Understanding Ponticulus Posticus treatments

Ross Hauser, MD.

Your doctor told you about ponticulus posticus. He/she may have told you that this is a somewhat rare condition and it may or may not be the cause of your health issues. But you wanted to learn more because this may be why you have headaches, migraines, double vision, dizziness, or orofacial (mouth and face) pain.

Understanding Ponticulus Posticus

In advancing cervical spine instability and neck problems, and with seemingly no alternative, the posterior atlantooccipital ligament transforms itself into a bony structure to “bridge” over the foramen in a last attempt to prevent vertebral artery and suboccipital nerve compression. The last chance to fight off cervical instability.

In this snap shot from the video belwop, Dr. Hauser shows the development of Ponticulus Posticus in a Digital Motion X-Ray of a patient. Dr. Hauser explains that with seemingly no alternative, the posterior atlantooccipital ligament has transformed itself into a bony structure to "bridge" over the foramen in a last attempt to prevent vertebral artery and the suboccipital nerve compression.

In this snapshot from the video below, Dr. Hauser shows the development of Ponticulus Posticus in a Digital Motion X-Ray of a patient. Dr. Hauser explains that with seemingly no alternative, the posterior atlantooccipital ligament has transformed itself into a bony structure to “bridge” over the foramen in a last attempt to prevent vertebral artery and suboccipital nerve compression.

The posterior atlantooccipital ligament is a protector of the groove where the vertebral artery passes at the C1. “Ponticulus posticus,” is a “little posterior bridge” that is trying to prevent vertebral artery and suboccipital nerve compression –

Ponticulus posticus also referred to as arcuate foramen or Kimmerle’s anomaly, is what its Latin name implies, “Ponticulus posticus,” a “little posterior bridge.” How did you develop this bony little bridge abnormality at the posterior of the atlas/C1 vertebra?

In simplest terms, the little bony bridge is a petrified ligament. But instead of the ligament turning into stone, the ligament turned into bone. Specifically, the ponticulus posticus formed as a result of ossification of the posterior atlantooccipital ligament. Why did this happen?

The posterior atlantooccipital ligament is a protector of the groove where the vertebral artery passes at the C1. When there is upper cervical instability, specifically at the C1 or Atlas, the vertebral artery and the suboccipital nerve which both travel through the C1 foramen (opening) can be compressed. The ligament which is not strong enough to protect this opening if instability is present, continuously weakens and becomes damaged in its attempt to provide this protection. With seemingly no alternative, the ligament transforms itself into a bony structure to “bridge” over the foramen in a last attempt to prevent vertebral artery and suboccipital nerve compression. This of course is not optimum for the patient. The ligaments serve to provide strong, natural, cervical motion when the ligament turns into bone, it is creating its own fusion, such as it is with bone spurs.

You may have learned about the ponticulus posticus from an incidental MRI or CT Scan – it may have been ignored or it may be the reason for your symptoms.

For many people, like yourself probably, you learned about the ponticulus posticus from an incidental MRI or CT Scan. This means that no one was looking for this but the little bony bridge showed up at your C1 on imaging.

In the video below, Ross Hauser, MD explains: A summary transcript is below the video:

The vertebral artery runs in the transverse foramen of the cervical vertebrae. If the cervical vertebrae are moving too much you can get compression the artery that supplies about 1/3 of the brain with its blood.

The vertebral artery runs in the transverse foramen of the cervical vertebrae. If the cervical vertebrae are moving too much you can get compression of the artery that supplies about 1/3 of the brain with its blood.

Research: Ponticulus Posticus in symptomatic and asymptomatic patients

As mentioned above, You may have learned about the ponticulus posticus from an incidental MRI or CT Scan – it may have been ignored or it may be the reason for your symptoms. In the DMX image, we saw in the above video, we saw how the ponticulus posticus could impact the C1 nerve root and the vertebral artery. This is not always an easy observation to make. Ponticulus posticus

The goal of this study was to substantiate whether the ponticulus posticus was the possible cause of chronic tension-type headaches and migraines.

Writing in the Journal of Clinical and Diagnostic Research, (1) researchers investigated the prevalence and morphological (the interaction between the bony, nerves, and soft-tissue structures)  features of ponticulus posticus in symptomatic and asymptomatic patients. The goal of this study was to substantiate whether the ponticulus posticus was the possible cause of chronic tension-type headaches and migraines.

This study refers to:

The researchers examined five hundred patients for the presence and type of ponticulus posticus. All the patients in whom ponticulus posticus was present in either partial or complete form were further studied for symptoms like chronic tension-type headache, orofacial pain, or diagnosed migraine.

The researchers concluded: “According to our study, a partial form of ponticulus posticus was found to be more prevalent as compared to complete form in the (study) population and complete form of ponticulus posticus can be considered as a possible cause for chronic tension-type headache, orofacial pain, and migraine.

Surgery and non-surgical treatments

There is not a lot of research on how to treat ponticulus posticus, As noted above, for many doctors this is an incidental finding and it does not require treatment. This is not true for every patient.

Here is a study from December 2017, published in the Journal of Craniovertebral Junction and Spine. (2) Here surgeons discuss ponticulus posticus described as Kimmerle’s anomaly.

