Vol. 118 No.

6 December 2014

Cone beam computed tomography imaging of ponticulus posticus:

prevalence, characteristics, and a review of the literature
Ibrahim Sevki Bayrakdar, DDS,a Ozkan Miloglu, DDS, PhD,b Oguzhan Altun, DDS, PhD,c Ismail Gumussoy, DDS,a
Dogan Durna, DDS, PhD,d and Ahmet Berhan Yilmaz, DDS, PhDe
Objective. The aim of this study was to investigate the frequency of ponticulus posticus (PP) using cone beam computed
tomography (CBCT) and to describe the radiologic characteristics of the detected cases.
Study Design. The presence and types of PP were investigated on 730 CBCT images.
Results. PP was found in 17.4% (127) of the 730 CBCT scans. Of these 127 patients, 79 (10.8%) had bilateral PP and 48
(6.6%) had unilateral PP. Male predominance was found with a prevalence of 19.5% (54 of 277) and female prevalence was
16.1% (73 of 453). The prevalence of PP increased with age; the highest prevalence of PP was seen in those who were 49 to 81
years of age.
Conclusions. This study shows that PP is not an uncommon anatomic variation and is a natural incidental finding on CBCT.
(Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:e210-e219)

The atlas is the rst cervical vertebra of the spine. This

cervical vertebra has several morphologic features that
differentiate it from other vertebrae, including the
absence of a vertebral body; a unique ring-shaped
arrangement surrounding the dens of the axis, which is
called the second cervical vertebra; and a unique
articulation with the cranium on its cephalad
perspective. Ponticulus posticus (PP) is a variation
occurring on the atlas vertebra. Ponticulus posticus, a
Latin term that means the little posterior bridge, is a
bony bridge between the posterior part of the superior
articular process and the posterolateral part of the superior margin of the posterior arch of the atlas.1,2 In
the literature, there are many terms that describe this
anomaly, including ponticulus posticus, foramen sagittale, foramen atlantoideum posterior, Kimmerles
anomaly, foramen retroarticulare superior, canalis
vertebralis, retroarticular vertebral artery ring, retroarticular canal, foramen arcuale, and retrocondylar
vertebral artery.1-5
PP can be evaluated radiographically. Although
lateral cephalography1,2,5-17 and computed tomography (CT)12,18-20 have been used to evaluate PP, cone
beam computed tomography (CBCT) has been
a

Research Assistant, Department of Dentomaxillofacial Radiology,

Faculty of Dentistry, Ataturk University, Erzurum, Turkey.
b
Associated Professor, Department of Dentomaxillofacial Radiology,
Faculty of Dentistry, Ataturk University, Erzurum, Turkey.
c
Assistant Professor, Department of Dentomaxillofacial Radiology,
Faculty of Dentistry, Inonu University, Malatya, Turkey.
d
Specialist, Department of Dentomaxillofacial Radiology, Faculty of
Dentistry, Ataturk University, Erzurum, Turkey.
e
Professor, Department of Dentomaxillofacial Radiology, Faculty of
Dentistry, Ataturk University, Erzurum, Turkey.
Received for publication Jul 7, 2014; accepted for publication Sep 11,
2014.
2014 Elsevier Inc. Open access under CC BY-NC-ND license.
2212-4403
http://dx.doi.org/10.1016/j.oooo.2014.09.014

e210

previously used only in one study.21 CBCT has low

doses of radiation, a short imaging time, and better
image resolution compared with CT. CBCT also produces data from all of the 2D images, including
panoramic radiography, lateral cephalography, and
others, and it can also create 3D images.22 The aim of
this study was to determine the prevalence of PP using
CBCT, to categorize the variation (absent, partial and
complete) of the detected cases, to suggest an imaging
protocol for PP on CBCT, and to present a review of
the literature on PP.

