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Unstable Upper Cervical Spine Injury with Concomitant Bilateral Ponticulus Posticus: A Case Report
Masashi Fujisawa1, Sota Wakahara1, Joji Inamasu1
1Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan.
Asian Journal of Neurosurgery
|August 25, 2025
Summary
Ponticulus posticus (PP) presents surgical challenges for upper cervical spine injuries. Alternative fixation methods, avoiding C1 lateral mass screws, are crucial to prevent vertebral artery injury.
Area of Science:
- Neurosurgery
- Orthopedic Surgery
- Anatomy
Background:
- Ponticulus posticus (PP), an anatomical variation of the atlas (C1), involves ossification of the posterior atlanto-occipital membrane.
- The V3 segment of the vertebral artery (VA) traverses this foramen, posing a risk during C1 lateral mass screw placement.
Observation:
- A 70-year-old male with an unstable upper cervical spine injury (traumatic C2 spondylolisthesis and C3-4 facet dislocation) presented with bilateral PP.
- Preoperative imaging confirmed bilateral PP, necessitating modification of the planned posterior fixation surgery.
Findings:
- The surgical team abandoned the standard C1 lateral mass screw fixation due to the presence of bilateral PP.
- An alternative fixation strategy was successfully employed, utilizing a laminar hook on one side and a C1 posterior arch screw on the other.
Implications:
- This case highlights the importance of tailoring surgical fixation techniques for upper cervical spine instability in patients with PP.
- Careful preoperative assessment and individualized surgical planning are essential to mitigate the risk of vertebral artery injury in such cases.
Keywords:
arcuate foramenlateral mass screwponticulus posticusupper cervical spine injuryvertebral arteryMore Related Videos
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