Learning points:

Ponticulus lateralis and compression of the vertebral artery

The same research team published a second study in September 2018. (3) Writing in the journal World Neurosurgery, the surgeons made these observations:

Explanatory note: The term ponticulus lateralis refers to when the ponticulus posticus bony bridge takes a vertical spike upwards to directly compress the vertebral artery. 

In this study, a case is demonstrated in a 34-year-old woman who had significant dizziness to the point of losing consciousness while rotating her head to the left. Computed tomography angiography of the cervical spine revealed С1 anomaly with the formation of ponticulus lateralis and ponticulus posticus with acute-angled С-shaped kinking of the vertebral artery.

What should be pointed out is that surgery, specifically for ponticulus lateralis and ponticulus posticus, has little research behind it and is rarely performed.

Bow hunter’s syndrome

I have an extensive article: Treating Vertebrobasilar insufficiency – Bow hunter’s syndrome. Every time I turn my head I get dizzy. Sometimes I almost pass out. Here I discuss the complexity and challenges of cervical neck instability treatment which is fully displayed in the controversies and confusions surrounding the diagnosis of vertebrobasilar insufficiency, also called vertebrobasilar artery insufficiency or Bow Hunter Syndrome. As a patient diagnosed with one of these diagnostic tags, you probably know firsthand that your journey of treatment has taken many turns. Some right, some not so right, but because you are reading this article, your journey of healing is probably far from complete.

Non-surgical treatment

As discussed in this article, there can be an association between ponticulus posticus and your symptoms that can include you passing out when you turn your head to one side, migraine headaches, facial pain, visual disturbances, among other problems. So for many people, this is not a benign finding and it could be a significant finding in resolving your particular problems.


Video update July 2021 

What causes calcification of the ligament? Elongation of the bone? What can we do to help the patients?

This video features Dr. Ross Hauser, MD, and his associate Dr. Brian Hutchison, DC. The Ponticulus Posticus is a common comorbidity that compresses and reduces the space that the vertebral artery can pass through the foramen.

 

What are we seeing in this image?

While the vertebral artery can get pinched anywhere along the cervical spine, we most commonly see this compression at the C1 level. This is displayed below in the “B” panel

Video at: (0:40) Dr. Hutcheson describes how Ponticulus Posticus problems can develop by describing this image. Ligamentous (ligament weakness or laxity) can cause the vertebral artery and the C1 nerve root to become encroached upon by the ossification of the ligament structures of the atlas.

Ponticulus Posticus creates a situation where the neck does not want to go back into a normal curve

One unique thing that we have been seeing when we begin our treatment for neck curve correction, often, because of the Ponticulus Posticus situation, when we try to get a patient’s neck into a good and proper position to help correct the curve of their neck, their neck becomes resistant to go into that position because of the posterior Ponticulus Posticus. It is inhibiting the neck. So we have to get really creative with how we restore the natural curve and still not put pressure on the vertebral artery.

Ligaments can get calcified, is it hormones or instability or a little of both? Why is it more common in females?

Do I need to get Ponticulus Posticus surgery to remove the calcified ligament?

At 4:50 of the video

Bilateral posterior ponticulus

Bilateral posterior ponticulus

Determining blood flow to the brain

At the Hauser Neck Center at Caring Medical Florida, we can utilize transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound examination to assess proper blood flow during positional changes of the neck.

In this video, when this patient is in a neutral position, head up, looking straight ahead, blood flow through the arteries can be seen and heard. When the patient is asked to extend their head backward and to the left, a clear and audible difference in the blood flow can be heard. This is demonstrated at the start of the video.

Determining at which head position decreased blood flow occurs can help us determine treatment for vertebrobasilar insufficiency. In the case of this article, is the ponticulus posticus pressing on the vertebral artery, if it is, at which head position? In the video above we saw the ponticulus posticus banging against the occiput at the base of the skull and the C1.

Demonstration of non-surgical Prolotherapy treatment option

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. In this article, Prolotherapy is demonstrated as a treatment to address upper cervical instability in cases of ponticulus posticus and without ponticulus posticus.

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

In the video below, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine


If you have questions and would like to discuss your cervical spine issues with our staff you can get help and information from us.

1 Chitroda PK, Katti G, Baba IA, Najmudin M, Ghali SR, Kalmath B, G V. Ponticulus posticus on the posterior arch of atlas, prevalence analysis in symptomatic and asymptomatic patients of gulbarga population. J Clin Diagn Res. 2013 Dec;7(12):3044-7. doi: 10.7860/JCDR/2013/6795.3847. Epub 2013 Dec 15. PMID: 24551723; PMCID: PMC3919343. [Google Scholar]
2 Lvov I, Lukianchikov V, Grin A, Sytnik A, Polunina N, Krylov V. Minimally invasive surgical treatment for Kimmerle anomaly. J Craniovertebr Junction Spine. 2017 Oct-Dec;8(4):359-363. doi: 10.4103/jcvjs.JCVJS_73_17. PMID: 29403250; PMCID: PMC5763595. [Google Scholar]
3 Lukianchikov V, Lvov I, Grin A, Kordonskiy A, Polunina N, Krylov V. Minimally Invasive Surgical Treatment for Vertebral Artery Compression in a Patient with One-Sided Ponticulus Posticus and Ponticulus Lateralis. World neurosurgery. 2018 Sep 1;117:97-102. [Google Scholar]

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