METHODS
Study population
We designed a retrospective cohort study using the
CBCT images from 730 patients who presented to the
Oral Diagnosis and Radiology service at Ataturk Universitys Faculty of Dentistry between January 2010
and December 2013. Cases in which the cervical
vertebrae could not be seen properly, for technical or
anatomic reasons, were not included in this study.
Imaging procedures
Cone beam imaging was performed using a NewTom
3G (Quantitative Radiology, Verona, Italy) at panele
based CBCT machine. The patient was placed in a

Statement of Clinical Relevance

Ponticulus posticus (PP) can have a signicant effect
in the management of cervical spine surgery, especially surgery that involves lateral mass screw
placement. Cone beam computed tomography
(CBCT) may be used to assess this anatomic
variation.

OOOO
Volume 118, Number 6

ORIGINAL ARTICLE
Bayrakdar et al. e211

Fig. 1. Imaging protocol. 3D, axial, coronal, and sagittal images.

horizontal position so that the Frankfort horizontal

plane was perpendicular to the table, with the head
within the circular gantry housing of the X-ray tubedetectors system; a 360-degree rotation around the head
of patient was performed, and the scanning time was 36
seconds. The scanner operated with a maximum output
of 110 kV and 15 mAs, 0.16 mm voxel size, and had a
typical exposure time of 5.4 seconds. The QR-NNT
version 2.21 (Quantitative Radiology) software program was used for analyses. After raw data were obtained, the patient left the examination room, and the
clinician was able to perform the primary reconstruction. The atlas vertebra was dened on 0.5 mmethick
axial slices. One of the axial views on which the atlas
vertebrae were seen with the widest latero-lateral extent
was used as a reference view for the secondary reconstruction. The sagittal slice of atlas vertebrae was performed perpendicular to the long axis of the atlas
vertebrae with 1-mm thickness, and the coronal slices
were performed parallel to the long axis of the atlas
vertebrae with 1-mm thickness, on the selected axial
image. After the secondary reconstruction 3D images
were obtained, the direction of the PP was determined
on 3D images. Then the direction of the PP was
adjusted on the axial images by using the multiplanar
rendering mode. Sagittal images were used for the
detection of the PP because of the direction of the PP on
the atlas vertebrae (Figure 1).

Evaluation of the images

A complete PP is one continuous bridge that extends
from the posterior aspect of the lateral mass to the
anterior aspect of the posterior tubercle. A partial PP is
one that does not extend fully from the posterior
lateral mass to the posterior tubercle. It is possible to
identify a PP incorrectly as a broad dorsal arch of the
atlas. A normal posterior arch of the atlas thins out
laterally and does not curve up cranially, whereas a PP
broadens laterally and extends cranially. Radiologists
examined each image for the presence of PP in any of
its forms: complete, partial, unilateral, or bilateral.
Each image was assessed by two radiologists, who
noted whether any type of PP (i.e., partial or complete)
was present. There were some cases where the radiologists disagreed about the presence of partial PP,
and only images that both radiologists agreed upon
with regard to the presence or absence of PP in any of
its forms (i.e., complete or partial) were included in
the calculation of the prevalence.
Literature review
The study included a detailed search of the reported
literature using the PubMed database for the years 1955
through to June 2014. The search strategy used the
keywords ponticulus posticus, posticus ponticus,
foramen arcuate, foramen arcuale, foramen sagittale, foramen atlantoideum posterior, Kimmerles

ORAL AND MAXILLOFACIAL RADIOLOGY

e212 Bayrakdar et al.

OOOO
December 2014

Table I. Prevalence of ponticulus posticus in the literature

Author, Year

Review source

Sample sizes

Population

Selby et al., 195515

Pyo and Lowman, 19591
Kendrick and Biggs, 196314

Lateral radiography
Lateral radiography
Lateral radiography

306
300
353

Romanus and Tovi, 196426

Lamberty and Zivanovic, 19738
Lamberty and Zivanovic, 19738
Saunders and Popovich,197816
Farman et al., 197942
Dugdale, 19816
Taitz and Nathan, 198637
Ruprecht et al., 19887

Cadaver
Cadaver
Lateral radiography
Lateral radiography
Lateral radiography
Lateral radiography
Cadaver
Lateral radiography

