Download - Prashant gmc cvj

PRESENTER DRPRASHANT SARDA

MODERATOR DRMANOJ HAZARIKA

CRANIO VERTEBRAL JUNCTION

CRANIOVERTEBRAL JUNCTION

bullThe craniovertebral junction(CVJ) is a collective term that refers to the occiput atlas axis and supporting ligaments

bullIt is a transition zone bw a mobile cranium amp relatively rigid spinal column

bullIt encloses the soft tissue structures of the cervico medullary junction (medulla spinal cord and lower cranial nerves)

EMBRYOLOGY amp DEVELOPMENT OF THE CVJ

Development of the cartilaginous cranium amp the adjacent structures begins during the early weeks of intrauterine life2ndGestational week Mesoderm cells condense in the midline to form notochordal process3rdGestational week -notochordal process invaginates in bw ectoamp endoderm to form notochord-dorsal ectoderm thickens to form neural groove which folds fuses amp becomes neural tube Between 3rdamp 5thweek -part of mesoderm which lies on either side of notochord (Paraxial mesoderm) gives rise to somites(Segmentation)-total 42 somitesform at 4thweek-ventromedial portion of somite is ka sclerotome which forms the vertebral bodies-each sclerotome differentiates into a cranial loosely arranged portion and a caudal compact portion by a fissure ka ldquoFissure of von Ebnerrdquo(Re-segmentation)

Each sclerotome differentiates into a cranial loosely arranged portion ( 1 ) and a caudal compact portion (2)

Notochord disappears at the vertebral bodies but persist as nucleus pulposus at disc

Out of 4 occipital sclerotomes the first 2 form basiocciput the 3rd Jugular tubercles and the 4th (Proatlas) form parts of foramen magnum atlas and axis

The ldquopro atlasrdquo (1) is derived from the cranial portion of the embryonic fourth occipitalsclerotome Its principal derivatives are the occipital condyles the dorsalcranial articular facets of the atlas and the tip of the odontoid

The ldquoprimitive atlasrdquo(2) is derived from the caudal portion of the fourth occipital and the cranial portionof the first cervical sclerotomes Its principal derivatives are the neural arches andlateral masses of the atlas and the remainder of the odontoid process of the axis

The ldquoprimitive axisrdquo (3) is derived from the caudal portion of the first cervical sclerotome and the cranial portion of the second Its principal derivatives are the body and neural arch of the axis and the C2-3 cervical disk

OSSIFICATION CENTRESOCCIPUT amp BASIOCCIPUT2 occipital squamous portions ndash2 centresBasiocciput(clivus) -1 centre2 Jugular tubercles ndash2 centres2 Occipital condylesndash2 centres

ATLAS ossifies from 3 centresEach half of post Arch with lateral mass unites at 3 ndash4 yearsAnterior arch unites with lateral mass at 6 ndash8 years

AXIS ossifies from 5 primary amp 2 secondary centres

2 Neural arches ndash2 centres appear at 7 ndash8 wkBody of axis ndash1 centre appear at 4 ndash5 monthsBody of dens ndash2 centres appear at 6 ndash7 months4 pieces (at birth) unite at 3 ndash6 years

Tip of odontoid appears at 3 ndash6 years unites with the body of odontoid at 12 years

ANATOMY


ATLAS no vertebral body amp no IV disc-major portion formed by first spinal sclerotome-trasitional vertebra as centrum of sclerotome is separated to fuse with the axis body forming the odontoid process-hypocentrum of 1st spinal sclerotome forms the anterior arch of the atlas-neural arch of the first spinal sclerotome forms the inferior portion of the posterior arch of atlas

AXIS develops from 2nd spinal sclerotome-hypocentrum of 2nd spinal sclerotome disappears during embryogenesis-centrum forms the body of the axis vertebra amp neural arch develops into the facets amp the posterior arch of the axis-At birth odontoid base is separate from the body of axis by a cartilage which persists until the age of 8 later the center gets ossified or may remain separate as Os-odontoidium-The apical segment is not ossified until 3 years of age at 12 years if fuses with odontoid to form normal odontoid failure leads to Os terminale

ANATOMY OF CVJ (ARTICULAR)

Upper surfaces of C1 lateral masses are concave which fit into the ball amp socket configuration

4 synovial joints bw atlas amp axis ndash

2 median ndashPivot variety2 lateral ndashPlane varietyEach joint has its own capsule amp synovial cavity

ANATOMY OF CVJ(LIGAMENTOUS)

ATLANTO-OCCIPITAL LIGAMENTS A) Anterior Atlanto-occipital Membrane ----about 2 cm wideLigament is continuous caudally with the anterior A-A ligament amp through it to the ALL of the spinal columnIt acts as a tension band that stretches during extension serving as a secondary stabilizer against this motion

