of axis by a
cartilage which persists until the
ageof 8, later -ossified,or may
remain separate as Os-
odontoidium.
⚫Independent osseous structure
lying cephalad to theaxis body in
the location of the odontoid
process.
⚫Anterior arch of the atlas is
rounded and hypertrophic but the
posteriorarch is hypoplastic.
⚫Cruciate ligament incompetence
and A-A instabilityare common
52. Persistent ossiculum terminale: Bergman ossicle
⚫Failureof fusion of the
terminal ossicle to the
remainderof theodontoid-
normally by 12 yearsof age.
⚫Confused with a type 1
odontoid fracture.
⚫Stable when isolated and
of relatively little clinical
significance.
⚫Odontoid process is
usually normal in height.
53. Condylar Hypoplasia:
⚫ Occipital condyles are
underdeveloped and havea
flattened -- and widening of
the AO jointaxis angle --
leading to BI.
⚫ Lateral masses of the atlas
may be fused to the
hypoplastic condyles, further
accentuating the BI.
⚫ Limits movementsat the A-O
joint.
⚫ Violationof the Chamberlain
line and widening of
atlantooccipital joint axis
angle
54. Basiocciput Hypoplasia:
⚫Hypoplasiaof the basiocciput
may be mild or severe,
depending on the numberof
occipital sclerotomes affected.
⚫Lead-basilar invagination.
⚫Clivus-canal angle is typically
decreased
55. Posterior Arch Anomalies
⚫ Posteriorrachischisis > aplasias and hypoplasia
⚫ Total orpartial aplasiaof the posterioratlasarch.
⚫ Isolated, is usuallyasymptomatic, but may beassociated
with anteriorAA subluxation.
⚫ Simulating Jefferson fracture.
56. SPLIT ATLAS
⚫Anterior +posteriorarch rachischisisis =“splitatlas”.
⚫Usuallyasymptomatic butwideclefts with only a
fibrouscovering may lead toatlas instability
57. Klippel- Feil Syndrome
Triad
⚫ Decreased rangeof motion in the
cervical spine m/c
⚫ Short, webbed neck
⚫ Low hairline.
Type
1- Massive fusionof cervical and upper
thoracicvertebra
2 –Fusion of 2 cervical vertebra
,hemivertebra, scoliosis, OA fusion
3 Lower thoracicand upper lumber
spineanomaly.
4 Sacral agenesis
58. ASSOCIATED CONDITIONS:
⚫Scoliosis- 60%.
⚫Genito-urinary- 65%. m/c is absence of kidney.
⚫Sprengel's deformity- 35%
⚫Cardio-pulmonary-5-15%, m/c V.S.D.
⚫Deafness-30%, all types, MC mixed.
⚫Sykinesis-Mirror motions 20%.
⚫Cranio-cervical abnormalities- (25%)- Includes C1-C2
hypermobilityand instability, BI, Chiari I malformation,
diastematomyelia, & syringomyelia.
59. ⚫20% of patients mayshow facial asymmetry, torticollis and
neck webbing (pterygiumcolli).
⚫Ptosis of theeye, Duane'seye contracture, lateral rectus
palsy, facial nerve palsyand cleft palate.
⚫Upperextremityabnormalities, ie. syndactyly, hypoplastic
thumb, supernumarydigitsand hypoplasiaof the upper
extremity.
SYMPTOMS:
⚫Due to the hypermobilityoccurring at theopen segments,
can lead toeither frank instabilityorosteoarthritis.
⚫Mechanical symptomsdue to joint irritation.
⚫Neurologic symptomsdue to root irritation or spinal cord
compression
60. Arnold-Chiari Malformation
⚫Type 1- m/c -caudal displacement of peglikecerebellar tonsils
below the level of the foramen magnum, -congenital tonsillar
herniation, tonsillar ectopia, or tonsillar descent.
Syringomyelia in 50 to 70%.