105
60
990
592
220
316
672
419

Hoenig and Schoener, 199243

Lateral radiography

60

Stubbs, 199213
Prescher, 199744
Mitchell, 199827
Wight et al., 19999

Lateral radiography
Cadaver
Cadaver
Lateral radiography

1000
200
1354
895

Hasan et al., 20013

Manjunath, 200138
Wysocki et al., 200345
Kavakli et al., 200440
Le Minor and Trost, 200446
Cakmak et al., 200511
Young et al., 20055
Cakmak et al., 200511
Paraskevas et.al., 200528
Young et al., 20055
Lee et al., 200634
Krishnamurthy et al., 200747
Tubbs et al, 200739
Kim et al, 200712

Cadaver
Cadaver
Cadaver
Cadaver
Cadaver
Lateral radiography
Lateral radiography
Cadaver
Cadaver
Cadaver
Cadaver
Cadaver
Cadaver
Lateral radiography

350
60
95
86
500
416
464
60
176
20
709
1044
60
312

Kim et al, 200712

CT

Gupta, 200836
Kobayashi et al., 200835
Simsek et al., 200841
Hong et al., 200820

Cadaver
Cadaver
Cadaver
CT

Cho, 200918

CT

200

Karau et al., 201048

Kuhta et al., 201017

Cadaver
Lateral
radiography
Lateral radiography
CT

102
246

North America
North American
orthodontic patients
Sweden
England
England
Canada
South Africa
Various continents
Saudi Arabian orthodontic
patients
Germany 30 cleft lip and
30 normal
North America
South Africa
Scottish Chiropractic
patients with headache
Northern India
Southern India
Poland
Turkey
France
Turkey
North America
Turkey
Northern Greece
North America
North America
India
North America
Korean orthodontic
patients
Korean patients with
cervical symptoms
India
Japan
Turkey
Korean patients with CT
angiography of neck
Korean patients with
cervical symptoms
Kenya
North American chiropractic
patients
Indian orthodontic patients
C1-C2 posterolateral fusion
(Harms procedure)
Gulbarga population

Sharma et al., 20102

Yeom et al., 201219
Chitroda et al., 201310

225
55
50
158
1013

858
52
500

Geist et al., 201421

Digital lateral
cephalography
CBCT

Present study, 2013

CBCT

730

576

American orthodontic
patients
Turkish population

Mean age or
Ponticulus
age ranges Female (%) Posticus (%)
N.A.
49.2
6-17

58.17
56.67
53.54

27.12
12.67
15.86

40.4
N.A.
N.A.
38.8
8-25
N.A.
N.A.
N.A.

48.57
N.A.
N.A.
50.00
N.A.
N.A.
N.A.
56.32

14.29
36.67
13.64
29.22
26.82
15.51
33.78
32.94

22.8

43.33

21.67

36.9
N.A.
20-80
44.0

53.40
N.A.
28.14
53.07

18.70
11.00
10.19
17.99

N.A.
N.A.
N.A.
N.A.
N.A.
49.5
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
73
28

N.A.
N.A.
N.A.
N.A.
N.A.
68.27
N.A.
N.A.
48.86
N.A
35.54
N.A.
35.00
62.50

6.57
11.70
31.58
22.09
14.20
13.46
15.52
15.00
34.66
15.00
26.94
13.79
5.00
14.10

45

35.11

25.78

16-60
62
N.A.
55.7

N.A.
23.91
N.A.
55.97

10.91
10.00
9.49
15.60

45

50.00

15.50

25-75
N.A.

51.96
N.A.

52.94
45.53

65.03
63.46

4.31
17.31

5-70

47.00

68.40

17

52.90

26.2

8-81

62.1

17.40

15.0
44.0

CBCT, cone beam computed tomography; CT, computed tomography; N.A., not available.

anomaly, foramen retroarticulare superior, canalis

vertebralis, retroarticular vertebral artery ring, retroarticular canal and retrocondylar vertebral artery.

The citation lists made from the references that were

included have subsequently been examined in an
attempt to identify additional reports (Table I).

