(arrows) There is diffuse homogeneous enhancement of the tumor. Physically there may be evidence of periauricular swelling and facial nerve dysfunction, such as ipsilateral facial weakness. These transverse and longitudinal bands together constitute the cruciform ligament. Occipital condyle fractures are often difficult to detect on plain films, and CT with reconstructions is the preferred diagnostic modality (Bloom et al., 1997). This syndrome occurs with metastasis to the occipital condyle, and accounts for 16% (Laigle-Donadey et al., 2005a) of cases of skull base syndromes. Think of a metal washer twisting around a bolt. Bilateral OCF can represent a unique presentation of AOD and needs to be evaluated carefully.35, Kelly G. Gwathmey, in Handbook of Clinical Neurology, 2018. Above: Articulation of atlas (C1) and axis (C2). Above: Lateral view of the skull with the occipital bone (and its occipital condyles) colored green and the first cervical vertebra or C1 (articulates with the occipital condyles) colored pink. Check out our free Atlas & Axis eBook! If such fractures are not associated with the more ominous AOD, patients usually present without neurological deficit and complain only of upper cervical pain. In most dinosaurs the occipital condyle is situated at the rear part of the skull, below the foramen magnum, and points toward the posterior of the animal. To their margins are attached the capsules of the atlanto-occipital joints, and on the medial side of each is a rough impression or tubercle for the alar ligament. Above: C2, also known as axis with (A) an anterior view and (B) a posterior view. The pedicles are broad and strong, especially in front, where they coalesce with the sides of the body and the root of the odontoid process. The axis is connected to the occipital bone by membrana tectoria, which is the upward continuation of the posterior longitudinal ligament, the alar ligaments between the lateral aspect of the apex of the dens and medial side of the occipital condyles, the apical ligament of the dens between the apex of the dens and the anterior margin of the foramen magnum, and the ligamentum nuchae. By continuing you agree to the use of cookies. When you nod your head as if to say "yes," that is neck flexion. Among the ligaments that connect the atlas to the axis, the anterior and posterior atlanto-axial ligaments are merely the anterior and posterior longitudinal ligaments. Legal. See our privacy policy for additional details. The vital structures related to this module are the inner ear with the seventh and eighth cranial nerves laterally, the petrous ICA superiorly, and the twelfth cranial nerve inferolaterally. ScienceDirect is a registered trademark of Elsevier B.V. ScienceDirect is a registered trademark of Elsevier B.V. Schmidek and Sweet Operative Neurosurgical Techniques (Sixth Edition), Principles of Neurological Surgery (Third Edition), Management of pediatric cervical spine and spinal cord injuries, 2002, Diagnosis and management of traumatic atlanto-occipital dislocation injuries, 2002, Eismont and Bohlman, 1978; Montane et al., 1991, Spence et al., 1970; Fielding et al., 1974, Levine and Edwards, 1986; Hadley et al., 1988; Sonntag et al., 1988; Fowler et al., 1990; McGuire and Harkey, 1995; Lee et al., 1998; Isolated fractures of the atlas in adults, 2002, Lourie and Stewart, 1961; Fielding and Hawkins, 1977; Phillips and Hensinger, 1989, Fielding and Hawkins, 1977; Phillips and Hensinger, 1989, Amyes and Anderson, 1956; Husby and Sorensen, 1974, Francis et al., 1981; Levine and Edwards, 1985, Endoscopic Approaches to Skull Base Lesions, Ventricular Tumors, and Cysts, This syndrome occurs with metastasis to the, (Courtesy of the Department of Neurosurgery at the University of Texas M.D. The head is removed at the juncture between the atlas vertebra and the occipital condyles (occipito-atlantal joint) of the skull. The transverse processes (the protrusions of bone on either side of the ring) serve as the attachment sites of muscles that assist in rotating the head. There are case reports in the literature reporting minor head trauma causing unilateral traumatic hypoglossal palsy without fracture.100 Patients with tongue deviation, dysphagia, or dysarthria should be evaluated for hypoglossal nerve injury. Some estimate that odontoid fractures lead to death at the time of accident in 2540% of patients (Crockard et al., 1993). The Axis (C2 vertebra) also known as epistropheus forms the pivot upon which the first cervical vertebra (the Atlas), which carries the head, rotates. The hearing loss can be conductive from eustachian tube dysfunction, and/or sensorineural from involvement of the cochlear nerve. Rotatory subluxation at the atlantoaxial junction is usually seen in children, can occur spontaneously, or can be seen with rheumatoid arthritis, Down's syndrome, congenital dens abnormalities, major or minor trauma, or Grisel's syndrome (Lourie and Stewart, 1961; Fielding and Hawkins, 1977; Phillips and Hensinger, 1989). This rotation made possible with the C1-C2 articulation enables individuals to move their head side to side to shake their head "no.". Open reduction and fixation of C12 is recommended in cases that fail to reduce in traction (Fielding and Hawkins, 1977; Phillips and Hensinger, 1989). Tumors of the skull base may also present clinically with syndromes that do not