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Semin Musculoskelet Radiol 2023; 27(05): 499-511
DOI: 10.1055/s-0043-1772190
Review Article

Imaging of the Craniocervical Junction: A Pictorial Review

Kris Mertens 
1   Department of Radiology, UZ Leuven, University of Leuven, Leuven, Belgium
2   Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium
,
Filip M. Vanhoenacker 
1   Department of Radiology, UZ Leuven, University of Leuven, Leuven, Belgium
2   Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium
3   Department of Diagnostic Sciences, UZ Gent, Faculty of Medicine and Health Sciences, Ghent, Belgium
4   Department of Radiology, UZ Antwerpen, University of Antwerp, Edegem, Belgium
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Abstract

The craniocervical junction (CCJ) is a complex anatomical structure comprising the occiput, the atlas, and the axis. The CCJ plays an important role in maintaining stability, providing protection, and supporting neurovascular structures. The CCJ can be affected by a wide range of congenital variants and traumatic, degenerative, inflammatory, and tumoral pathologies. This pictorial review the normal anatomy of the CCJ and presents the most common anatomical variants and pathologic conditions affecting the CCJ.

Keywords

cervical spine - craniocervical junction - conventional radiography - magnetic resonance imaging - computed tomography

Supplementary Material



Publication History

Article published online:
10 October 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Offiah CE, Day E. The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. Insights Imaging 2017; 8 (01) 29-47
    CrossrefPubMedGoogle Scholar
  • 2 Menezes AH, Traynelis VC. Anatomy and biomechanics of normal craniovertebral junction (a) and biomechanics of stabilization (b). Childs Nerv Syst 2008; 24 (10) 1091-1100
    CrossrefPubMedGoogle Scholar
  • 3 Tubbs RS, Hallock JD, Radcliff V. et al. Ligaments of the craniocervical junction. J Neurosurg Spine 2011; 14 (06) 697-709
    CrossrefPubMedGoogle Scholar
  • 4 Tubbs RS, Wellons III JC, Blount JP, Oakes WJ. Posterior atlantooccipital membrane for duraplasty. Technical note. J Neurosurg 2002; 97 (02) 266-268
    PubMedGoogle Scholar
  • 5 Krakenes J, Kaale BR, Rorvik J, Gilhus NE. MRI assessment of normal ligamentous structures in the craniovertebral junction. Neuroradiology 2001; 43 (12) 1089-1097
    CrossrefPubMedGoogle Scholar
  • 6 Fiester P, Rao D, Soule E, Orallo P, Rahmathulla G. Anatomic, functional, and radiographic review of the ligaments of the craniocervical junction. J Craniovertebr Junction Spine 2021; 12 (01) 4-9
    CrossrefPubMedGoogle Scholar
  • 7 Jain N, Verma R, Garga UC, Baruah BP, Jain SK, Bhaskar SNCT. CT and MR imaging of odontoid abnormalities: a pictorial review. Indian J Radiol Imaging 2016; 26 (01) 108-119
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Smoker WR, Khanna G. Imaging the craniocervical junction. Childs Nerv Syst 2008; 24 (10) 1123-1145
    CrossrefPubMedGoogle Scholar
  • 9 Ahn J, Duran M, Syldort S. et al. Arcuate foramen: anatomy, embryology, nomenclature, pathology, and surgical considerations. World Neurosurg 2018; 118: 197-202
    CrossrefPubMedGoogle Scholar
  • 10 McClugage SG, Oakes WJ. The Chiari I malformation. J Neurosurg Pediatr 2019; 24 (03) 217-226
    CrossrefPubMedGoogle Scholar
  • 11 Tubbs RS, Beckman J, Naftel RP. et al. Institutional experience with 500 cases of surgically treated pediatric Chiari malformation type I. J Neurosurg Pediatr 2011; 7 (03) 248-256
    CrossrefPubMedGoogle Scholar