B) POSTERIOR ATLANTO-OCCIPITAL MEMBRANEA less strong ligament containing no significant elastic tissueLigament invests itself on either side to form a canal through which the vertebral artery accompanying veins amp the first cranial nerve pass

C) LATERAL ATLANTO-OCCIPITAL LIGAMENTS-ascending lig which reinforce the A-O joint capsules

ATLANTO AXIAL LIGAMENTSAnterior A-A ligamentPosterior A-A ligamentTransverse ligament of the atlas

-thick strong amp about 6mm in height

-Caudal crus amp Rostral crus(Fasciculi longitudinales) fibres joined with transverse ligament on its dorsal aspect to form Cruciate ligament of atlas

TAL effectively limits anterior translation and flexion of the atlanto axial joint

An accessory band ventral to the ascending crus attaching to the apex of the odontoid process is termed Gerberrsquos ligament

A) TECTORIAL MEMBRANE bullDorsal to the cruciate ligamentbullAttached to the dorsal surface of the C3 vertebra axis body amp to the body of densbullRostral extension of the PLL of the vertebral columnbullEssential for limiting flexionbullThe accessory bands of the ligament passing to the lateral capsule of the A-A joints --Arnoldrsquos ligament

B) ALAR LIGAMENTSbull2 strong cords that attach to the dorsal lateral body of the dens bullExtend laterally amp rostrallybullVentral amp cranial to the transverse lig allow an anterior shift of C1 from 3 to 5 mmbullLimit the head ndashatlas rotatory movement on the odontoid axis bullStrengthen the A-O capsule

C) APICAL LIGAMENTNo mechanical significance

AXIS ndashOCCIPITAL LIGAMENTS

ANATOMY OF CVJ (MUSCLES)

Muscles have only a minor role related to CVJ stabilization amp do not limit the movements of the joints

Their principal function is one of initiating amp maintaining movement at the CVJ

Neural structures related to CVJ are ndash

Caudal portion of brainstem (Medulla)CerebellumFourth ventricleRostral part of spinal cordLower cranial amp upper cervical nerves

ANATOMY OF CVJ (NEURAL)

In cerebellum only the tonsils biventral lobules amp the lower part of the vermis(nodule uvula amp pyramid) are related to CVJBiventral lobule is located above the lateral part of FM amp the tonsils lie above the posterior edge

CRANIAL NERVES Lower four cranial N are closely related to CVJ9th amp 10th cranial N arise from the medulla in the groove bw the inferior olivary nucleus amp the inferior cerebellar peduncle

The accessory N is the only cranial N that passes through the FM

SPINAL NERVE ROOTSThe C1 C2 and C3 nerves distal to the ganglion divide into dorsal and ventral rami

The first cervical nerve located just below the foramen magnum

The dorsal rami divide into medial and lateral branches that supply the skin and muscles of the posterior region of the neck

ANATOMY OF CVJ (ARTERIAL)

The major arteries related to CVJ are vertebral postero inferior cerebellar arteries (PICA) and the meningeal branches of the vertebral and external and internal carotid arteries

VERTEBRAL ARTERY arises from the upper posterior part of the first segment of the subclavian artery in the neck

Each artery is divided into intradural and extradural parts

The branches arising from the vertebral artery in the region of the FM are the posterior spinal anterior spinal PICA and anterior and posterior meningeal arteries

The PICA is the largest branch of the vertebral artery

Brain stem arteries - anterior view 1 Posterior cerebral artery2 Superior cerebellar artery3 Pontine branches of the basilar artery4 Anterior inferior cerebellar artery5 Internal auditory artery6 Vertebral artery7 Posterior inferior cerebellar artery8 Anterior spinal artery9 Basilar artery

The tonsillo medullary PICA segment which forms the caudal loop related to the lower part of the tonsil is most intimately related to the foramen magnum

ANATOMY OF CVJ (LYMPHATICS)

The lymphatic drainage of the O-A-A joints is primarily into the retropharyngeal LN amp then into the deep cervical chain

These LNrsquos also drain the nasopharynx amp hence retrograde infection may affect the synovial lining of the CVJ complex with resultant neck stiffness amp instability

ANATOMY OF CVJ (VENOUS)The venous structures in the region of the FM are divided into three groups

-Extradural veins(extraspinal amp intraspinal part)-Intradural(neural) veins amp -Dural venous sinuses( superior petrosal marginal amp occipital)

1048708The three groups anastomose through bridging and emissary veins

KINETIC ANATOMY OF CVJ

1048708CVJ units are unique with respect to the rest of the spine in that they do not bear weight through disks but rather through synovial joints lined with hyaline cartilage thus exhibit significantly more movement than any other spinal level