⚫Type II -less common and more severe, almost invariably
associated with myelomeningocele. Symptomatic in infancy
orearlychildhood. -caudal displacement of lower brainstem
(vermis, medulla, pons, 4th ventricle) through the foramen
magnum.
⚫Type III -herniation of cerebellum intoa high cervical
myelomeningocele.
⚫Type IV -cerebellar agenesis.
type III and IV -exceedingly rareand incompatible with life .
61. ⚫ Chiari type I malformation.
⚫ (white line) down to the level of C1 posterior arch.
62. TREATMENT:
⚫No role forprophylactic treatment in an asymptomatic
patientwith an incidental CMI.
⚫All symptomatic patients requiresurgical treatment.
⚫In patients with CMI and hydrocephalus, the primary
treatment must be shunting theventricularsystem.
⚫In presenceof symptomaticventral compression from BI or
retroflexion of the odontoid, the treatment is ventral
decompression.
⚫In patients with a CMI,syrinx with scoliosis, the initial
treatment is posteriorcervicomedullary decompression.
63. OUTCOMES:
⚫Patients presenting with pain (mainly headache and neck
pain) & weakness withoutassociated atrophy –best results.
⚫Cranial nervedysfunction –moderate recovery
⚫Sensory recovery poor.
⚫Presence of central cord syndrome due toa syrinx-
indicativeof poor recovery
.
⚫Three factors most prognostic of pooroutcome are atrophy,
ataxia, and scoliosis.
⚫Brain stem and cerebellar syndromes -good recovery
64. TUBERCULOUS AAD
⚫<1% of all cases of spinal TB.
⚫Local pain, restriction of neck movements & acute
tenderness of upper C-spine –Cardinal features.
⚫Compressionof CMJ could bedue togranulation tissue,
cold abscess or bony instability & displacement.
⚫Waxing & waning picture .
⚫Ligaments areextensively infiltrated .
⚫Hyperaemicdecalcification occurs.
65. Radiological findings in 3 stages–
⚫Stage I: Retropharyngeal abscess with ligamentous laxity +,
bonyarchitecture of C1-C2 preserved.
⚫Stage II: Ligamentous disruptionwith AAD, minimal bone
destruction & retropharyngeal mass +
⚫Stage III: marked destruction of bone, complete
obliteration of anteriorarch of C1 & complete loss of
odontoid process, marked AAD & O-A instability.
66. TREATMENT:
⚫ Bed rest, cervical traction, evacuation of retropharyngeal abscess
& prolonged external immobilizationalong with ATT.
Indicationsof Surgery :
⚫ Gross bonydestruction with instability
⚫ Major neurological deficits
⚫ Unstablespine following conservativeTx
Surgery :
⚫ Posteriorfusion
⚫ Anteriordecompression with orwithout fusion
67. RHEUMATOID ARTHRITIS & CVJ
⚫20% of RA have AAD.
⚫Osteophyte formation (stabilizing effect) does not occur
secondary todeficient osteogenesis(characteristic of RA).
⚫Loss of tensile strength & stretching of TL due to
destructive inflammatorychanges as well as secondary
degenerativechanges in tissues from vasculitis--AAD.
⚫Granulation tissue in thesynovial joints.
⚫Odontoid process –osteoporosis, angulation/#.
68.
69. REFFERENCES-
⚫ Textbook of contemporary neurosurgery vol 1 By Vincent A
Thamburaj
⚫ Apley’s Textbook of Orthopaedics
⚫ A Textbook of Neuroanatomy GARTNER and Rhoton
⚫ Youmanstextbook of neurosurgury
⚫ Texbook of neurosurgery –rengacharyand shetty.
⚫ Managementof Congenital Atlanto-Axial Dislocation Neurology
India, Vol. 50, No. 4, Dec, 2002, pp. 386-397 Review Article
⚫ Uptodate.com
⚫ Radiopedia.org