  • 12 Pindrik J, McAllister AS, Jones JY. Imaging in Chiari I malformation. Neurosurg Clin N Am 2023; 34 (01) 67-79
    CrossrefPubMedGoogle Scholar
  • 13 Barkovich AJ, Wippold FJ, Sherman JL, Citrin CM. Significance of cerebellar tonsillar position on MR. AJNR Am J Neuroradiol 1986; 7 (05) 795-799
    PubMedGoogle Scholar
  • 14 Wallace MJ, Kruse RW, Shah SA. The spine in patients with osteogenesis imperfecta. J Am Acad Orthop Surg 2017; 25 (02) 100-109
    CrossrefPubMedGoogle Scholar
  • 15 Van Dijk FS, Sillence DO. Osteogenesis imperfecta: clinical diagnosis, nomenclature and severity assessment. Am J Med Genet A 2014; 164A (06) 1470-1481
    CrossrefPubMedGoogle Scholar
  • 16 Marom R, Rabenhorst BM, Morello R. Osteogenesis imperfecta: an update on clinical features and therapies. Eur J Endocrinol 2020; 183 (04) R95-R106
    CrossrefPubMedGoogle Scholar
  • 17 Menezes AH. Specific entities affecting the craniocervical region: osteogenesis imperfecta and related osteochondrodysplasias: medical and surgical management of basilar impression. Childs Nerv Syst 2008; 24 (10) 1169-1172
    CrossrefPubMedGoogle Scholar
  • 18 Janus GJ, Engelbert RH, Beek E, Gooskens RH, Pruijs JE. Osteogenesis imperfecta in childhood: MR imaging of basilar impression. Eur J Radiol 2003; 47 (01) 19-24
    CrossrefPubMedGoogle Scholar
  • 19 Hughes DG, Chadderton RD, Cowie RA, Wraith JE, Jenkins JP. MRI of the brain and craniocervical junction in Morquio's disease. Neuroradiology 1997; 39 (05) 381-385
    CrossrefPubMedGoogle Scholar
  • 20 Padash S, Obaid H, Henderson RDE. et al. A pictorial review of the radiographic skeletal findings in Morquio syndrome (mucopolysaccharidosis type IV). Pediatr Radiol 2023; 53 (05) 971-983
    CrossrefPubMedGoogle Scholar
  • 21 Izzo R, Popolizio T, Balzano RF. et al. Imaging of cranio-cervical junction traumas. Eur J Radiol 2020; 127: 108960
    CrossrefPubMedGoogle Scholar
  • 22 Santos-Nunez G, Lo HS, Kotecha H, Jose J, Abayazeed A. Imaging of spine fractures with emphasis on the craniocervical junction. Semin Ultrasound CT MR 2018; 39 (04) 324-335
    CrossrefPubMedGoogle Scholar
  • 23 Anderson PA, Montesano PX. Morphology and treatment of occipital condyle fractures. Spine 1988; 13 (07) 731-736
    CrossrefPubMedGoogle Scholar
  • 24 Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am 1977; 59 (01) 37-44
    CrossrefPubMedGoogle Scholar
  • 25 Lustrin ES, Karakas SP, Ortiz AO. et al. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics 2003; 23 (03) 539-560
    CrossrefPubMedGoogle Scholar
  • 26 Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974; 56 (08) 1663-1674
    CrossrefPubMedGoogle Scholar
  • 27 Chu EC, Wong AY, Lee LY. Craniocervical instability associated with rheumatoid arthritis: a case report and brief review. AME Case Rep 2021; 5: 12
    CrossrefPubMedGoogle Scholar
  • 28 Ellatif M, Sharif B, Baxter D, Saifuddin A. Update on imaging of the cervical spine in rheumatoid arthritis. Skeletal Radiol 2022; 51 (08) 1535-1551
    CrossrefPubMedGoogle Scholar
  • 29 Shlobin NA, Dahdaleh NS. Cervical spine manifestations of rheumatoid arthritis: a review. Neurosurg Rev 2021; 44 (04) 1957-1965
    CrossrefPubMedGoogle Scholar
  • 30 Joaquim AF, Ghizoni E, Tedeschi H, Appenzeller S, Riew KD. Radiological evaluation of cervical spine involvement in rheumatoid arthritis. Neurosurg Focus 2015; 38 (04) E4
    CrossrefPubMedGoogle Scholar
  • 31 Drosos AA, Pelechas E, Voulgari PV. Radiological findings of the cervical spine in rheumatoid arthritis: what a rheumatologist should know. Curr Rheumatol Rep 2020; 22 (06) 19
