Variants and deformities of atlas vertebrae in Eastern Anatolian people.
ABSTRACT At the craniocervical junction, developmental anomalies of the atlas may produce clinical symptoms by compressing on the vertebral artery, particularly during extreme rotational movements of the cervical spine. The aim of the present study was to investigate several varieties and deformities of the atlas vertebra from the skeletal specimens of Eastern Anatolian people.
This study was carried out over a 3-year period, 2000 through to 2002 in the Department of Anatomy, Firat, Yuzuncu Yil and Ataturk University, Turkey. Developmental anomalies and the variants of the first vertebrae were investigated on 86 atlas.
Ponticulus posterior was observed with a low frequency on right as 2.3%. The bilateral localization was 10.5% and the left-side localization was 9.3%. Ponticulus lateralis showed an equal localization as 1.2% on the right, 1.2% on the left and 1.2% bilateral. In the present study, a complete subdivision of the joint surface was observed in 11 atlases (12.8%). Processus infratransversarius atlantis with a frequency between 1.2-7%, arthrotic formation and corona atlantis peridentals in 8 cases (9.3%) were also found.
The low frequency for fonticulus posterior might be peculiar to the population living in this area.
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ABSTRACT: We reviewed published radiographic and cadaver series describing the incidence of the anatomical anomaly ponticulus posticus and discuss its relevance to C1 lateral mass screw (C1LMS) insertion. Online databases were searched for English-language articles describing the presence of ponticulus posticus in cadaver and radiographic studies. Forty-four reports describing 21,879 patients (n=15,542) or bony/cadaver specimens (n=6247) fulfilled inclusion criteria. Meta-analysis techniques were applied to estimate the prevalence of this anomaly. The overall prevalence of ponticulus posticus was 16.7%. The anomaly was identified in 18.8% of cadaver, 17.2% of CT and 16.6% on XR studies. The anomaly comprised a complete foramen in 9.3% of patients and was partial/incomplete in 8.7%. It was present bilaterally in 5.4% of cases and unilateral in 7.6%. There was no significant difference in prevalence between males (15.8%) and females (14.6%). Review of that literature demonstrated a dramatic increase in the number of patients treated with C1LMS through the posterior arch since first described in 2002, necessitating recognition of this anomaly when performing the Goel-Harms procedure. The atlantal anomaly ponticulus posticus is not rare, occurring in 16.7% of patients in radiographic and cadaver studies. This anomaly may give the false impression that the posterior arch of the atlas is of adequate size to accommodate a C1LMS and may lead to inadvertent vertebral artery injury. Careful assessment via preoperative multiplanar CT imaging should be performed prior to consideration of C1LMS implantation.World Neurosurgery 09/2013; · 2.42 Impact Factor
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ABSTRACT: Objectives. To determine the prevalence and pathogenesis of ponticulus posticus (PP) and ponticulus lateralis (PL) in children and adolescents. Methods. Cone beam CT scans of 576 patients were examined for PP and PL. The patients were divided into three age groups: 10 years and younger, 11 to 13 years, and 14 years and older. Ponticulus formation was categorized as absent, partial, or complete. Gender, race, and location (right, left, or bilateral) were recorded. Data were analyzed with the chi-square test, with significance at p < 0.05. IRB approval was granted. Results. Overall prevalence of PP was 26.2%, with complete lesions in 10.4%. The frequency of PP was greater in patients 14 and older (p < 0.038). The occurrence of complete PP was greater in patients 11 and older (p = 0.028). Lesions were more common in males (p = 0.014) and in blacks compared to other non-white races (p = 0.035). Bilateral PP was more common than right sided lesions (p = 0.008) and more frequent in the oldest cohort (p = 0.006). Overall prevalence of PL was 6.1% (3.0% complete), with no differences between age groups, genders, races or by location. Conclusions. PP is not uncommon even in the first decade and increases in frequency, completeness of calcification, and numbers in mid-adolescence. It appears to be more common in males and in blacks. PP may be a congenital osseous anomaly of the atlas that mineralizes at various times. PL is less frequent with no demographic predilections.Dentomaxillofacial Radiology 04/2014; · 1.27 Impact Factor
