Craniocervical

junction
 Overview
Craniocervical
junction comprises
occiput, atlas, axis,
their articulations,
ligaments
Components of
Craniocervical
Junction

Bones
Occipital bone
Occipital condyles are
paired, oval-shaped, inferior
prominences of lateral
exoccipital portion of
occipital bone
Articular facet projects
laterally
C1 (atlas)
Composed of anterior and
posterior arches, no body
Paired lateral masses with
their superior and inferior
articular facets
Large transverse processes
with transverse foramen
C2 (axis)
Large body and superiorly projecting
odontoid process
Superior articulating facet surface is
convex & directed laterally
Inferior articular process + facet surface
is typical of lower cervical vertebrae
Superior facet is positioned relatively
anteriorly, inferior facet is posterior
with elongated pars interarticularis
Joints
Atlanto-occipital joints
Inferior articular facet of
occipital condyle: Oval, convex
surface, projects laterally
Superior articular facet of C1:
Oval, concave anteroposteriorly,
projects medially
Median atlanto-axial joints
Pivot type joint between dens
+ ring formed by anterior
arch + transverse ligament of
C1
Synovial cavities between
transverse
ligament/odontoid &
atlas/odontoid articulations
Lateral atlanto-axial joints
Inferior articular facet of C1:
Concave mediolaterally,
projects medially in coronal
plane
Superior articular facet of C2:
Convex surface, projects
laterally
Ligaments (from
anterior to posterior)
Anterior atlanto-
occipital membrane:
Connects anterior arch
C1 with anterior margin
foramen magnum
Odontoid ligaments
Apical ligament: Small fibrous
band extending from dens tip to
basion
Alar ligaments: Thick,
horizontally directed ligaments
extending from lateral surface of
dens tip to anteromedial
occipital condyles
Cruciate ligament
Transverse ligament: Strong
horizontal component between
lateral masses of C1, passes
behind dens
Craniocaudal component:
Fibrous band running from
transverse ligament superiorly to
foramen magnum and inferiorly
to C2
Tectorial membrane:
Continuation of posterior
longitudinal ligament;
attaches to anterior rim
foramen magnum
(posterior clivus)
Posterior atlanto-
occipital membrane
Posterior arch C1 to margin
of foramen magnum
Deficit laterally where
vertebral artery enters on
superior surface of C1
Biomechanics
Atlanto-occipital joint:
50% cervical
flexion/extension and
limited lateral motion
Atlanto-axial joint: 50%
cervical rotation
 Sagittal midline graphic of the
craniocervical junction. The
complex articulations and
ligamentous attachments are
highlighted. The midline atlanto-
axial articulations consist of
anterior & posterior median
atlanto-axial joints.
 The anterior joint is
between the posterior
aspect of the anterior C1
arch and the ventral
aspect of odontoid
process.
 The posterior joint is between the dorsal
aspect of the odontoid process and the
cruciate ligament. The midline view
shows a series of ligamentous connection
to the skull base including the anterior
atlanto-occipital membrane, apical
ligament, superior component of cruciate
ligament, tectorial membrane & posterior
atlanto-occipital membrane
 Posterior view of
craniocervical junction with
posterior elements cut
away to define the
components of the cruciate
ligament & alar ligaments
Axial graphic view of atlas
viewed from above. The
characteristic ring shape is
shown, composed of
anterior & posterior arches
& paired large lateral
masses.
 The superior articular facet is
concave anteroposteriorly &
projects medially for articulation
with the convex surface of the
occipital condyle at the atlanto-
occipital joint. The anterior arch
articulates with the odontoid
process at the anterior median
atlanto-axial joint
Atlas viewed from below. The
large inferior facet surface is
concave mediolaterally &
projects medially for
articulation with the convex
surface of the superior
articular facet of C2.
The canal of the atlas 3 cm in AP
diameter: Spinal cord, odontoid
process & free space for cord are
each about 1 cm in diameter. The
size of the anterior midline
tubercle of the anterior arch, and
spinous process of posterior arch
are quite variable.
Atlas viewed from anterior
perspective. The odontoid
process is the "purloined"
embryologic centrum of C1
which is incorporated into
C2, giving C2 its unique
morphology.
 The C2 body laterally is defined
by large lateral masses for
articulation with the inferior facet
of C1. The elongated pars
interarticularis of C2 ends with
the inferior articular process for
articulation with the superior
articular facet of C3.
 Atlas viewed from posterior
perspective. The odontoid process
has anterior and posterior joints
for articulation with C1. The
anterior median joint articulates
with the C1 arch, while the
posterior median joint (shown
here) involves the transverse
ligament.
 Sagittal graphic shows
important skull base
craniometry.