OOOO
Volume 118, Number 6

ORIGINAL ARTICLE
Bayrakdar et al. e213

Table II. Details of the ponticulus posticus cases detected in the present study
Gender
Female
Male
Age (Years)
8-18
19-28
29-38
39-48
49-81
Laterality
Unilateral
Bilateral
Type
Complete
Partial
Complete Partial
Total

Ponticulus posticus

Prevalence (%)

453
277

73
54

16.1
19.5

178
249
127
107
69

25
44
22
21
15

14.1
17.7
17.3
19.6
21.7

48
79

6.6
10.8

46
58
23
127

6.3
8
3.2
17.4

730

Complete Partial indicates 1 side complete and other side partial PP on the same patient.

Fig. 2. A, Absence of ponticulus posticus. B, Partial ponticulus posticus. C, Complete ponticulus posticus.

Fig. 3. Bilateral complete ponticulus posticus on sagittal slices. A, Left-side view. B, Right-side view.

ORAL AND MAXILLOFACIAL RADIOLOGY

e214 Bayrakdar et al.

OOOO
December 2014

Fig. 4. 3D images showing bilateral complete ponticulus posticus. A, Left-side view. B, Right-side view. C, Rear view.

Fig. 5. 3D images showing bilateral complete ponticulus posticus on extracted atlas vertebra. A, Left-side view. B, Right-side
view. C, Top view.

OOOO
Volume 118, Number 6

ORIGINAL ARTICLE
Bayrakdar et al. e215

Fig. 6. Ponticulus posticus on sagittal slices, with one side complete and the other side partial. A, Complete PP on the left-side
view. B, Partial PP on the right-side view.

Fig. 7. 3D images showing ponticulus posticus, with one side complete and the other side partial. A, Left-side view. B, Right-side
view. C, Rear view.

RESULTS
Analysis of 730 CBCT images revealed PP in 127 patients, constituting 17.4% of the studied sample. Male
predominance was found with a prevalence of 19.5% (54
of 277) and female prevalence was 16.1% (73 of 453).
Table II illustrates the prevalence of PP in the current
study. Figures 2 through 11 are several examples of PP.

DISCUSSION
Although PP is usually regarded as a simple anatomic
variant on the atlas vertebrae, it is an important,
common anomaly of the posterolateral aspect of the
posterior arch of the atlas. In the literature, it has been
reported to be associated with some conditions,
including vertebrobasilar insufciency, headache and

ORAL AND MAXILLOFACIAL RADIOLOGY

e216 Bayrakdar et al.

OOOO
December 2014

Fig. 8. 3D images showing ponticulus posticus on extracted atlas vertebra, with one side complete and the other side partial.
A, Left-side view. B, Right-side view. C, Rear view.

Fig. 9. Bilateral partial ponticulus posticus on sagittal slices. A, Left-side view. B, Right-side view.

cervical pain syndrome, migraine without aura, onset

of acute hearing loss, and chronic tension-type headaches.2,4,10,22-25 The PP is a bony arch on the atlas
vertebrae that converts from a groove on the upper
surface of the arcus posterior atlantis to the foramen.
This foramen is called the arcuate foramen and

contains important anatomic structures, such as the

vertebral artery and the suboccipital nerve.8,26-28 In
addition, PP is attached to the atlanto-occipital membrane, which is connected to the dura.8 Since PP is in
an important anatomic location, the relationship between the presence of PP and the conditions cited

OOOO
Volume 118, Number 6

ORIGINAL ARTICLE
Bayrakdar et al. e217

Fig. 10. 3D images showing bilateral partial ponticulus posticus. A, Left-side view. B, Right-side view. C, Rear view.

Fig. 11. 3D images showing bilateral partial ponticulus posticus on extracted atlas vertebra. A, Left-side view. B, Right-side view.
C, Rear view.

ORAL AND MAXILLOFACIAL RADIOLOGY

e218 Bayrakdar et al.