involve cranial nerve dysfunction. Without them, head and neck movement would be impossible. as part of an atlanto-occipital dislocation or the "occipital ring fracture") are rare, but often fatal. The most common primary tumor associated with this syndrome is prostate cancer, causing nearly half of all cases (Capobianco et al., 2002). The paracondylar approach is achieved via drilling of the area lateral to the condyle to resect lesions of the jugular process and of the posterior aspect of the mastoid.5,11,13, Nancy McLaughlin, Sheri K. Palejwala, in Principles of Neurological Surgery (Third Edition), 2012. The atlanto-axial joint is a compound synovial joint. Such fractures have also been classified on the basis of their radiographic appearance. Atlanto-occipital dislocation is estimated to be present in 58% of fatal traffic injuries and in 835% of all fatal cervical spine injuries (Fig. The atlas and the occipital bone form the atlanto-occipital joint, which allows neck flexion. Despite the anatomic proximity of the occipital condyle to the brain stem and cerebellum, most patients present with isolated lower cranial injuries.98,99 The incidence of brain stem involvement may be higher as some patients do not present to emergency departments because of a higher fatality rate. The muscles are semisplinalis servicis ,the rectus capitis posterior major,the inferior oblique, the spinalis cervicis , the interspinalis and the multifidus. Of those 24 (not counting the sacrum and coccyx), two vertebrae are fortunate enough to have names. The occipitaltranscondylar approach exposes the clivus and the lower medulla and is performed after drilling the atlanto-occipital joint, condyle, and lower border of the hypoglossal canal. The occipital condyles are undersurface protuberances of the occipital bone in vertebrates, which function in articulation with the superior facets of the atlas vertebra. Type III injuries involve complete avulsion of the condyle and are presumed to result from excessive loading in rotation or lateral bending.4. The atlas (C01) and axis (C02) are two of the most important vertebrae in the spine. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. These are generally treated with immobilization if there is minimal displacement, or halo ring traction to reduce the fracture, then immobilization (Francis et al., 1981; Levine and Edwards, 1985). The pain radiates to the mastoid, ear, and vertex and is associated with scalp allodynia. The posterior portion ends at the level of the middle portion of the FM and blocks the angle of view to an anterior portion of the FM and of the craniovertebral junction. Learn more here. Patients failing immobilization may eventually require C12 fusion. The superior articular condyles form a joint (articulation) with the two occipital condyles of the occipital bone of the skull. CT reveals that type I injuries involve comminution of the condyle without fragment displacement. The apical ligament is 23.5 mm, the transverse ligament 21.9 mm, and the alar ligaments are 10.3 mm in length (Panjabi et al., 1991a). Check out the. Subluxation can generally be managed with traction starting at 7lb in children, increasing to 15lb, or in adults, starting at 15lb, and increasing to 20lb. Each head must be tagged and identified so that the carcass and the head can be reunited for further inspection if necessary; this is usually done using a four-piece gang-tag or head-tag, which maintains the sequence and identity of each carcass, head, tongue and organs. The resection of the posterior aspect of the condyle increases the angle of exposure, reduces brain stem retraction, and increases the working area of the posterior fossa.4-8,10,18,19 The presence of small anterior tumors, an elongated FM, a short distance between the foramen and the brain stem, and relatively large OCs represent the ideal conditions for resection of the condyle.20, A high-speed drill is used to remove the posterior portion of the condyle after displacement of the VAs to avoid injury of the vessel. In some dinosaurs, where the skull has not been preserved, the presence of a small occipital condyle suggests to some paleontologists that the skull of the dinosaur was relatively small. You're born with 33, but the sacrum and coccyx fuse to the rest of the spine, making it 24 by the time you're an adult. Its purpose is very important, but I'll get to that later. The structures of C1 and C2 are distinctive and are covered below. At presentation, patients with these fractures may be neurologically intact or can have significant neurological deficits ranging from mono- to quadriparesis (Clark and White, 1985; Przybylski, 1998). The foramina (the holes) give passage to the vertebral artery and vertebral vein. 8.5.3: Cervical Vertebrae is shared under a not declared license and was authored, remixed, and/or curated by Rosanna Hartline. The anterior portion of the condyle is directed anteriorly and medially toward the basion. Some exceptions to this exist, such as in the iguanodontian Anabisetia saldiviai where the condyle points downward. The atlas is the top-most bone, sitting just below the skull; it is followed by the axis. Use the links at the bottom of any email to manage the type of emails you receive or to unsubscribe. The prevalence of occipital condyle fractures is not definitely known. It is most commonly seen in high-energy trauma, often associated with other skull and/or cervical spine injuries.