    CrossrefPubMedGoogle Scholar
  • 32 Stiskal MA, Neuhold A, Szolar DH. et al. Rheumatoid arthritis of the craniocervical region by MR imaging: detection and characterization. AJR Am J Roentgenol 1995; 165 (03) 585-592
    CrossrefPubMedGoogle Scholar
  • 33 Kumar Y, Gupta N, Chhabra A, Fukuda T, Soni N, Hayashi D. Magnetic resonance imaging of bacterial and tuberculous spondylodiscitis with associated complications and non-infectious spinal pathology mimicking infections: a pictorial review. BMC Musculoskelet Disord 2017; 18 (01) 244
    CrossrefPubMedGoogle Scholar
  • 34 Rivas-Garcia A, Sarria-Estrada S, Torrents-Odin C, Casas-Gomila L, Franquet E. Imaging findings of Pott's disease. Eur Spine J 2013; 22 (Suppl. 04) 567-578
    CrossrefPubMedGoogle Scholar
  • 35 Teka M, Ghozlen HB, Zaier AY, Hnia MB, Naouar N, Abid F. Cervical spine tuberculosis. Pan Afr Med J 2020; 37: 7
    CrossrefPubMedGoogle Scholar
  • 36 Garg RK, Somvanshi DS. Spinal tuberculosis: a review. J Spinal Cord Med 2011; 34 (05) 440-454
    CrossrefPubMedGoogle Scholar
  • 37 Tali ET. Spinal infections. Eur J Radiol 2004; 50 (02) 120-133
    CrossrefPubMedGoogle Scholar
  • 38 Currie S, Galea-Soler S, Barron D, Chandramohan M, Groves C. MRI characteristics of tuberculous spondylitis. Clin Radiol 2011; 66 (08) 778-787
    CrossrefPubMedGoogle Scholar
  • 39 Scutellari PN, Galeotti R, Leprotti S, Ridolfi M, Franciosi R, Antinolfi G. The crowned dens syndrome. Evaluation with CT imaging. Radiol Med (Torino) 2007; 112 (02) 195-207
    CrossrefPubMedGoogle Scholar
  • 40 Feydy A, Lioté F, Carlier R, Chevrot A, Drapé JL. Cervical spine and crystal-associated diseases: imaging findings. Eur Radiol 2006; 16 (02) 459-468
    CrossrefPubMedGoogle Scholar
  • 41 Lee GS, Kim RS, Park HK, Chang JC. Crowned dens syndrome: a case report and review of the literature. Korean J Spine 2014; 11 (01) 15-17
    CrossrefPubMedGoogle Scholar
  • 42 Nahi H, Genell A, Wålinder G. et al. Incidence, characteristics, and outcome of solitary plasmacytoma and plasma cell leukemia. Population-based data from the Swedish Myeloma Register. Eur J Haematol 2017; 99 (03) 216-222
    CrossrefPubMedGoogle Scholar
  • 43 Ozsahin M, Tsang RW, Poortmans P. et al. Outcomes and patterns of failure in solitary plasmacytoma: a multicenter Rare Cancer Network study of 258 patients. Int J Radiat Oncol Biol Phys 2006; 64 (01) 210-217
    CrossrefPubMedGoogle Scholar
  • 44 Pinter NK, Pfiffner TJ, Mechtler LL. Neuroimaging of spine tumors. Handb Clin Neurol 2016; 136: 689-706
    CrossrefPubMedGoogle Scholar
  • 45 Saad A, Azzopardi C, Haleem S, Czyz M, James SL, Botchu R. Tumours of the odontoid peg revisited. Indian J Radiol Imaging 2020; 30 (04) 420-426
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Major NM, Helms CA, Richardson WJ. The “mini brain”: plasmacytoma in a vertebral body on MR imaging. AJR Am J Roentgenol 2000; 175 (01) 261-263
    CrossrefPubMedGoogle Scholar
  • 47 O'Sullivan MD, Lyons F, Morris S, Synnott K, Munigangaiah S, Devitt A. Metastasis affecting craniocervical junction: current concepts and an update on surgical management. Global Spine J 2018; 8 (08) 866-871
    CrossrefPubMedGoogle Scholar
  • 48 Schweitzer ME, Levine C, Mitchell DG, Gannon FH, Gomella LG. Bull's-eyes and halos: useful MR discriminators of osseous metastases. Radiology 1993; 188 (01) 249-252
    CrossrefPubMedGoogle Scholar
  • 49 Setzer M, Vatter H, Marquardt G, Seifert V, Vrionis FD. Management of spinal meningiomas: surgical results and a review of the literature. Neurosurg Focus 2007; 23 (04) E14