1048708ROTATION when movement occurs about an axis1048708TRANSLATION when movement occurs along an axis

ATLANTO-OCCIPITAL JOINTS The C1 lateral masses contain the occipital condyles in a cup-like fashion

Joint is biaxial having movements only around the transverse amp A-P axes

2 types of movement permitted are forward or backward bending amp a slight lateral tilting motion to either sideThese joints do not permit rotation

ATLANTOAXIAL JOINTS

1048708Consists of 2 lateral zygapophyseal amp 2 median odontoid joints (pivot joint)

1048708Rotation of atlas occurs around the odontoid

1048708The superior facet of the axis is convex amp the inferior facet of the atlas is either horizontal or slightly convexSo the facets slide forward amp backward on each other with rotation

1048708The A-A joints allow less flexion ndashextension motion than rotation1048708There is greater movement with extention (upto10deg ) than with flexion (upto5deg)

1048708Total rotation of the entire cervical spine is upto 90deg amp approx frac12occurs at the A-A joint

1048708With a certain degree of anteflexion the tectorial membrane cruciform amp Apical dens ligaments become slack amp do not check movement

1048708Caput of dens then acts as a fulcrum resulting in tightening of the tectorial membrane with consequent checking of anteflexion(checking effect)

THE RADIOLOGIC IMAGING MODALITIES

Conventional Radiography including standard and special projection

Computed tomography (CT) ndash MP amp 3D reconstructions

Magnetic resonance imaging (MRI)

CERVICAL SPINE PROJECTIONS

RADIOLOGY OF CVJ

PLAIN FILM EXAMINATIONA) LATERAL VIEW

B) ANTERO-POSTERIOR (AP)-OPEN MOUTH VIEW Additionally detects dens anomalies amp its lateral displacement

C) OBLIQUE VIEWSAllows visualization of homolateral superior amp inferior facets as well as a small portion of the contralateral superior facetIntervertebral neural canal for the 3rdcervical nerve also evident

Cerebellar tonsils

medulla

Vertebral artery

basion

Medulla oblongata

basion

Anterior arch of atlas

Atlas (anterior arch)

Transverse lig atlasDens of axis

Medulla oblongata

Vertebral artery

Atlas posterior arch

Atlas lateral mass

Transverse ligament of atlas

Transverse process and foramen transversarium

Anterior longitudinal ligament

Apical ligament of dens

Tectorial membrane



Dens of axis (C2)

Clivus

Anterior atlanto-occipital membraneAtlas (lateral

mass)Axis

Int carotid artery

Alar ligaments

Atlanto-axial jointAtlanto-occipital joint

CRANIOMETRYCraniometry of the CVJ uses a series of lines planes amp angles to define the normal anatomic relationships of the CVJ

These measurements can be taken on plain X rays 3D CT or on MRI

THE CHAMBERLAINrsquoS LINE

NAME amp SYNONYMS OF LINES

DEFINITION NORMAL MEASUREMENT IMPLICATIONS

Chamberlain lsquos line Palato-occipital line

Posterior pole of hard palate to the Opisthion

Tip of the dens usually below and upto 3 mm above this line

Dens gt 6mm in basilar impression

H O

THE MCGREGORrsquoS LINE

H

Low occiput



Mc Gregorrsquos lineBasal lineMOST ACCURATE

Postero-superior margin of Hard palate ndash most inferior surface of occipital bone

Odontoid apex shouldnrsquot lie above lt 5mm

Superior lie of odontoid indicates basilar impression(gt5mm)

Low occiput

THE MCRAErsquoS LINE

B O

Mc Raersquos lineFormen magnum line

Anterior and posterior ends of formen magnum(Basion and Opisthion)

Inf margin of occiput should lie at below this line Tip of dens does not exceed this line Perpendicular line along odontoid intersects 1st line in its anterior quadrant

Inf margin of occiput lies superior ndash Basilar imp

If sagittal diameter lt 20mm neurological symptoms (+) (foramen magnum stenosis)

CLIVUS-CANAL LINE

C

B

OC2

H

N



Wackenhiersquos lineClivus canal line

Drawn along clivus into cervical canal

Odontoid tip is ventral and tangential to line

Odontoid transects the line in basilar imp

BASILAR ANGLE

Mid sella

B

N

S

B

N



Basilar angle Welckerrsquos Martinrsquos Spheno-BA

Nasion ndash Centre of the sella ndash Basion

Angle 1370 (123-1520)

gt1520 Platybasia(Base is elevated)+- Basilar impression

Modified MRI techniqueThis technique described by Koenigsbert et al yields a normal value range (95 CI) 116deg - 118deg for adults and 113deg - 115deg for children Angle formed by line extending across the anterior cranial fossa to the tip to the dorsum sellae line drawn along the posterior margin of the clivus