raniocervical junction is the area comprising
the inferior portion of the occipital bone that
surrounds the foramen magnum and the first 2
cervical vertebrae, atlas and axis. Due to its
complicated embryonic development, this area is
easily susceptible to
developmental variants and anomalies, producing a
wide spectrum of symptom.1 Clinical syndromes
develop as a result of mechanical disturbance of
movement or of deformities of the cervical cord
accompanying these developmental anomalies and
the variants of skeletal elements. The bone
deformity itself may be sufficient to cause pressure
on the upper cervical cord and the vertebral artery
during movements of the head and neck. In some
skeletal and neural
situations (such as, transient vertebra basilar
insufficiency, Barre-Lieou syndrome and chronic
upper cervical syndrome) a developmental variant
of the atlas is a significant factor.2-5 Due to the
clinical significance, a variation of the first
vertebrae, retroarticular canal, was examined in
several populations.3,5-9 Recently, a review by
Prescher10 also reported the osseous variations in the
The present study was undertaken to investigate
several varieties or deformities of the atlas vertebra
from skeletal specimens of the Eastern Anatolian
people. The purpose of the present study was to
determine the frequencies of the varieties of the first
From the Department of Anatomy (Kavakli, Kus), School of Medicine, Firat University, Elazig, Department of Anatomy (Aydinlioglu, Erdem),
Department of Neurology (Anlar), School of Medicine, Yuzuncu Yil University, Van, Department of Anatomy (Yesilyurt, Diyarbakırlı), School of
Medicine, Atatürk University, Erzurum, Turkey.
Received 11th August 2003. Accepted for publication in final form 29th October 2003.
Address correspondence and reprint request to: Dr. Ahmet Kavakli, Fırat University, Department of Anatomy, School of Medicine, 23119 Elazıg,
Turkey. Tel. +90 (424) 2370000. Fax . +90 (424) 2379138. E-mail: firstname.lastname@example.org
Variants and deformities of atlas vertebrae in
Eastern Anatolian people
Ahmet Kavaklı, MD PhD, Atıf Aydınlıoglu, MD PhD, Hakkı Yesilyurt, MD PhD, Ilter Kus, PhD,
Semih Diyarbakırlı, PhD, Saadet Erdem, MSc, Ömer Anlar, MD.
developmental anomalies of the atlas may produce
clinical symptoms by compressing on the vertebral
artery, particularly during extreme rotational movements
of the cervical spine. The aim of the present study was to
investigate several varieties and deformities of the atlas
vertebra from the skeletal specimens of Eastern Anatolian
At the craniocervical junction,
period, 2000 through to 2002 in the Department of
Anatomy, Firat, Yuzuncu Yil and Ataturk University,
Turkey. Developmental anomalies and the variants of the
first vertebrae were investigated on 86 atlas.
This study was carried out over a 3-year
Ponticulus posterior was observed with a low
frequency on right as 2.3%. The bilateral localization was
10.5% and the left-side localization was 9.3%. Ponticulus
lateralis showed an equal localization as 1.2% on the
right, 1.2% on the left and 1.2% bilateral. In the present
study, a complete subdivision of the joint surface was
observed in 11 atlases
infratransversarius atlantis with a frequency between
1.2-7%, arthrotic formation and corona atlantis
peridentals in 8 cases (9.3%) were also found.
might be peculiar to the population living in this area.
The low frequency for fonticulus posterior
Saudi Med J 2004; Vol. 25 (3): 322-325
Variations of atlas ... Kavakli et al
www.smj.org.saSaudi Med J 2004; Vol. 25 (3) 323
localization of 3.5% on the right, 1.2% on the left
and 7% bilateral (Table 1).