above was considered and has also been widely

studied in the literature. Lamberty and Zivanovic8
have shown that PP is closely attached to the atlantooccipital membrane, and it is known that this membrane is connected to the dura. Especially when the
head is moving, the neurodynamic process may lead to
these conditions because of traction on the dura, and
this can result in pain. The authors dene PP as the
causative factor in headaches, vertigo, Barr-Lieou
syndrome, eye pain, and photophobia because these
lead to ischemia of the vertebrobasilar circulation
through compression of the vertebral artery. Surgical
excision of PP alleviates these symptoms.4,9,29 Cushing et al.30 studied children who have had vertebrobasilar artery stroke and suggested a causal
relationship between PP and dissection of the vertebral
artery. Wight et al.9 have reported an important correlation between the presence of a greater amount of
PP of the atlas and migraine without aura. Their study
has contributed to the mounting evidence linking
migraine and cervicogenic headache to the upper
cervical spine. The literature also contains investigations of the relationship between PP and acute
hearing loss. This relationship could be based on a
functional disturbance in the area of cervico-occipital
junction.9,11
PP has become an important anomaly of the atlas
since the lateral mass screws began being used for the
treatment of atlantoaxial instability.2,12,18 The atlas
and axis permit a greater range of motion compared
with normal vertebrae and are responsible for the
exing, extending, and rotation movements of the
head. Atlantoaxial instability is excessive movement at
the junction between the atlas and the axis. This
problem may lead to such symptoms as balance
problems, blurred vision, frequent head and neck pain,
difculty swallowing, dizziness, fullness in the ears,
migraine headache, neck pain with no motion, reduced
activity, severe fatigue, suboccipital headache,
tinnitus, and vertigo.31,32 A lateral mass screw for the
xation of the atlas is a popular treatment for managing atlantoaxial instability.5,19,31-35 PP is a signicant anomaly of the atlas for which this procedure is
applied.2,12,18,19,31-36,40,42 The procedure is a difcult
one because the region includes the epidural venous
plexus and the major occipital nerve. Injury to the
region can cause signicant bleeding and occipital
neuralgia. Since placing the lateral mass screws at the
rst cervical level can be difcult, some surgeons have
proposed placing the screws higher than the classical
entry point, starting at the posterior aspect of the
posterior arch of the atlas. A broad posterior arch of
the atlas provides the best way for applying this procedure. However, although this may be effective in
most patients, PP has the possibility of being

OOOO
December 2014

incorrectly identied as the broad posterior arch in

patients who have PP. Placing the screw incorrectly
can result in injury to the vertebral artery and can
cause stroke and death by thrombosis, embolism, or
arterial dissection.2,5,12,18,31,32 The present study was
designed retrospectively; therefore, it is limited
because the sample does not include any special patient groups. However, considering the importance of
this serious complication, we need to evaluate the
morphologic characteristics and the prevalence of PP.

CONCLUSIONS
Establishing the presence of the PP is important for
patients. PP can have a signicant effect in the management of cervical spine surgery, especially surgery
that involves lateral mass screw placement. As this
study has indicated, PP is not an uncommon anatomic
variation and is a natural incidental nding on CBCT.
CBCT, thus, might be used to assess this anatomic
variation.
REFERENCES

1. Pyo J, Lowman RM. The ponticulus posticus of the rst cervical

vertebra. Radiology. 1959;72:850-854.
2. Sharma V, Chaudhary D, Mitra R. Prevalence of ponticulus
posticus in Indian orthodontic patients. Dentomaxillofac Radiol.
2010;39:277-283.
3. Hasan M, Shukla S, Siddiqui MS, Singh D. Posterolateral tunnels
and ponticuli in human atlas vertebrae. J Anat. 2001;199:339-343.
4. Koutsouraki E, Avdelidi E, Michmizos D, Kapsali SE, Costa V,
Baloyannis S. Kimmerles anomaly as a possible causative factor
of chronic tension-type headaches and neurosensory hearing loss:
case report and literature review. Int J Neurosci. 2010;120:
236-239.
5. Young JP, Young PH, Ackermann MJ, Anderson PA, Riew KD.
The ponticulus posticus: implications for screw insertion into the
rst cervical lateral mass. J Bone Joint Surg Am. 2005;87:
2495-2498.
6. Dugdale LM. The ponticulus posterior of the atlas. Australas
Radiol. 1981;25:237-238.
7. Ruprecht A, Nashashibi I, Lambourne A. Ponticles of the atlas.
Dentomaxillofac Radiol. 1988;17:67-71.
8. Lamberty BG, Zivanovic S. The retro-articular vertebral artery
ring of the atlas and its signicance. Acta Anat (Basel). 1973;85:
113-122.
9. Wight S, Osborne N, Breen AC. Incidence of ponticulus posterior
of the atlas in migraine and cervicogenic headache.
J Manipulative Physiol Ther. 1999;22:15-20.
10. Chitroda PK, Katti G, Baba IA, et al. Ponticulus posticus on the
posterior arch of atlas, prevalence analysis in symptomatic and
asymptomatic patients of gulbarga population. J Clin Diagn Res.
2013;7:3044-3047.
11. Cakmak O, Gurdal E, Ekinci G, Yildiz E, Cavdar S. Arcuate
foramen and its clinical signicance. Saudi Med J. 2005;26:
1409-1413.
12. Kim KH, Park KW, Manh TH, Yeom JS, Chang BS, Lee CK.
Prevalence and morphologic features of ponticulus posticus in
Koreans: analysis of 312 radiographs and 225 three-dimensional
CT scans. Asian Spine J. 2007;1:27-31.
13. Stubbs DM. The arcuate foramen: variability in distribution
related to race and sex. Spine. 1992;17:1502-1504.