THE BOOGARDrsquoS LINE

N

O



Boogard lsquos Line Nasion to Opisthion Basion should lie below this line

Altered in basilar impression

BOOGARDrsquoS ANGLE

Tuberculum sellaTuberculum sella

B o

N

Mc Ray

s

C



Boogard lsquos Angle Angle intersected by1st line between Dorsum sellae to Basion amp Mc Raersquos line

119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain

Bull lsquos angle Atlanto-palatine angle

Posterior Angle betn 1st line from Post tip of hard palate to post margin of foramen magnum 2nd line betn ant amp post tubercles of atlas

Post angle lt130 If odontoid is tilted posteriorly or in case of change of atlas position The angle gt 130

RANAWAT METHOD

C2

C1

Ranawat method Line joining center of the anterior arch of C1 to post ring amp another line along the axis of the odontoid from the centre of the pedicle of C2 to 1st line

Normal distance between C-1 and C-2 in Men averages 17 mm (plusmn2 mm SD) Women 15 mm (plusmn 2 mm SD)

A decrease in this distance indicates cephalad migration of C-2

C2

C1

C2

C1

PEDICLE

SCHMIDT ndash FISCHER ANGLE (ATLANTO-OCCIPITAL JT AXIS ANGLE)

O

C2AA JT

AO JT

C1 C1



Schmidt ndash Fischer Angle

Angle of axis of Atlanto-Occipital joint

125 +- 2 degrees Angle is wider in condylar hypoplasia

CRANIO-VERTEBRAL ANGLE

ax

C



Cranio vertebral angle Between clivus line and post axial line

Flexion ndash 1500

Extension - 1800

lt1500 Platybasiacord compressionBasilar impression

bullBDI less than 85 mm compared with 12 mm on data from plain radiographsbull The Powers ratio demonstrated no significant difference compared with data obtained by plain radiographs bullAn ADI less than 2 mm compared with 3 mm previously accepted bullThe AOI demonstrated 95 of the population ranged between 05 mm and 14 mm

Midsagittal MDCT image of the craniocervical junction demonstrates the BDI as the distance from the most inferior portion of the basion to the closest point of the superior aspect of the dens

MDCT VS PLAIN RADIOGRAPHY IN CRANIOMETRYhellip

Midsagittal MDCT image of the craniocervical junction demonstrates the Powers ratio which is calculated by dividing the distance between the tip of the basion to the spinolaminar line by the distance from the tip of the opisthion to the midpoint of the posterior aspect of the anterior arch of C1

MDCT image of the craniocervical junction demonstrates the ADI which is calculated by drawing a line from the posterior aspect of the anterior arch of C1 to the most anterior aspect of the dens at the midpoint of the thickness of the arch in craniocaudal dimension

Sagittal MDCT image of the craniocervical junction demonstrates the AOI which is calculated by drawing a line perpendicular to the articular surfaces of the occipital condyle and the lateral mass of C1 This line is drawn at the center of the articulation by correlating the sagittal and coronal images

(NORMAL VARIANTS amp ANOMALIES)THE OCCIPUT 1048708The basiocciput forms the lower portion of the clivus1048708The upper portion of the clivusis formed by the basisphenoid separated from the basiocciput by the sphenooccipital synchondrosis1048708The age at which this synchondrosis fuses ranges from ldquoafter the twelvth yearrdquoto 14-16 years for girls and 16-185 years for boys 1048708Most occipital anomalies are associated with decreased skull base height and basilar invagination CondylusTertius1048708When the hypochordal bow of the fourth occipital sclerotome(proatlas) persists or when the proatlas fails to integrate an ossified remnant may be present at the distal end of the clivus called the condylus tertius or third occipital condyle1048708This third condyle may form a joint or pseudojoint with the odontoid process or with the anterior arch of the atlas and may lead to limitation in the range of motion of the CVJ 1048708There is an increased prevalence of osodontoideum associated with this abnormality

The Mach effect of the overlying anterior arch of the atlas may be mistaken for a

fracture of the apical region of the odontoid on the open

mouth view

Pseudo fracture of the odontoid

The Mach effect of the medial aspects of the overlying incisors simulates avertical defect in the odontoid on the open mouth

view A bicornuate odontoid should be considered

The characteristic V shaped cleft in the superior aspect of the odontoid and the diamond shaped distal

ossification centre of pro atlas origin are seen in the open mouth view This

is a normal finding in adolescent children

Bicornuate odontoidhelliphellip

The radiolucent band separating the base of the odontoid from the body of the axis in the

lateral projection is a normal finding in infants

Sub dental synchondrosishelliphellip

The irregular fragments located inferior to the Anterior arch of the atlas may be mistaken for fracture

fragments The clear cortical margins and characteristic location

help to differentiate this variant from a fracture

Accessory ossification centre for the anterior arch of the atlashelliphellip

CondylarHypoplasiabullIn condylar hypoplasia the occipital condyles are underdeveloped bullHave a flattened appearance leading to BI Basiocciput HypoplasiabullIt results in shortening of the clivus and violation of the Chamberlain line bullVirtually always associated with basilar invagination bullThe Wackenheim clivus baseline is usually normalbull Clivus-canal angle is typically decreased bull Bow-string deformity of the cervicomedullary junction