    CrossrefPubMedGoogle Scholar
  • 50 Dührsen L, Emami P, Matschke J, Abboud T, Westphal M, Regelsberger J. Meninigiomas of the craniocervical junction—a distinctive subgroup of meningiomas. PLoS One 2016; 11 (04) e0153405
    CrossrefPubMedGoogle Scholar
  • 51 Sotoudeh H, Yazdi HR. A review on dural tail sign. World J Radiol 2010; 2 (05) 188-192
    CrossrefPubMedGoogle Scholar
  • 52 Parmar HA, Ibrahim M, Castillo M, Mukherji SK. Pictorial essay: diverse imaging features of spinal schwannomas. J Comput Assist Tomogr 2007; 31 (03) 329-334
    CrossrefPubMedGoogle Scholar
  • 53 Bhargava R, Parham DM, Lasater OE, Chari RS, Chen G, Fletcher BD. MR imaging differentiation of benign and malignant peripheral nerve sheath tumors: use of the target sign. Pediatr Radiol 1997; 27 (02) 124-129
    CrossrefPubMedGoogle Scholar
  • 54 Orguc S, Arkun R. Primary tumors of the spine. Semin Musculoskelet Radiol 2014; 18 (03) 280-299
    Article in Thieme ConnectPubMedGoogle Scholar
  • 55 Murphey MD, Minn MJ, Contreras AL. et al. Imaging of spinal chordoma and benign notochordal cell tumor (BNCT) with radiologic pathologic correlation. Skeletal Radiol 2023; 52 (03) 349-363
    CrossrefPubMedGoogle Scholar
  • 56 Yamazawa E, Takahashi S, Shin M. et al. MRI-based radiomics differentiates skull base chordoma and chondrosarcoma: a preliminary study. Cancers (Basel) 2022; 14 (13) x
    CrossrefPubMedGoogle Scholar
  • 57 Cui JF, Hao DP, Chen HS, Liu JH, Hou F, Xu WJ. Computed tomography and magnetic resonance imaging features of cervical chordoma. Oncol Lett 2018; 16 (01) 861-865
    PubMedGoogle Scholar
  • 58 Smolders D, Wang X, Drevelengas A, Vanhoenacker F, De Schepper AM. Value of MRI in the diagnosis of non-clival, non-sacral chordoma. Skeletal Radiol 2003; 32 (06) 343-350
    CrossrefPubMedGoogle Scholar
  • 59 Lakhani DA, Martin D. Ecchordosis physaliphora: case report and brief review of the literature. Radiol Case Rep 2021; 16 (12) 3937-3939
    CrossrefPubMedGoogle Scholar
  • 60 Sarkar N, Chakravarthy S, Chakravarty R, Mukhopadhyay S. Radiological diagnosis of a rare prepontine lesion: ecchordosis physaliphora. Cureus 2022; 14 (04) e24335
    PubMedGoogle Scholar
  • 61 Chihara C, Korogi Y, Kakeda S. et al. Ecchordosis physaliphora and its variants: proposed new classification based on high-resolution fast MR imaging employing steady-state acquisition. Eur Radiol 2013; 23 (10) 2854-2860
    CrossrefPubMedGoogle Scholar
  • 62 Awad M, Gogos AJ, Kaye AH. Skull base chondrosarcoma. J Clin Neurosci 2016; 24: 1-5
    CrossrefPubMedGoogle Scholar
  • 63 Hasegawa H, Shin M, Niwa R. et al. Revisitation of imaging features of skull base chondrosarcoma in comparison to chordoma. J Neurooncol 2022; 159 (03) 581-590
    CrossrefPubMedGoogle Scholar
  • 64 Flemming DJ, Murphey MD, Carmichael BB, Bernard SA. Primary tumors of the spine. Semin Musculoskelet Radiol 2000; 4 (03) 299-320
    Article in Thieme ConnectPubMedGoogle Scholar
  • 65 Liu JK, Burger PC, Harnsberger HR, Couldwell WT. Primary intraosseous skull base cavernous hemangioma: case report. Skull Base 2003; 13 (04) 219-228
    Article in Thieme ConnectPubMedGoogle Scholar
  • 66 Hoyle JM, Layfield LJ, Crim J. The lipid-poor hemangioma: an investigation into the behavior of the “atypical” hemangioma. Skeletal Radiol 2020; 49 (01) 93-100
    CrossrefPubMedGoogle Scholar
  • 67 Alexiou GA, Lampros M, Gavra MM, Vlachos N, Ydreos J, Boviatsis EJ. Primary intraosseous cavernous hemangioma of the cranium: a systematic review of the literature. World Neurosurg 2022; 164: 323-329
    CrossrefPubMedGoogle Scholar