Arthritic deformities. (Figures 3 & 4). In our
study, an arthritic formation at the arcus anterior
atlantis was found in 8 cases with a frequency of
9.3% (Table 1).
vertebrae: ponticulus posterior and ponticulus
description, a wide groove for vertebral artery and
suboccipital nerve on the superior aspect of the
posterior arch of the atlas vertebra crosses behind
each lateral mass. In some cases it is partly or
wholly made of a foramen by bone arching back
from the superior surface of the lateral mass.11 This
bony bridge was first reported by MacAlister.6 It
was variously described as ponticulus posterior or
posticus, Kimmerle’s variant, retroarticular canal,
foramen retro-articular superior, retro condylar
vertebral artery ring, posterior atlantoid foramen,
foramen arcual and atlas bridging.2-5,8,10,12,13 The
ponticulus posterior was observed with a low
frequency on the right (2.3%) (Table 1). The
percentage of the bilateral and left side localization
(Figure 1) showed no difference with those of the
American population, which was reported to be
between 9-15%.3,5,6,9 Its incidence in the Indian
population was found as 11.4%14 while in the South
African population, it was reported with complete
occurrence as 11.7% on the right and 24.6% on the
left.4 Our study presented with partial posterior
bridge formation with 9.3% and complete formation
with 12.8% (Table 1). Taitz and Nathan5 found
partial formation as 25.9% and complete formation
bridge, which extends from the upper edge of the
massa lateralis to fuse with the posterior root of the
transverse process.5,10 The frequency of the lateral
Bridge formations of the atlas
Represents the lateral
cervical vertebra in the mentioned population,
which have not been documented in the literature.
The clinical symptoms and disturbances caused by
the anomalies of the atlas were also reviewed.
3-year period from 2000 through to 2002, in the
Department of Anatomy, Firat, Yuzuncu Yil and
Ataturk University, Turkey. The present study is
based on the examination of 86 complete and
undamaged adult atlas vertebrae. Most of them were
the course materials obtained from cadavers for our
medical students. The others were from a collection
of vertebrae available in our departments. Our
materials were of undetermined age and gender.
Special attention was directed to the bridge
formation and arthritic changes of the atlas, which
are responsible for clinical symptoms.
This study was carried out over a
as the shape variations and arthritic formations
Bony bridges. (Figure 1) In the present study,
ponticulus posterior was observed with a frequency
of 2.3% on the right. The percentage of bilateral
localization was 10.5%
localization was found with 9.3%. Partial posterior
bridge formation was found with 9.3% and
complete formation with 12%. The lateral bony
bridge, ponticulus lateralis represented an equal
localization with frequencies of 1.2% on the right,
1.2% on the left and 1.2% bilateral. One case
showed both posterior and lateral bridges (Table 1).
Facies articularis superior atlantis bipartite.
(Figure 2) Eleven atlases (12.8%) presented with a
complete subdivision of the joint surface was found
in our study (Table 1). No incomplete subdivision
Processus infratransversarius atlantis. (Figure 3)
This variation was observed with a frequency and
The results are summarized in Table 1
and the left-sided
Table 1 - Variations and arthrotic changes of atlas found in the present study (N=86).