Orange: Chamberlain line -

drawn between hard palate &
opisthion.
 Yellow: McGregor
line - drawn between
hard palate to caudal
point of occipital bone
(base of occipital
bone).
 Green:
Wackenheim line -
drawn along
posterior surface
of clivus.
 Blue: McRae
foramen magnum
line - drawn
between basion &
opisthion.
 Red: Redlund-
Johnell line -
drawn from base
of C2 to McGregor
line
 Sagittal midline graphic of
Welcher basal angle - defined by
angle between lines drawn along
plane of sphenoid bone & along
clivus (nasion to sella, sella along
posterior clivus to basion).
Normal < 1400, platybasia if >
1400.
 Coronal graphic of
craniocervical junction
showing lines drawn along
atlanto-occipital joints to
measure atlanto-occipital joint
angle. Normal 125-130 , < 124
0 0

may reflect condyle hypoplasia.

 Sagittal CT reformat in the midline.
Chamberlain line is shown in orange
extending from hard palate to
opisthion. Projection of up to 1/3 of
dens (5 mm) above this line normal.
Wackenheim line is shown in green
along the clivus. The dens should lie
immediately inferior to line, & any
intersection is considered abnormal.
Sagittal T1 MR with Chamberlain line
shown in orange. Odontoid tip 5 mm
or more above line defines basilar
impression. McGregor line shown in
yellow. This line has the same
significance as Chamberlain line,
with the odontoid tip 7 mm or more
above line defining basilar
impression.
In this lateral plain film the Welcher basal
angle is shown in red. Platybasia exists if
angle > 1400 (normal < 1400). Ranawat
measurement shown in blue - used to
assess collapse at the C1-2 articulation.
Measurement taken from center of C2
pedicle to line connecting anterior &
posterior arch of C1. Normal ? 14 mm in
men & ? 13 mm in women. < 13 mm is
consistent with impaction.
 In this lateral plain film,
McCrae line is shown in
blue.
Normal : 35 mm diameter.
The normal odontoid
process does not extend
above this line.
 Redlund-Johnell
measurement shown in red.
This measurement is from
the base of C2 body to
McGregor line (shown in
yellow).
yellow Normal : 34 mm
in men, : 28 mm for women
Lateral plain film of the cervical spine in
a child shows physiologic anterior
displacement of C2 with respect to C3,
and C3 with respect to C4, the so-called
pseudosubluxation. Physiologic
subluxation is differentiated from
pathologic anterior displacement by the
absence of prevertebral soft tissue
swelling, reduction on extension &
assessment of the posterior cervical line
as described below.
 Posterior cervical line is drawn
along anterior aspect of C1-3
spinous processes. The anterior
C2 spinous process should be
within 2 mm of this line in flexion
& extension. Atlantodental
interval < 3.5 mm in children (< 3
mm in adults).
 AP open mouth view of odontoid
process. With proper positioning,
the odontoid process is visualized
in the midline with symmetrically
placed lateral C1 masses on either
side. The medial space between
odontoid and C1 lateral masses
should be symmetric as well.
 The lateral cortical margins of
the C1 & C2 lateral masses
should align. The atlanto-
occipital and atlanto-axial
joints are visible bilaterally,
with smooth cortical margins.
The bifid C2 process should not
be confused for fracture.
Lateral radiograph of craniocervical
junction. There is smooth anatomic
alignment of the posterior vertebral
body margins, and the posterior
spino-laminar line of the posterior
elements. The anterior arch of C1
should assume a well-defined oval
appearance, with sharp margination
between the anterior C1 arch and the
odontoid process.
 First of two coronal bone CT
reconstructions of the
craniocervical junction are
presented from anterior to
posterior. The odontoid process is
visualized in the midline as a
sharply corticated bony peg with
symmetrically placed lateral C1
masses on either side.
The lateral cortical margins of
the C1 lateral masses, and the
C2 lateral masses should align.
The atlanto-occipital and
atlanto-axial joints are visible
bilaterally, with even joint
margins, and sharp cortical
margins
 More posterior view of the
craniocervical junction. Both
atlanto-occipital joints are now
well-defined with smooth cortical
margins, sloping superolateral to
inferomedial. The atlanto-axial
joints are smoothly sloping
inferolateral to superomedial.
 First of six axial bone CT images
through the craniocervical junction
are presented from superior to
inferior. The anterolateral margin of
the foramen magnum is formed by
the prominent occipital condyles
which articulate with the superior
articular facets of the C1 lateral
masses.
 More inferior image of craniocervical
junction. The anterior arch of C1 is now
well-defined, with the odontoid process of
C2 coming into plane. The atlanto-
occipital joint is seen in oblique section
and therefore has poorly-defined margins.
The odontoid is tightly applied to the
posterior margin of the C1 arch, held in
place by the strong transverse component
of the cruciate ligament.
 Image at level of atlas.
The unique morphology
of the C1 body is defined
with its large transverse
process with transverse
foramen and ring shape.
 Image through lateral atlanto-
axial joints. This section defines
the junction of the odontoid
process with the body of C2. The
obliquely oriented atlanto-axial
joints are partially seen, with the
