Skip to main content

Advertisement

SpringerLink
Log in

Atlas posterior arch and vertebral artery’s groove variants: a classification, morphometric study, clinical and surgical implications

  • Original Article
  • Published:
Surgical and Radiologic Anatomy Aims and scope Submit manuscript

Abstract

Background

The third part of the vertebral artery (VA) coursing in vertebral artery groove (VAG) may be injured during posterior craniocervical junction approaches.

Objective

The current study classifies all possible variants of the posterior arch (PA) of the atlas vertebra (C1), focusing on VAG and calculates their incidence. PA and VAG morphometry is studied in correlation with gender and age. Clinical and surgical implications of recorded variants are provided in an effort to explain associated pathology. The usefulness of three-dimensional computed tomography (3D-CT) in detecting PA variants is highlighted.

Materials and methods

Two hundred and forty-four Greek adult dry C1 were classified in types according to PA morphology [i.e. presence of an imprint or a distinct VAG and occurrence of a partially or completely ossified dorsal (PDP or CDP) or lateral (PLP or CLP) ponticle unilaterally or bilaterally]. Combined variants were also included.

Results

A VAG and an imprint were detected in 42.62% and 15.16%. A PDP and CDP were observed in 18.03% and 15.98%, while a CLP and PLP in 2.05% and 1.64%, respectively. Combined PDP and PLP were detected in 2.05%, a CDP and CLP similarly to a CDP and PLP in 1.23% and a PDP and CLP in 0.40%.

Conclusions

Variants’ classification will contribute to an in depth understanding of the complex C1 anatomy and may explain cases of VA entrapment and injury during PA fixation. Surgeons should carefully study 3D-CT imaging to ensure type, location, size and shape of C1 ponticles in combination with VAG morphology and VA course before screw insertion.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

C1:

Atlas vertebra

PA:

Posterior arch

VA:

Vertebral artery

VAG:

Vertebral artery groove

I:

Imprint

DP:

Dorsal ponticle

LP:

Lateral ponticle

PDP:

Partially ossified dorsal ponticle

CDP:

Completely ossified dorsal ponticle

PLP:

Partially ossified lateral ponticle

CLP:

Completely ossified lateral ponticle

DLP:

Dorsolateral ponticle

LM:

Lateral mass

TP:

Transverse process

TF:

Transverse foramen

AF:

Arcuate foramen

RTF:

Retrotransverse foramen

R:

Right side

L:

Left side

D1:

Linear distance of vertebral artery groove from the posterior midline to the most medial edge of vertebral artery groove on the inner cortex

D2:

Linear distance of vertebral artery groove from the posterior midline to the most medial edge of vertebral artery groove on the outer cortex

D3:

Linear distances of vertebral artery groove from the posterior midline to the most lateral edge of vertebral artery groove to the inner cortex

D4:

Linear distances of vertebral artery groove from the posterior midline to the most lateral edge of vertebral artery groove to the outer cortex

TEM:

Technical error of measurement

rTEM:

Relative technical error of measurement

R :

Coefficient of reliability

References

  1. Ansari MS, Singla M, Ravi KS, Goel P (2015) Morphometric analysis of atlas and its clinical significance: an anatomical study of indian human atlas vertebrae. Indian J Neurosurg 4:92–97

    Article  Google Scholar 

  2. Arslan D, Ozer MA, Govsa F, Kıtıs O (2018) The ponticulus posticus as risk factor for screw insertion into the first cervical lateral mass. World Neurosurg 113:579–585. https://doi.org/10.1016/j.wneu.2018.02.100 (Epub 2018 Feb 25)

    Article  Google Scholar 

  3. Barge JAJ (1918) Problems in kranio-vertebral Gebiet section. Verh K Akad Wetensch Amsterdam 20(2):102–105

    Google Scholar 

  4. Bodon G, Grimm A, Hirt B, Seifarth H (2016) Applied anatomy of screw placement via the posterior arch of the atlas and anatomy-based refinements of the technique. Eur J Orthop Surg Traumatol 26:793–803