Sagittal T1 weighted (60020) MRI shows deformity of the pons and medulla due to basilar impression Note basiocciput hypoplasia

Atlantooccipital Assimilation Occipitalization of AtlasbullThe failure of segmentation between the skull and first cervical vertebra results in assimilation of the atlasbullThe assimilation may be complete or partial bullIt invariably results in basilar invagination bullWackenheim clivus baseline may be normal but the clivus-canal angle may be decreased

TOPOGRAPHIC FORMS (WACKENHEIM)bullType I Occipitalization(generally subtotal) associated with BIbullType II Occipitalization(generally subtotal) associated with BI amp fusion of axis amp C3bullType III Total or subtotal occipitalization with BI amp maldevelopment of the transverse ligament

ATLAS 1048708Most atlas anomalies when isolated produce no abnormal CVJ relationships and are not associated with basilar invagination 1048708The vast majority of anomalies consist of various arch clefts aplasias and hypoplasias

1048708Arch anomalies are frequently mistaken for fractures in the evaluation of plain radiographs of patients with a history of cervical spine trauma

PONTICULUS POSTICUS KIMMERLErsquoS DEFORMITY 1048708It is a bony ridge projecting posteriorly from the articular edge of the atlas superior articular facet1048708The bony projection unite with the adjacent neural arch of the atlas to produce an ldquoARCUATE CANALrdquothrough which the vertebral artery passes1048708This is due to ossification of a portion of the oblique A-O ligament

Posterior Arch Anomalies (MC atlas anomaly) 1048708Total or partial aplasia of the posterior atlas arch is rare1048708Although absence of the posterior arch when isolated is usually asymptomatic but may be associated with anterior atlantoaxial subluxation

Posterior arch hemiplasia

Split Atlas

bullIn anterior arch rachischisis the anterior arch appears fat or plump and rounded in configuration appearing to lsquolsquooverlaprsquolsquo the odontoid processbullThe arch may have unsharp duplicated anterior margins

Persistent OssiculumTerminale1048708Also called Bergman ossicle results from failure of fusion of the terminal ossicle to the remainder of the odontoid process1048708The fusion typically is accomplished by 12 years of age1048708Bergman ossicle may be confused with a type 1 odontoid fracture (avulsion of the terminal ossicle) and absolute differentiation between the two diagnoses may be difficult

OdontoidAplasiaTotal aplasia of the odontoid process is extremely rare

A true aplasiais associated with an excavation defect into the body of axis

CONGENITAL ODONTOID ANOMALIES OR DYSPLASIAS

OS ODONTOIDEUMbullan independent osseous structure lying cephalad to the axis body in the location of the odontoid processbullThe anterior arch of the atlas is rounded and hypertrophic but the posterior arch is hypoplasticbullCruciate ligament incompetence and A-A instability are commonbullThe margins of the axis body the os and anterior arch are all well corticated bullOdontoid fracture flattened sharp uncorticated margin to the upper axis body

Types ndashOrthotopic amp DystopicInstability is more common with dystopic type

PLATYBASIA

BASILAR IMPRESSION

BASILAR INVAGINATION

These terms are not synonymous

PLATYBASIAMartinrsquos anamoly

Flattening of angle between the clivus and the body of the sphenoid CFPRIMARY- Isolated or in conjunction with other dysplasias like Achondroplasia Osteogenesis imperfecta

SECONDARY - Pagetrsquos disease bone softening degenerative diseaseBasilar angle gt 152deg(N=123-1520)

Craniovertebral = clivus-canal angle becomes acute (lt150deg) MC associated changes - Basilar invagination anomalies of C1(occipitalisation)block vertebra Klippel-Feil syndrome

bullBASILAR INVAGINATION

bullFloor of the skull is indented by the upper cervical spine amp hence the tip of odontoid is more cephalad protruding into the FM

bullTwo types of basilar invagination primary invagination and secondary

bullPrimary invagination can be associated with occipito atlantal fusion hypoplasia of the atlas a bifid posterior arch of the atlas odontoid anomalies bullBI is associated with high incidence of vertebral artery anomalies