Facies articularis superior atlantis bipartita
Processus infratransversarius atlantis
Corona atlantis peridentalis
Variations of atlas ... Kavakli et al
Variations of atlas ... Kavakli et al
324 Saudi Med J 2004; Vol. 25 (3)www.smj.org.sa
materials of the dorsal arch and the lateral
extensions of the proatlas and to belong to the
manifestations of the occipital vertebra.10
The clinical significance of bridge formation has
been discussed in reference to their possible effect
on normal vertebral artery function due to the
ponticulus formations that can be identified on the
conventional lateral and a.-p. radiographs.3,10,18 This
formation can cause compression of the vertebral
artery, particularly during extreme rotational
movements of the cervical spine. This may play a
role in reduction of vertebral artery blood flow,
leading to symptoms
insufficiency.3,4,7 A correlation between migraine
cervicale and the presence of a ponticulus posterior
was reported. In such cases, resection of the
ponticulus may be indicated, which results in
decompression of the vertebral artery and the
The superior articular surface of the
bridge in our study generally resembles to that of
the previous studies. In the literature, this variation
is reported with a percentage between 1.8-3.8,5,10,15
which agrees with our findings. Our study also
presented an equal localization for this formation,
namely 1.2% on the right, 1.2% on the left and 1.2%
bilateral. Our observations showed a ratio of 2:1 for
complete and incomplete formation, similar to Taitz
and Nathan5 finding. In our study, one atlas (1.2%)
showed both posterior and lateral bridges (Table 1),
which accords with the literature.5,10 The origin of
atlas bridging has been debated in the literature. The
opinion of ancient authors was that the posterior
bridge is a direct homologue of the superior oblique
process of other mammals.6,16 Familial nature of
atlas bridging proposed by Selby et al17 and an
acquired ossification of ligaments occurring with
aging5,8 was not the same with the study of Lamberty
and Zivanovic,3 that
posteriores have been seen in fetuses and children.
Recently, atlas bridging is supposed to develop from
Figure 1 - A bony arch bridging the sulcus arteriae vertebralis
(arrows) behind the massa lateralis atlantis, namely,
ponticulus posterior. A complete bridge over the foramen
processus transversi of the atlas, ponticulus lateralis
Figure 2 - Superior articular facet of atlas vertebra showing
subdivision into 2 parts, facies articularis superior atlantis
bipartite, with bilateral localisation (asterisk).
Figure 3 - A bony extension in the caudal direction, emerging from
the transverse process of the atlas (such as, processus
infratransversarius atlantis) (arrows) and arthrotic
formation of the atlas at the arcus anterior atlantis
Figure 4 - A bony element at the arcus anterior atlantis, corona
atlantis peridentalis or "coulisse of the atlas" (asterisk).
Variations of atlas ... Kavakli et al
www.smj.org.saSaudi Med J 2004; Vol. 25 (3) 325
1. Kumar A, Jafar J, Mafee M, Glick R. Diagnosis and
management of anomalies of the craniovertebral junction.
Ann Otol Rhinol Laryngol 1986; 95: 487-497.
2. Buna M, Coghlan W, deGruchy M, Williams D, Zmiywsky
O. Ponticles of the atlas: a review and clinical perspective.
J Manipulative Physiol Ther 1984; 7: 261-266.
3. Lamberty BGH, Zivanovic S. The retro-articular vertebral
artery ring of the atlas and its significance. Acta Anat
1973; 85: 113-122.
4. Mitchell J. The incidence and dimensions of the
retroarticular canal of the atlas vertebra. Acta Anat (Basel)
1998; 163: 113-120.
5. Taitz C, Nathan H. Some observations on the posterior and
lateral bridge of the atlas. Acta Anat (Basel) 1986; 127:
6. MacAlister A. Notes on the development and variations of
the atlas. Journal of Anatomy and Physiology 1893; 27:
7. Ossenfort WP. The atlas in whites and Negroes. Am J Phys
Anthropol 1926; 9: 439-443.
8. Pyo J, Lowman RM. The ‘ponticulus posticus’ of the first
cervical vertebra. Radiology 1959; 72: 850-854.
9. Romanus T, Tovi A. A variation of the atlas:
Roentgenologic incidence of a bridge over the groove on
the atlas for the vertebral artery. Acta Radiol Diagn
(Stockh) 1964; 2: 289-297.
10. Prescher A. The craniocervical junction in man, the osseous
variations, their significance and differential diagnosis.
Anat Anz 1997; 179: 1-19.
11. Williams PL, Warwick R, Dyson M, Bannister LH. Grays
Anatomy. 37th ed. London (UK): Churchill Livingstone;
1989. p. 318.
12. Kendrick GS, Biggs NL. Incidence of the ponticulus
posticus of the first cervical vertebra between ages six to
seventeen. Anat Rec 1963; 145: 449-454.