    Article  PubMed  Google Scholar 

  5. Chevrel JP, Pineau H, Delmas A (1965) L’arc postérieur de l’atlas, ses variations, étude morphologique et statistique. CR Assoc Anat 50:280–288

    Google Scholar 

  6. Christensen DM, Eastlack RK, Lynch JJ, Yaszemski MJ, Currier BL (2007) C1 anatomy and dimensions relative to lateral mass screw placement. Spine 32:844–848

    Article  PubMed  Google Scholar 

  7. Cirpan S, Yonguc GN, Edizer M, Mas NG, Magden AO (2017) Foramen arcuale: a rare morphological variation located in atlas vertebrae. Surgi Radiol Anat 39(8):877–884

    Article  Google Scholar 

  8. Srijit Das, Suri R, Kapur V (2005) Double foramen transversarium. An osteological study with clinical implications. Int Med J 12:311–313

    Google Scholar 

  9. De Carvalho MF, Rocha RT, Monteiro JTS, Pereira CU, Leite RF, Defino HLA (2009) Vertebral artery groove anatomy. Acta Ortop Bras 17:50–54

    Article  Google Scholar 

  10. Dhall U, Chhabra S, Dhall JC (1993) Bilateral asymmetry in bridges and superior articular facets of atlas vertebra. J Anat Soc India 42:23–27

    Google Scholar 

  11. Ebraheim NA, Xu R, Lin D, Ahmad M, Heck BE (1998) The quantitative anatomy of the vertebral artery groove of atlas and its relation to the posterior atlanto-axial approach. Spine 23:320–323

    Article  CAS  PubMed  Google Scholar 

  12. El-S Hassanein GH (2013) Injury risk of vertebral artery during screw placement through atlas posterior arch. Basic Sci Med 2:21–23

    Google Scholar 

  13. Gosavi SN, Vatsalaswamy P (2012) Morphometric study of the atlas vertebra using manual method. Malays Orthop J 6:18–20

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gupta C, Radhakrishnan P, Palimar V, D’Souza AS, Kiruba NL (2013) A quantitative analysis of atlas vertebrae and its abnormalities. J Morphol Sci 30(Suppl 2):77–81

    Google Scholar 

  15. Gupta T (2008) Quantitative anatomy of vertebral artery groove on the posterior arch of atlas in relation to spinal surgical procedures. Surg Radiol Anat 30:239–242

    Article  PubMed  Google Scholar 

  16. Hasan M, Shukla S, Siddiqui MS, Singh D (2001) Posterolateral tunnels and ponticuli in human atlas vertebrae. J Anat 199:339–343

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Huang DG, He SM, Pan JW, Hui H, Hu HM, He BR, Li H, Zhang XF, Hao DJ (2014) Is the 4 mm height of the vertebral artery groove really a limitation of C1 pedicle screw insertion? Eur Spine J 23:1109–1114

    Article  PubMed  Google Scholar 

  18. Ishak B, Schneider T, Tubbs RS, Gimmy V, Younsi A, Unterberg AW, Kiening KL (2017) Modified posterior C1 lateral mass screw insertion for type II odontoid process fractures using intraoperative computed tomography-based spinal navigation to minimize postoperative occipital neuralgia. World Neurosurg 107:194–201

    Article  PubMed  Google Scholar 

  19. Karau PB, Ogeng’o JA, Hassanali J, Odula P (2010) Anatomy and prevalence of atlas vertebrae bridges in a Kenyan population: an osteological study. Clin Anat 23:649–653

    Article  PubMed  Google Scholar 

  20. Khanfour AA, El Sekily NM (2015) Relation of the vertebral artery segment from C1 to C2 vertebrae: an anatomical study. Alexandria J Med 51:143–151