OOOO
Volume 118, Number 6
14. Kendrick GS, Biggs NL. Incidence of the ponticulus posticus of
the rst cervical vertebra between ages six to seventeen. Anat Rec.
1963;145:449-453.
15. Selby S, Garn SM, Kanareff V. The incidence and familial nature
of a bony bridge on the rst cervical vertebra. Am J Phys
Anthropol. 1955;13:129-141.
16. Saunders SR, Popovich F. A family study of two skeletal variants:
atlas bridging and clinoid bridging. Am J Phys Anthropol.
1978;49:193-203.
17. Kuhta P, Hart J, Greene-Orndorff L, McDowell-Reizer B, Rush P.
The prevalence of posticus ponticus: retrospective analysis of
radiographs from a chiropractic health center. J Chiropr Med.
2010;9:162-165.
18. Cho YJ. Radiological analysis of ponticulus posticus in Koreans.
Yonsei Med J. 2009;50:45-49.
19. Yeom JS, Kae D, Nguyen NQ, et al. Routine insertion of the
lateral mass screw via the posterior arch for C1 xation: feasibility and related complications. Spine J. 2012;12:476-483.
20. Hong JT, Lee SW, Son BC, et al. Analysis of anatomical variations of bone and vascular structures around the posterior atlantal
arch using three-dimensional computed tomography angiography.
J Neurosurg Spine. 2008;8:230-236.
21. Geist JR, Geist SM, Lin LM. A cone beam CT investigation of
ponticulus posticus and lateralis in children and adolescents.
Dentomaxillofac Radiol. 2014;43:20130451.
22. Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. Basic principles for use of dental cone beam computed tomography: consensus
guidelines of the European Academy of Dental and Maxillofacial
Radiology. Dentomaxillofac Radiol. 2009;38:187-195.
23. Bernal SM, Hrmann K, Weh L. Sudden hearing loss and the craniocervical junction. Acta Otorrinolaringol Esp. 1990;41:93-95.
24. Li S, Li W, Sun J. Operative treatment for cervical vertigo caused
by foramen arcuale. Zhonghua Wai Ke Za Zhi. 1995;33:137-139.
25. Sun JY. Foramen arcuale and vertigo. Zhonghua Wai Ke Za Zhi.
1990;28:592-594.
26. Romanus T, Tovi A. A variation of the atlas. Roentgenologic
incidence of a bridge over the groove of the atlas for the vertebral
artery. Acta Radiol Diagn (Stockh). 1964;2:289-297.
27. Mitchell J. The incidence and dimensions of the retroarticular
canal of the atlas vertebra. Acta Anat (Basel). 1998;163:113-120.
28. Paraskevas G, Papaziogas B, Tsonidis C, Kapetanos G. Gross
morphology of the bridges over the vertebral artery groove on the
atlas. Surg Radiol Anat. 2005;27:129-136.
29. Travan L, Saccheri P, Sabbadini G, Crivellato E. Bilateral arcuate
foramen associated with partial defect of the posterior arch of the
atlas in a medieval skeleton: case report and review of the literature. Looking backward to go forward. Surg Radiol Anat.
2011;33:495-500.
30. Cushing KE, Ramesh V, Gardner-Medwin D, et al. Tethering of
the vertebral artery in the congenital arcuate foramen of the atlas
vertebra: a possible cause of vertebral artery dissection in children. Dev Med Child Neurol. 2001;43:491-496.
31. Goel A. Screws, facets, and atlantoaxial instability. World Neurosurg. 2013;80:514-515.
32. Goel A, Desai K, Muzumdar D. Atlantoaxial xation using plate
and screw method: a report of 160 treated patients. Neurosurgery.
2002;51:1351-1357.