13. Saunders SR, Popovich F. A family study of two skeletal
variants: Atlas bridging and clinoid bridging. Am J Phys
Anthropol 1978; 49: 193-204.
14. Gupta SC, Gupta CD, Arora AK, Maheshwari BB. The
retrotransverse groove (canal) in the Indian atlas vertebrae.
Anat Anz 1979; 145: 514-516.
15. Radojevic S, Negovanovic B. La Goittiére et les anneaux
osseux de l’artére vertébrale de l’atlas. Acta Anat (Basel)
1963; 55: 186-194.
16. Allen W. The varieties of the atlas in the human subject and
the homologies of its transverse process. J Anat 1879; 14:
17. Selby S, Garn SM, Kanareff V. The incidence and familial
nature of a bony bridge on the first cervical vertebra. Am J
Phys Anthropol 1955; 13: 129-141.
18. Von Turklus D, Gehle W. The upper cervical spine. London
(UK): Butterworth Heinemann; 1972. p. 93.
19. Singh S. Variations of the superior articular facets of atlas
vertebrae. J Anat 1965; 99: 565-571.
20. Ganguly DN, Singh-Roy KK. A study on the
cranio-vertebral joint in the man. Anat Anz 1964; 114:
21. Kattan KR. Two features of the atlas vertebra simulating
fractures by tomography. Am J Roentgenol 1979; 132:
22. Schmidt H. Über den processus infratransversarius.
Fortschr Geb Rontgenstr. Fortschr Geb Rontgenstr
Nuklearmed 1968; 109: 110-111.
23. Prescher A, Brors D, Adam G. Anatomic and radiologic
appearance of several variants of the craniocervical
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1961; 86: 260-269.
atlas is concave and elongated, joint with the
corresponding occipital condyle. Sometimes the
articular surface is divided into 2-facet.11 In the
present study, a complete subdivision of the joint
surface was observed in 11 atlases (12.8%) (Table 1)
(Figure 2). Prescher10 found this variation in 28 out
of 200 atlases (14%): 7.5% on the right, 2% on the
left, 4.5% bilateral. In the literature, the frequency
of the bipartite superior joint surface was reported
between 5.5-33%.10,19 That this variation develops
from 2 sources, namely, the proatlas and C1
segment, may explain its origin.10,18,20
symptoms and disturbances caused by facies
articularis superior bipartita atlantis have not been
reported. However, it may be mistaken for fractures
Processus infratransversarius atlantis.
a bony extension emerging from the transverse
process in caudal direction.10 In the present study,
this structure was observed in different localization
with a frequency of 1.2-7% in variable lengths
(Figure 3). Clinically, this variation may represent
symptomatic disturbances at the craniocervical
junction.22 Patients with symptomatic variations of
the craniocervical junction often complain of pain in
the neck region or at the back of the head or they
suffer from vertigo or disturbances in balance.
Principal mechanisms of symptoms are mechanical
compression of nervous and vascular structures,
marked instability or in contrast, elevated rigidity.23
Corona atlantis peridentalis.
arthritic formation, corona atlantis peridentalis or
"coulisse of the atlas" termed by Prescher,10 at the
arcus anterior atlantis was found in 8 cases (9.3%),
corresponding to the "coulisse of the dens" (Figure 3
& 4). Lombardi24 reported that these formations
might be partly attributed to the occipital vertebra.
He also observed that the patients in his series were
free of any physical disturbances attributable to the
In conclusion, the findings from our study
generally agree with those of the previous. The only
difference was that ponticulus posterior was
observed with a low frequency on the right, only
perhaps encountered by chance. It might even be
peculiar to the population living in the area. Our
results for processus infratransversarius atlantis,
arthrotic formation and corona atlantis peridentalis,
will also be compared with those of further works
for our literature survey failed to find any data
concerning them in other populations.
In the present study,
Assoc. Prof. Hassan Boynukara who made the necessary
correction of the English grammar.
The authors would like to thank