C1 component lateral to the joint
space, and the C2 component
medial.
Image through inferior
C2 body level showing
large C2 vertebral body
& vertebral arch formed
by gracile pedicles &
laminae.
Image through C2-3 intervertebral
disc level. The C2-3 neural foramen
is well-defined, with the posterior
margin formed by the superior
articular process of C3. The spinous
process of C2 is large and typically
bifid. The C2-3 disc assumes the
characteristic cervical cup-shaped
morphology bounded by uncinate
processes.
 Anterior view of a 3D-VRT
NECT examination. The
unique ability of the C1-2
articulation to provide
rotation is apparent in this
projection, with the bony peg
of the odontoid process
forming the pivot point for the
C1 ring.
 Lateral view of a 3D-VRT NECT
examination. The complex lateral
components of C1 and C2 bodies are
highlighted in this projection. The
superior facet of C2 is anteriorly
positioned to articulate with the inferior
articular facet of C1 while the inferior
articular facet of C2 is more posterior,
and forms the top of the cervical articular
"pillar". The articular facets are separated
by the elongated pars interarticularis.
 Superior view of a 3D-
VRT NECT examination
shows relationship of C1
ring with underlying C2
odontoid and lateral
masses.
 Anterior view of a 3D-VRT NECT
examination of craniocervical
junction. The relationship of the
atlanto-axial complex with the skull
base is highlighted in this projection.
The basion forms the anterior
margin of the foramen magnum,
with the tip of the odontoid process
below that level
 Posterior view of a 3D-VRT NECT
examination of cervical spine. The
opisthion forms the posterior margin
of the foramen magnum. The sloping
nature of both the C0-1 and C1-2
articulation is evident. The posterior
elements form broad attachments for
muscles, with prominent spinous
processes.
Posterior view of a 3D-VRT NECT
examination of craniocervical
junction with removal of posterior
elements shows the orientation of
atlanto-occipital & atlanto-axial
joints well. The proximity of the
basion to the odontoid tip is
evident.
Midline sagittal view of a 3D-VRT NECT
examination of cervical spine shows the
right half of the craniocervical junction.
Note the anterior position of the atlanto-
occipital & atlanto-axial joints relative to
the facet joints of the sub-axial cervical
spine. The midline relationship of the
basion, anterior C1 arch, and odontoid tip
are well shown.
 Sagittal view of a 3D-VRT NECT
examination of cervical spine with
attention to the lateral elements. The
midline structures have been cut
away, showing the posterior "pillar"
of the left side of the cervical spine
starting with the inferior articular
process of C2 and extending
caudally.
 The atlanto-axial and
atlanto-occipital joints
form a more anterior
column. The convex
inferior shape of the
occipital condyles allows
for flexion and extension
First of three axial T2 MR images
through the craniocervical
junction from superior to inferior
shows the anterior margin of the
foramen magnum, the
cervicomedullary junction and
adjacent vertebral artery flow
voids
 Image at level of C1 anterior arch. The
odontoid tip is seen as rounded
intermediate signal in the midline,
ventral to the cervical cord. The anterior
arch of C1 is visible, with its well-defined
cortical margins. The alar ligaments are
identified as low signal intensity bands
extending laterally from the lateral
margins of the odontoid process towards
the occipital condyles.
 More inferior image through
atlantodental joint. The anterior
atlantodental joint is seen along
ventral margin of odontoid
process. The cruciate ligament
(transverse component) is seen as
low signal bands curving over
dorsal margin of odontoid.
 Sagittal midline CT reformat shows the
ligamentous structures visible at the
craniocervical junction. The apical
ligament is visible as a linear band
between odontoid tip and clivus. The
tectorial membrane is the superior
extension of the posterior longitudinal
ligament. The anterior atlanto-occipital
membrane is the extension of the anterior
longitudinal ligament.
 Sagittal T1 MR midline image of
craniocervical junction. The
atlantodental interval is well-
defined by the adjacent low signal
cortical margins of C1 anterior
arch and the odontoid process.
The cruciate ligament is a low
signal band dorsal to the
odontoid.
 Sagittal T2 MR image of the
craniocervical junction. The
tectorial membrane, superior
extension of cruciate ligament,
apical ligament & anterior
atlanto-occipital membranes
are evident.
First of three parasagittal T1 MR images
shown from medial to lateral through
atlanto-occipital joint. This image
extends through the lateral cortical
margin of the odontoid, which is
incompletely visualized. The anterior
arch of C1 is obliquely visualized as it
curves posterolaterally. The lateral
extension of the cruciate ligament, the
transverse ligament is prominent.
The relationship of the occipital
condyle, C1 lateral mass +
atlanto-axial joint is
highlighted in this image. The
articular surface of occipital
condyle is convex & the
superior facet of C1 is concave
allowing for flexion/extension
 More lateral image of
craniocervical junction.
The atlanto-occipital
joint and atlanto-axial
joints are visible with
sharp, smooth cortical
margins