[1][2]. The cervical vertebrae are easily distinguished from thoracic and lumbar vertebrae not only by their size, but also because they have foramina in their transverse processes whereas the other vertebrae do not (with the exception of C2). The dens (above, in green), or odontoid process, is a toothlike projection of bone that rises perpendicularly from the upper surface of the body of the axis. An atlantodental interval of greater than 3.5mm is also suggestive of an incompetent transverse ligament. Breast and prostate cancer were the most common, followed by lung and colorectal carcinomas (Rodrguez-Pardo et al., 2016). The classical Jefferson fracture is a four-point burst fracture of the C1 ring, but more commonly is a two- or three-point fracture. (Top) Anatomical model of a cervical vertebra. The atlas and axis in particular work with the ligaments to move the neck. hbspt.cta._relativeUrls=true;hbspt.cta.load(189659, '7da024a9-4451-44f6-a682-29eaf2d8974b', {"useNewLoader":"true","region":"na1"}); hbspt.cta._relativeUrls=true;hbspt.cta.load(189659, 'd81c2b40-64cb-4f78-a901-2d949123900d', {"useNewLoader":"true","region":"na1"}); When you select "Subscribe" you will start receiving our email newsletter. Are you an instructor? Type II injuries are classified as stable and can be treated with or without a rigid external orthosis for pain control. 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Onset of neurologic symptoms may be immediate or delayed. 7.2A,B) (Alker et al., 1978; Bucholz et al., 1979). 23.9).61 Type I fractures (axial load and comminuted fractures) and type II fractures (extension of a skull-base fracture) are usually considered stable if isolated. Fig. 14.13. On physical examination, these patients often hold their neck rigidly, have tenderness of the occipital region (Capobianco et al., 2002), and may have fasciculations of the tongue associated with weakness (Posner, 1995a). Due to the pain and disability associated with it, this syndrome warrants timely treatment (Fig. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. A smaller longitudinal band extends from the dens to the ventral margin of foramen magnum. The diagnosis is usually on the basis of computed tomography (CT), and MRI may be useful in determining the extent of associated ligamentous injuries, although this has little utility from a treatment perspective. There are many types of vertebral joints, but the atlas and axis form the only craniovertebral joints in the body. The superior vertebral notches are very shallow, and lie behind the articular processes; the inferior lie in front of the articular processes, as in the other cervical vertebrae. The dens articulates with the facet on the atlas, as well as the transverse ligament, and this articulation provides the head with approximately 50% of its movement. The laminae are thick and strong, and the vertebral foramen large, but smaller than that of the atlas. The alar ligaments (Mauchart's ligament) have a length of approximately 10 mm and may occasionally insert to the atlas (Panjabi et al., 1991a). SekulaJr., in Schmidek and Sweet Operative Neurosurgical Techniques (Sixth Edition), 2012. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. Those failing external mobilization with pain, neurological deficit, or instability may require posterior occipitocervical fusion. All of the cervical vertebrae are smaller in size compared to thoracic and lumbar vertebrae. Want to learn more about the top two cervical vertebrae? Fractures with intact transverse ligaments can be treated in cervical collar or halo vest, and those with disruption in a halo vest with or without C12 surgical fusion (Levine and Edwards, 1986; Hadley et al., 1988; Sonntag et al., 1988; Fowler et al., 1990; McGuire and Harkey, 1995; Lee et al., 1998; Isolated fractures of the atlas in adults, 2002). We have award-winning 3D products and resources for your anatomy and physiology course! Traction is associated with a 10% risk of neurological deterioration (Diagnosis and management of traumatic atlanto-occipital dislocation injuries, 2002), and is contraindicated in longitudinal dislocations. For example, spontaneous epidural hematoma has been reported from an SBM in a patient with hepatocellular carcinoma (Woo et al., 2010). Depending on severity, these fractures may or may not present with neurological deficits ranging from lower cranial nerve deficits to quadriparesis. This is often also accompanied by neck stiffness (Moris et al., 1998). I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Additionally, cervical vertebrae are roughly triangle-shaped and C3 through C6 have spinous processes that have two branches (bifurcated). These transverse foramina serve as passages for paired vertebral arteries (right and left) traveling to the head. Doesn't matterbothnumbers are correct. The ligaments in the spine support and reinforce the joints between the vertebrae. The axis articulates with the atlas via its superior articular facets, which are convex and face upward and outward. Open surgical reduction is recommended for cases with severe angulation or displacement (Tay and Eismont, 2006). Occipital condyle injures are relatively rare and often associated with an occipitocervical dislocation.
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