Chamberlainrsquos line- tip of dens is gt6mm above this line Mc Gregorrsquos line- tip of dens is gt 5mm above this line Mc Raersquos line- tip of dens is above this line Boogardrsquos line- basion is above this line Height index of Klaus lt 30mm

Topographic types of BI 1048708Anterior BI hypoplasiaof basilar process of the occipital bone1048708BI of the occipital condyles(Paramedian BI)Condylar hypoplasia1048708BI in the lateral condylar area1048708Posterior BI posterior margin of the FM is invaginated1048708Unilateral BI1048708GeneralisedBI

usually occur in 2nd or 3rd decade

BASILAR IMPRESSION (SECONDARY BASILAR INVAGINATION

bullBasilar impression refers to secondary or acquired forms of BI bull Due to softening of the bone bull Seen in conditions such as rickets hyperparathyroidism osteogenesis imperfecta Paget disease neurofibromatosis skeletal dysplasias and RA amp infection producing bone destruction

KLIPPEL FEIL SYNDROME

Described first by Klippel and Feilin 1912 Etiology is unknown Due to failure of the normal segmentation of cervical somites during the third and eighth weeks of gestation

Classic triad of low posterior hair line short neck and limited neck ROM found in less than 50 of cases

The most consistent finding is limitation of neck motion

AchondroplasiaGenetically dominant disorder characterized by inhibition of endochondral bone formation

The base of the skull is affected but the membraneous convexity skull bone grows normally

This differential bone growth results in large calvarium on a small base

A small FM with hypertrophic bone amp a posterior dural shelf results in compression of neural structures

CRANIOVERTEBRAL JUNCTION ANOMALIES IN DOWN SYNDROME

1048708First described in 1965 by Tishleramp Martel

1048708Characterized by increased ligamentous laxity and abnormal joint and bony anatomy which predispose to instability 1048708The incidence of bony anomalies involving the occipital condyle C1 ring and odontoidis also increased in Down syndrome

CHIARI MALFORMATION

1048708The Chiari malformations are a group of hindbrain herniation syndromes initially described by Austrian pathologist Hans Chiari in 1891

ARNOLD-CHIARI MALFORMATION I Present in adulthood =cerebellar tonsillar ectopia Herniation of cerebellar tonsils gt 5mm below a line connecting Basion with Opisthion (= foramen magnum)

Causesbull small posterior fossabullcerebellar overgrowthbulldisproportionate CSF absorptionAssociated with1 Syringohydromyelia (30-56)2 Hydrocephalus (25-44)3 Malformation of skull base

NECTEffaced Posterior Fossa cisterns Crowded Foramen Magnum Lateral3rd ventricles usually normal

Look for absent cisterna magna posteriorly angled odontoid with compressed brainstem short posterior arch C1 short supra occiputsyrinx

ARNOLD-CHIARI MALFORMATION II Des Most common and serious complex of anomalies

HALLMARK is dysgenesis of hindbrain with(1)caudally displaced 4th ventricle(2)caudally displaced brainstem(3)tonsillar + vermian herniation through foramen magnum

Associated with(a)spinal anomalies(1)lumbar myelomeningocele (2)syringohydromyelia3)dysgenesis of corpus callosum

Radiography Lucken shadel -Craniolacunia = Lacunar Skull = mesenchymal dysplasia of calvarial ossificationAbsent Hypoplastic posterior arch of C1

Myelography Tethered cord

NECT Small posterior fossa Large funnel-shaped foramen magnum Scalloped petrous pyramid notched clivus Absent falx cerebelliBest diagnostic clue Presence of Myelomeningocele Small posterior fossa Elongated straw-like 4th ventricle Cascade of tissue herniates through foramen magnum behind upper cervical cordbull Vermis (nodulus)bull Choroid plexus of 4th Vbull Medullary spur

ARNOLD-CHIARI MALFORMATION III

bull High cervical occipital meningoencephalocele + intracranial Chiari 2malformation

NECTo Occipital squamo defectPosterior spina bifida at the P1ndashP2 levelo Bony features of Chiari 2Small posterior cranial fossa scalloped clivus lacunar skullMR FindingsTIWI Sac contentsbull Meninges cerebellum plusmn brain stembull Cisterns 4th ventricle dural sinuses o HydrocephalusT2WI Tissues in sac may be bright (gliosis)MRV plusmn Veins in cephalocele

ARNOLD-CHIARI MALFORMATION IV

Extremely rare anomaly probably erroneously included as type of Chiari malformation Agenesis of cerebellumHypoplasia of pons Small + Funnel-shaped posterior fossa

Atlanto-Axial Instability

bullA RotationalndashAround the densbullB TranslationalndashTranslation between C1ndashC2 where transverse lig is disruptedbullC DistractionndashIndicating craniocervical dissociation

