Understanding Ponticulus Posticus treatments

Ross Hauser, MD.

Very rarely does someone contact our office and come in with a primary diagnosis of ponticulus posticus. Perhaps like many of you reading this article, they heard that they have this condition from their doctor following a review of their x-rays and scans looking for a source of their varied and possibly large list of symptoms. Like these people, your doctor may have told you that ponticulus posticus 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 up until now, no one has been able to properly determine why you have headaches, migraines, double vision, dizziness, or orofacial (mouth and face) pain.

Article outline:

Part 1: Understanding Ponticulus Posticus.

Part 2: Expanding symptoms of Ponticulus Posticus. Surgery and non-surgical treatments.

Understanding Ponticulus Posticus

The people we see are people with a lot of symptoms. Here are some examples of the emails we get. They have been edited for clarity.

I have a history of 20 years of unexplained cervical nerve and muscle pain. Recently the pain had become debilitating. After detailed testing, I was diagnosed with ponticulus posticus – arcuate foramen, C1 misalignment, military neck, cervical radiculopathy, and three bulging cervical discs. This causes me bilateral numbness and tingling in my fingers, constant headache, diplopia, brain fog, depression and anxiety, postural dizziness, facial numbness, postural unilateral facial droopiness, tinnitus, obstructive sleep apnea, and personality changes. Doctors are not sure if the Ponticulus posticus plays a role in all this.

I was in a car accident that resulted in me having Post Concussion Syndrome. My symptoms are non-stop pressure/tension headaches, dizziness, light headiness, light sensitivity, noise sensitivity, neck strain, pain, stiffness (around the c1 area), loss of balance at times, loss of motor skills at times, weakness on my left side, and more. I’ve been trying to get help with this from numerous doctors but I haven’t had any success yet. In my first CT Scan, the doctor noticed I had Bilateral Posterior Ponticles at C1, but they claimed this was a normal variant (I should be asymptomatic) I noticed a lot of the symptoms in your article (this article) are similar to what I have.

I’ve suffered from tension headaches for a few years now. They are one-sided, on my left side. I’ve seen two orthopedic surgeons who unfortunately could not help me. When I get my left-sided tension headaches I’m also nauseous, and extremely tired. I experience pain behind my left eye and left side of the jaw, and it always feels to me like the pain begins right at the base of my skull on the left side. It feels extremely tight and painful and seems like that’s the epicenter of my pain. I also lose hearing in my left ear (my Eustachian tube gets affected and my ear “clogs” like I have an earplug in). The left side of my neck is painful as well as my left shoulder.

December 2013: 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.

October 2022 Ponticulus Posticus in symptomatic and asymptomatic patients.

An October 2022 paper in the journal Oral radiology (2) investigated the presence and types of ponticulus posticus from 640 digital lateral cephalograms of patients.

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 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.

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, atlantal posterior foramen, foramen sagittal, retroarticular vertebral artery ring, and the retroarticular canal 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. Ponticulus posticus can be partial, complete, unilateral, or bilateral. Complete Ponticulus posticus, where the bony ring is fully formed, thus resembling a foramen (a hole, specifically the hole that the blood vessels and nerves pass through in the skull), decreases the cross-sectional area for the vertebral artery. 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. Please see our article on treatments for Atlas displacement c1 forward misalignment. 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.

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.

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

Ponticulus Posticus problems can develop. 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.

Part 2: Surgery and non-surgical treatments


Surgeons discuss a connection between ponticulus posticus and cervicogenic headache.

A March 2022 study in the journal Frontiers in surgery (3) demonstrates how insignificant ponticulus posticus was thought to be and now, how this thinking should change: “Ponticulus posticus has not been a matter of concern for spine surgeons until an increasing number of epidemiology (looking for a cause) studies indicated its non-negligible (importance as a factor in) morbidity. More published studies showed a close connection between ponticulus posticus and cervicogenic headache. Surgical significance of ponticulus posticus in the insertion of screws into the lateral mass of the atlas was also reported.” What is important here is that ponticulus posticus became a factor when it may impede other cervical spine surgeries. Not a surgery on the Ponticulus posticus itself.

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. (4) Here surgeons discuss ponticulus posticus described as Kimmerle’s anomaly.

Learning points:

Ponticulus lateralis and compression of the vertebral artery – the patient passes out with a turn of the head.

The same research team published a second study in September 2018. (5) 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.

A case history of a 23-year-old man: torticollis, facial asymmetry, localized pain, and Barré-Liéou syndrome. Surgery helps some symptoms, not all.

In June 2022, a case history was presented in the Orthopaedic surgery (6) about a 23-year-old male who presented with the chief complaint of continuous significant dizziness to the point of losing consciousness while rotating his head to the right. The attending doctors noted: “Ponticulus posticus occurs frequently and may cause symptom series, including vertebrobasilar insufficiency, migraine, hearing loss, and Barré-Liéou syndrome. . .”

Case presentation: A 23-year-old male patient’s plain radiographs and computed tomography (CT) scans of the cervical spine showed a С1 anomaly with the formation of complete Ponticulus posticus on the left (dominant) side, with acute-angled, С-shaped kinking of the vertebral artery.

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, and 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.

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?

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 examinations 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, and 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

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, is 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.


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 Najmuddin M. Prevalence of ponticulus posticus on the posterior arch of the atlas in symptomatic and asymptomatic patients. Oral radiology. 2022 Oct;38(4):527-33. [Google Scholar]
3 Xu X, Zhu Y, Ding X, Yin M, Mo W, Ma J. Research Progress of Ponticulus Posticus: A Narrative Literature Review. Frontiers in Surgery. 2022;9. [Google Scholar]
4 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]
5 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]
6 Li G, Wang Q, Wang G. Torticollis, Facial Asymmetry, Local Pain, and Barré‐Liéou Syndrome in Connection with One‐Sided Ponticulus Posticus: A Case Report and Review of the Literature. Orthopaedic Surgery. 2022 Apr 25. [Google Scholar]

This article was updated on February 25, 2023

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