    Article  Google Scholar 

  21. Koutsouraki E, Avdelidi E, Michmizos D, Kapsali SE, Costa V, Baloyannis S (2010) Kimmerle’s anomaly as a possible causative factor of chronic tension-type headaches and neurosensory hearing loss: case report and literature review. Int J Neurosci 120:236–239

    Article  PubMed  Google Scholar 

  22. Le Double AF (1912) Traité des variations de la colonne vertébrale de l’homme. Vigot, Paris

    Google Scholar 

  23. Le Minor JM (1997) The retrotransverse foramen of the human atlas vertebra: a distinctive variant within primates. Acta Anat (Basel) 160(3):208–212

    Article  Google Scholar 

  24. Ma X-Y, Yin Q-S, Wu Z-H, Xia H, Lu J-F, Zhong S-Z (2005) Anatomic considerations for the pedicle screw placement in the first cervical vertebra. Spine 30:1519–1523

    Article  PubMed  Google Scholar 

  25. Macalister A (1869) Notes on the homologies and comparative anatomy of the atlas and axis. J Anat 3:54–64

    Google Scholar 

  26. Ouyang ZY, Qiu MJ, Zhao Z, Wu XB, Tong LS (2017) Congenital anomaly of the posterior arch of the atlas: a rare risk factor for posterior circulation stroke. J Neurointerventional Surg 9(7):e27

    Article  Google Scholar 

  27. Patel NP, Gupta DS (2016) A morphometric study of adult human atlas vertebrae in South Gujarat population, India. Int J Res Med Sci 4:4380–4386

    Article  Google Scholar 

  28. Pękala PA, Henry BM, Pękala JR, Hsieh WC, Vikse J, Sanna B, Walocha JA, Tubbs RS, Tomaszewski KA (2017) Prevalence of foramen arcuale and its clinical significance: a meta-analysis of 55,985 subjects. J Neurosurg Spine 27:276–290

    Article  PubMed  Google Scholar 

  29. Pękala PA, Henry BM, Phan K, Pękala JR, Taterra D, Walocha JA, Tubbs RS, Tomaszewski KA (2018) Presence of a foramen arcuale as a possible cause for headaches and migraine: systematic review and meta-analysis. J Clin Neurosci 54:113–118

    Article  PubMed  Google Scholar 

  30. Radojevic S, Negovanovic B (1963) La gouttière et les anneaux osseux de l’artère vertébrale de l’atlas. Acta Anat (Basel) 55:186–194

    Article  CAS  Google Scholar 

  31. Ravichandan ND, Shanthi KC, Shrinivasan V (2011) Vertebral artery groove in the atlas and its clinical significance. J Clin Diagnos Res 5:542–545

    Google Scholar 

  32. Rekha BS, D’Sa Divya Shanthi (2016) Morphometric anatomy of the atlas (C1) vertebra among Karnataka population in India. Int J Anat Res 4:1981–1984

    Article  Google Scholar 

  33. Sanchis-Gimeno JA, Llido S, Perez-Bermejo M, Nalla S (2018) Prevalence of anatomic variations of the atlas vertebra. Spine J. 2018

  34. Sato E, Noriyasu S (1978) Studies on the ponticulus posterior and ponticulus lateralis of the human first cervical vertebra. Sapporo Med J 47:599–617

    Google Scholar 

  35. Saunders SR, Popovich S (1978) A family study of two skeletal variants: atlas bridging and clinoid bridging. Am J Phys Anthropol 49:193–204

    Article  CAS  PubMed  Google Scholar 

  36. Sengul G, Kadioglu HH (2006) Morphometric anatomy of atlas and axis vertebra. Turkish Neurosurgery 16:69–76

    Google Scholar 

  37. Senoglu M, Gümüşalan Y, Yüksel KZ, Uzel M, Celik M, Ozbag D (2006) The effect of posterior bridging of C-1 on craniovertebral junction surgery. J Neurosurg Spine 5:50–52