Non-traumatic conditions associated with increase in the atlanto axial distance1048708Down syndrome 1048708Due to laxity of the transverse ligament 1048708Grisel syndrome 1048708Atlantoaxial subluxation associated with inflammation of adjacent soft tissues of the neck 1048708Rheumatoid arthritis1048708From laxity of the ligaments and destruction of the articular cartilage 1048708Osteogenesis imperfecta1048708Neurofibromatosis 1048708Morquio syndrome 1048708Secondary to odontoid hypoplasia or aplasia1048708Other arthridities (PsoriasisLupus)

On the open mouth odontoid view the combined spread of the lateral masses of C1 greater than 69 mm would indicate rupture of the transverse ligamentAn atlantoaxial distance greater than 4-5 mm by lateral radiographs is indicative of AAI Posterior atlanto dental interval (PADI) Normal range is 19 ndash32 mm in male amp 19 ndash30mm in femalesBelow 19mm neurological manifestations occur

Rotatory displacement (Fielding and Hawkins classification)1048708Type I is simple rotatory displacement with an intact transverse ligament1048708Type II injuries involve anterior displacement of C1 on C2 of 3-5 mm with one lateral mass serving as a pivot point and a deficiency of the transverse ligament1048708Type III injuries involve greater than 5 mm of anterior displacement1048708Type IV injuries involve the posterior displacement of C1 on C2

TUBERCULOUS AAD

Compression of CMJ could be due to granulation tissue cold abscess or bony instability amp displacement

Ligaments are extensively infiltrated by the disease process amp give wayHyperaemic decalcification occurs

Radiological findings in 3 stagesndashStage I Retropharyngeal abscess with ligamentous laxity + bony architecture of C1-C2 preservedStage II Ligamentous disruption with AAD minimal bone destruction amp retropharyngeal mass +Stage III marked destruction of bone complete obliteration of anterior arch of C1 amp complete loss of odontoid process marked AAD amp O-A instability

RHEUMATOID ARTHRITIS amp CVJ

1048708First described by Garrodin 1890104870820 of the patients with RA have AAD1048708AAD is due to loss of tensile strength amp stretching of TL due to destructive inflammatory changes as well as secondary degenerative changes in tissues from vasculitis1048708Odontoid process ndashosteoporosis angulation

1048708BI occurs secondary to loss of bone in lateral mass of the atlas with resultant rostral migration of axis vertebra1048708The lateral mass of atlas may with lateral displacement of bone fragment1048708Later on erosion of occipital condyles occur

A hook like appearance of the odontoid process occurs seconadary to the cruciate lig pannus eroding into the odontoid process

TRAUMATIC LESIONS OF CVJ

OCCIPITAL CONDYLE

MC clinical features are LOC or cranial nerve damage

Classification (Anderson amp Montesano)Type I amp II are stable injuries while type III is potentially unstable

Type I (comminuted fracture with minimal or no displacementType II (basilar skull fracture extending to the occipital condyle)Type III (fracture with a fragment displaced medially from the inferomedial aspect into the foramen magnum)

OCCIPITO-ATLANTAL INSTABILITYTraumatic non traumaticTraumatic usually fatal 8 incidence in RTA

Traynelis classification

OF ATLAS1048708Posterior arch 23rdof all occur at the junction of posterior arch amp lateral mass (hyperextension injury)Anterior arch rare

Jefferson s burst of atlas 1st described by Geoffrey jefferson in 1920

HANGMANrsquoS ( TRAUMATIC SPONDYLOLISTHESIS OF AXIS )

ldquoJudicial Hangingrdquo- submental knots causes dislocation of neural arch of axis

IBilateral pars fractures with translation lt3 mm and no angulation most commonIACT extension of one fracture line into the body and often through the foramen transversarium(vertebral artery injury may occur)

II C2-3 disc and PLL are disrupted resulting in translation gt3 mm and marked angulationIIA Fracture line is more oblique than vertical

IIIA combination of pars fracture with dislocation of the C2-3 facet joints

ODONTOID

Constitute about 7 ndash14 of cervical spine Flexion is the MC mechanism of injury causing anterior displacement of C1 on C2

Type III more stable than type II fractures

NEOPLASMS OF CVJ

1048708Unusual 1048708Metastatic malignancies such as carcinoma of the breast lung prostate kidney and thyroid in adults and neuroblastoma Ewingrsquos tumor leukemia hepatoma and retinoblastoma in children are most common1048708Primary malignancies involving the cranio cervical junction are rare(multiple myeloma)

1048708Benign tumors are very rare

Craniovertebral junction (CVJ) abnormalities involve the osseous structures and the contained nervous system

-Advances in Digital radiography computed tomography and magnetic resonance imaging (MRI) have provided better insight into the normal anatomy and pathology of this complex area

