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CLASSIFICATION&
CLINICAL SIGNS
DR NILESH JAIN
23.06.2007
THE TERM ‘CV JUNCTION’ REFERS
TO THE OCCIPITAL BONE
THAT SURROUNDS THE FORAMEN MAGNUM
AND THE ATLAS AND
THE AXIS VERTEBRAE
HISTORICAL ASPECT
Sclerotome division
ANTERIOR ATLANTO
-OCCIPITAL MEMBRANE
EXTENDS FROM
ANT.EDGE OF FM TO
ANT.ARCH C1
ANTERIOR LIGAMENTS
TECTORIAL MEMBRANE
CEPHALIC EXTENSION
OF PLL
INSERTED INTO
PROCESSUS BASILARIS
1 –2 cm ABOVE BASION
CRUCIATE LIGAMENT
OCCIPITOTRANSVERSE
LIGAMENT: TO BASION
INFERIOR LOGITUDINAL
BAND: TO AXIS BODY
TRUE TRANSVERSE
LIGAMENT
TRUE TRANSVERSE LIGAMENT
STRONG HORIZONTAL
PORTION
MAINTAINS THE
POSITION OF DENS IN
SAGITTAL &
CRANIOCAUDAL
DIRECTION
ARTICULATES WITH
ODONTOID FACET
INSERTED LATERALLY
IN BONY PROMINENCE
IN INNER
ASPECT OF CONDYLES
IT IS 8mm IN HEIGHT
AND 2-3 MM THICK IN
MIDLINE
ANTERIOR LIGAMENTS
BARKOWS LIG- FROM TIP
OF DENS TO ANT.LAT. FM
RIM
APICAL LIG- TIP OF DENS
TIP OF DENS TO MIDDLE
PART OF FM RIM
GRUBERS LIG- TRANSVERSE
LIG TO TIP OF DENS
ALAR LIGAMENT-
VERY STRONG
LIGAMENT
6 – 8 mm IN
DIAMETER
DENS TIP TO
OF FM
BLOOD SUPPLY
VERTIBRAL ARTERIES - ANT.
& POST. ASCENDING a.
CAROTID ARTERY : ANT.
ASCENDING a.
FORMS AN APICAL ARTERIAL
ARCADE IN THE REGION OF
ALAR LIGAMENT & SEND
PERFORATORS
VENOUS DRAINAGE :
PERIODONTAL VENOUS
PLEXUS &
SUBOCCIPITAL
EPIDURAL SINUS DRAIN TO
PHARYNGOVERTIBRAL
VEINS
LYMPHATIC DRAINAGE :
6.Tumors(neurofibromatosis,syringomy
elia)
7.Miscellaneous(e.g fetal warfarin
syndrome,Conradis syndrome)
Greenberg’s Classification of AAD
I Incompetence of odontoid process
A. Congenital
1. Type I Separate odontoid: OS odontoideum
2. Type II Free apical segment: Ossiculum Terminale
3. Type III Agenesis of odontoid base
4. Type IV Agenesis of Apical segment
5. Type V Agenesis of odontoid process totally
B. Traumatic
1. Acute
2. Chronic
C. Infectious
e.g Tuberculosis
D. Tumors
1. Primary
2. Metastatic
II Incompetence of Transverse Atlantal ligament
A. Congenital:
1. Idiopathic
2. Mongolism
B. Traumatic
1. Acute - Rupture of TAL
2. Chronic - Assimilation of atlas
- Block vertebrae C2 & C3
C. Hyperaemic
1.Infection –Bacterial/viral(Grisel’s syndrome)/granulomatous
2.Rheumatoid arthritis
Wadia proposed the following classification
Definition - Dens has developed necessarily but has failed to fuse with body
of the axis.
Two types:
A. Orthotopic variety: OS lies in place of dens and moves with atlas and axis.
B. Dystopic variety: OS lies near the skull-base and moves with clivus with
which it may be fused.
poly/syndactyly
pes cavus
scoliosis
sprengel shoulder,
Myelopathic features
Motor deficits- legs more involved
Cruciate paralysis
Posterior tract symptoms- Lhermitte
sign
Central cord syndrome
Neck pain/ cough headcahe
Cranial nerve symptoms
Lower cranial nerve paresis
Hearing loss(most common)-25%
Hypoglossal paralysis (Klaus 1969)
Brain stem/cerebellar signs
Sleep apnea and dysphagia
Nystagmus
Gait ataxia
Vascular symptoms
Syncope
Vertigo
Episodic paresis
Transient visual loss.
Due to vertebro basilar insufficiency
Present in 15 – 25% of cases.
The phenomenon of basilar migraine
affects about 25% of children with BI &
compression of the medulla.
This is usually involves compression of
vertebro basilar arterial system.
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