ORIGINAL ARTICLE
Bayrakdar et al. e219
33. Elliott RE, Tanweer O. The prevalence of the ponticulus posticus
(arcuate foramen) and its importance in the Goel-Harms procedure: meta-analysis and review of the literature. World Neurosurg. 2014 July - August;82(1-2):e335-e343. doi:10.1016/j.wneu.
2013.09.014. Epub ahead of print 2013 Sep 18. Review.
34. Lee MJ, Cassinelli E, Riew KD. The feasibility of inserting
atlas lateral mass screws via the posterior arch. Spine. 2006;31:
2798-2801.
35. Kobayashi Y, Kikuchi S, Konno S, Sekiguchi M. Insertion of
lateral mass screw of the atlas via the posterior arch: anatomical
study of screw insertion using dry bone samples of the atlas from
Japanese cadavers. J Orthop Sci. 2008;13:452-455.
36. Gupta T. Quantitative anatomy of vertebral artery groove on the
posterior arch of atlas in relation to spinal surgical procedures.
Surg Radiol Anat. 2008;30:239-242.
37. Taitz C, Nathan H. Some observations on the posterior and lateral
bridge of the atlas. Acta Anat (Basel). 1986;127:212-217.
38. Manjunath KY. Posterior bridging of the atlas vertebra in south
Indians. Indian J Med Sci. 2001;55:488-490.
39. Tubbs RS, Johnson PC, Shoja MM, Loukas M, Oakes WJ.
Foramen arcuale: anatomical study and review of the literature.
J Neurosurg Spine. 2007;6:31-34.
40. Kavakli A, Aydinlioglu A, Yesilyurt H, et al. Variants and deformities of atlas vertebrae in Eastern Anatolian people. Saudi
Med J. 2004;25:322-325.
41. Simsek S, Yigitkanli K, Comert A, et al. Posterior osseous
bridging of C1. J Clin Neurosci. 2008;15:686-688.
42. Farman AG, Nortje CJ, Joubert JJ. Radiographic prole of the
rst cervical vertebra. J Anat. 1979;128:595-600.
43. Hoenig JF, Schoener WF. Radiological survey of the cervical spine
in cleft lip and palate. Dentomaxillofac Radiol. 1992;21:36-39.
44. Prescher A. The craniocervical junction in man, the osseous
variations, their signicance and differential diagnosis. Ann Anat.
1997;179:1-19.
45. Wysocki J, Bubrowski M, Reymond J, Kwiatkowski J.
Anatomical variants of the cervical vertebrae and the rst thoracic
vertebra in man. Folia Morphol (Warsz). 2003;62:357-363.
46. Le Minor JM, Trost O. Bony ponticles of the atlas (C1) over the
groove for the vertebral artery in humans and primates: polymorphism and evolutionary trends. Am J Phys Anthropol.
2004;125:16-29.
47. Krishnamurthy A, Nayak SR, Khan S, et al. Arcuate foramen of
atlas: incidence, phylogenetic and clinical signicance. Rom J
Morphol Embryol. 2007;48:263-266.
48. Karau PB, Ogengo JA, Hassanali J, Odula P. Anatomy and
prevalence of atlas vertebrae bridges in a Kenyan population: an
osteological study. Clin Anat. 2010;23:649-653.
Reprint requests:
Dr. Ozkan Miloglu
Department of Dentomaxillofacial Radiology
Faculty of Dentistry
Ataturk University
25240, Erzurum
Turkey.
omiloglu@hotmail.com