    Article  PubMed  Google Scholar 

  38. Smith JD, Jack MM, Harn NR, Bertsch JR, Arnold PM (2016) Screw placement accuracy and outcomes following O-Arm-navigated atlantoaxial fusion: a feasibility study. Global Spine J 6:344–349

    Article  PubMed  Google Scholar 

  39. Song MS, Lee HJ, Kim JT, Kim JH, Hong JT (2017) Ponticulus posticus: morphometric analysis and Its anatomical Implications for occipito-cervical fusion. Clin Neurol Neurosurg 157:76–81

    Article  PubMed  Google Scholar 

  40. Tan M, Wang H, Wang W, Zhang G, Yi P, Li Z, Wei H, Yang F (2003) Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass. Spine 28:888–895

    PubMed  Google Scholar 

  41. Vaněk P, Bradáč O, de Lacy P, Konopková R, Lacman J, Beneš V (2017) Vertebral artery and osseous anomalies characteristic at the craniocervical junction diagnosed by CT and 3D CT angiography in normal Czech population: analysis of 511 consecutive patients. Neurosurg Rev 40:369–376

    Article  PubMed  Google Scholar 

  42. Von Torklus D, Gele W (1972) The upper cervical spine. Grune and Stratton, New York, pp 28–30

    Google Scholar 

  43. Wright NM, Lauryssen C (1998) Vertebral artery injury in C1–C2 transarticular screw fixation: results of a surgery of the AANS/CNS section on disorders of the spine and peripheral nerves. J Neurosurg 88:634–640

    Article  CAS  PubMed  Google Scholar 

  44. Yamaguchi S, Eguchi K, Kiura Y, Takeda M, Kurisu K (2008) Posterolateral protrusion of the vertebral artery over the posterior arch of the atlas: quantitative anatomical study using three-dimensional computed tomography angiography. J Neurosurg Spine 9:167–174

    Article  PubMed  Google Scholar 

  45. Yeom JS, Kafle D, Nguyen NQ, Noh W, Park KW, Chang BS, Lee CK, Riew KD (2012) Routine insertion of the lateral mass screw via the posterior arch for C1 fixation: feasibility and related complications. Spine J 12:476–483

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Konstantinos Natsis and Maria Piagkou equally contributed to the paper.

Authors and Affiliations

  1. Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Konstantinos Natsis & Nikolaos Lazaridis

  2. Department of Microbiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

    Evangelia-Theophano Piperaki

  3. Department of Neurosurgery, General District Hospital of Nikaia, Piraeus, Greece

    Moschos Fratzoglou

  4. Department of Neurosurgery, Hippokratio General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Parmenion P. Tsitsopoulos

  5. Department of Anatomy, Faculty of Health Sciences, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

    Αlexandros Samolis, Michael Kostares & Maria Piagkou

Authors
  1. Konstantinos Natsis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Evangelia-Theophano Piperaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Moschos Fratzoglou
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nikolaos Lazaridis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Parmenion P. Tsitsopoulos
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Αlexandros Samolis
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Michael Kostares
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Maria Piagkou
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KN: project development, data analysis, classification system, manuscript editing and final approval, ETP: data collection, data analysis, schematic drawings, PPT, MF and NL: manuscript editing, AS: data analysis, manuscript editing, MK: data analysis, and MP: project development, data collection, data analysis and manuscript editing.

Corresponding author

Correspondence to Konstantinos Natsis.

Ethics declarations

Conflict of interest

There is no conflict of interest.

Informed consent

The authors of the current study express their gratitude to the body donors who donated their bodies before death (written informed consent) and throughout this act; their vertebrae were used for this study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Natsis, K., Piperaki, ET., Fratzoglou, M. et al. Atlas posterior arch and vertebral artery’s groove variants: a classification, morphometric study, clinical and surgical implications. Surg Radiol Anat 41, 985–1001 (2019). https://doi.org/10.1007/s00276-019-02256-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00276-019-02256-1

Keywords

Search

Navigation