THANK YOUhellip

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The Radiologic imaging modalities

Cervical spine projections

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The Chamberlainrsquos line

The McGregorrsquos line

The McRaersquos line

Clivus-Canal line

Basilar Angle

The Boogardrsquos line

Boogardrsquos angle

Method of Bull

Ranawat method

Schmidt ndash Fischer Angle (ATLANTO-OCCIPITAL JT AXIS ANGLE)


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CRANIOVERTEBRAL JUNCTION

bullThe craniovertebral junction(CVJ) is a collective term that refers to the occiput atlas axis and supporting ligaments

bullIt is a transition zone bw a mobile cranium amp relatively rigid spinal column

bullIt encloses the soft tissue structures of the cervico medullary junction (medulla spinal cord and lower cranial nerves)














ANATOMY





















































ATLANTOAXIAL JOINTS













RADIOLOGY OF CVJ




Cerebellar tonsils

medulla

Vertebral artery

basion

Medulla oblongata

basion




Medulla oblongata

Vertebral artery


Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

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Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



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Slide 95

Slide 96

Slide 97














ANATOMY





















































ATLANTOAXIAL JOINTS













RADIOLOGY OF CVJ




Cerebellar tonsils

medulla

Vertebral artery

basion

Medulla oblongata

basion




Medulla oblongata

Vertebral artery


Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

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Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 95

Slide 96

Slide 97





















































ATLANTOAXIAL JOINTS













RADIOLOGY OF CVJ




Cerebellar tonsils

medulla

Vertebral artery

basion

Medulla oblongata

basion




Medulla oblongata

Vertebral artery


Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

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Slide 31

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Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 53

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Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97









RADIOLOGY OF CVJ




Cerebellar tonsils

medulla

Vertebral artery

basion

Medulla oblongata

basion




Medulla oblongata

Vertebral artery


Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

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Slide 26

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Slide 31

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Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 51

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Slide 53

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Slide 94

Slide 95

Slide 96

Slide 97

Cerebellar tonsils

medulla

Vertebral artery

basion

Medulla oblongata

basion




Medulla oblongata

Vertebral artery


Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

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Slide 31

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Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 51

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Slide 53

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Slide 56

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Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

Medulla oblongata

basion




Medulla oblongata

Vertebral artery


Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

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Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

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Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97



Medulla oblongata

Vertebral artery


Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

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Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

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Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

Atlas lateral mass





Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

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Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

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Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97



Tectorial membrane



Dens of axis (C2)

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

Clivus


mass)Axis

Int carotid artery

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

Alar ligaments











H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97










H O


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97


H

Low occiput







Low occiput


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97


B O






CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

CLIVUS-CANAL LINE

C

B

OC2

H

N







BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

BASILAR ANGLE

Mid sella

B

N

S

B

N





Angle 1370 (123-1520)




N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97


N

O





BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

BOOGARDrsquoS ANGLE


B o

N

Mc Ray

s

C




119-1350

Average - 1220

gt 1350

Basillar impression

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

METHOD OF BULL

C2

Atlas plane

Chamberlain




RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23



Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Slide 80

Slide 81

Slide 82

Slide 83

Slide 84

Slide 85

Slide 86

Slide 87

Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

RANAWAT METHOD

C2

C1




C2

C1

C2

C1

PEDICLE


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

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Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



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Slide 97


O

C2AA JT

AO JT

C1 C1







ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

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Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 50

Slide 51

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Slide 53

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Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97


ax

C




Flexion ndash 1500

Extension - 1800











mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

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Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

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Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97










mouth view
























Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

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Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 50

Slide 51

Slide 52

Slide 53

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Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97





















Split Atlas








PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

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Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 50

Slide 51

Slide 52

Slide 53

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Slide 93

Slide 94

Slide 95

Slide 96

Slide 97







PLATYBASIA

BASILAR IMPRESSION



























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

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Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

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Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97

























CHIARI MALFORMATION






















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

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Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

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Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97





















TUBERCULOUS AAD









OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

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Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

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Slide 50

Slide 51

Slide 52

Slide 53

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Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97






OCCIPITAL CONDYLE













ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

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Slide 31

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Slide 33

Slide 34

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Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

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Slide 88

Slide 89

Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97










ODONTOID



NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

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Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

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Slide 90

Slide 91

Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97


NEOPLASMS OF CVJ





THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

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Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

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Slide 92

Slide 93

Slide 94

Slide 95

Slide 96

Slide 97



THANK YOUhellip

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Slide 7

Slide 8

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Slide 10

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Slide 26

Slide 27

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Slide 29

Slide 30

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36




Clivus-Canal line

Basilar Angle


Boogardrsquos angle

Method of Bull

Ranawat method



Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 55

Slide 56

Slide 57

Slide 58

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Download - Prashant gmc cvj

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