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.

• December 2013: Ponticulus posticus in symptomatic and asymptomatic patients.
• October 2022: Ponticulus posticus in symptomatic and asymptomatic 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.
• “Ponticulus posticus,” is a “little posterior bridge” that is trying to prevent vertebral artery and suboccipital nerve compression.

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

• Surgeons discuss a connection between ponticulus posticus and cervicogenic headache.
• Compression of the vertebral artery – the patient passes out with a turn of the head.
• Torticollis, facial asymmetry, localized pain, and Barré-Liéou syndrome.
• Do I need to get Ponticulus Posticus surgery to remove the calcified ligament?
• Demonstration of non-surgical Prolotherapy treatment option.

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:

• Partial Ponticulus Posticus – unilateral one-side
• Complete Ponticulus Posticus – bilateral – both sides

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.

• Among the sample of 500 cases, partial ponticulus posticus was found in 302 patients (60%) (Males 48% and Females 52%).
• The complete variant was found in 40 cases (8%) (Males 65% and females 35% both, who were in the age group of 16-45 years),
• In partial Ponticulus Posticous, 42 patients (14%) were found to be symptomatic. In complete form, 32 patients (78%) were found to be symptomatic.
• Symptoms were mainly in the form of migraines or chronic types of headaches.

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.

• The prevalence of ponticulus posticus in this study was 9.8%, with complete form in 45 (7%) patients of which 29 (64.5%) were male and 16 (35.5%) were female.
• Partial ponticulus posticus was found in 18 (2.8%) of patients, of which 12 (66.6%) patients were male and six (33.33%) were female.
• In patients with the complete form of ponticulus posticus, 37 (82.22%) were symptomatic. Among these 37 patients, 22 (59.45%) were male and 15 (40.54%) were female.
• In complete ponticulus posticus patients, symptoms were slightly worse in males than females.
• In partial ponticulus posticus, 13 (72.22%) patients were found to be symptomatic. Of these 13 patients, seven (53.84%) were male and six (46.15%) were female.
• Of the 72 patients with a history of cervical pain, 50 (69.44%) showed ponticulus posticus on a lateral cephalogram.
• Of the 568 patients with no history of cervical pain, only 13 (2.2%) showed ponticulus posticus on the lateral cephalogram.

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:

• Ponticulus posticus can be missed on x-rays and even digital motion X-rays (DMX) and often it’s just discarded as kind of a normal variant. In our office, we see ponticulus posticus in some patients. For many of them, this is not a normal variant but the cause of many of their problem symptoms. (Headache, migraine, double vision, dizziness, or orofacial (mouth and face) pain.)
• At 0:40 of the video, the ponticulus posticus structure is identified in the patient’s digital motion x-ray.
• Surrounding the ponticulus posticus is a lot of vital structures, such as the vertebral artery and the suboccipital nerve. These structures can be squeezed or compressed by the ponticulus posticus, this is why we do not see this as a normal variant in many people.
• In this particular patient, they have ponticulus posticus only on the right side. Some people develop ponticulus posticus on both sides of the cervical column. In this person, being on the right side, the symptoms they develop would be right-side facial pain, migraines, etc.
• At 1:13 of the video, the patient starts to move their neck to allow us to see their cervical spine in motion.
• At its location on the C1 vertebrae or superior articulate to the posterolateral part of the atlas (C1), you can see how this patient’s neck movements the ponticulus posticus can come into contact with the C1 nerve root on the right side and the right side vertebral artery. So when this patient bends forward or back you could see the ponticulus posticus gets closer to the occiput with one of the movements and gets closer to the atlas with one of the movements which means that on the side that it is there is a narrowed space and compression of the vertebral artery and the C1 nerve root.
• Especially noted is that the C1 nerve innervates the dura which covers the brain so if you have unexplained pain on the right side (as this patient may have) or deep pain,  a weird pain such as in between the eyebrows or in the face, or migraine headaches on one side there can be an association with the Ponticulus posticus.

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 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

• C1 has the most mobility out of any bone in your neck so if C1 is turning, twisting, flexing, and extending, it has the unwanted opportunity and ability for that bone to wander into a place where it can compress the vertebral artery.

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:

• Reports on the surgical treatment of the Kimmerle anomaly are rare.
• Surgical treatment of vertebral artery compression in patients with Kimmerle anomaly is preferable in cases where conservative treatment is inefficient. A minimally invasive procedure can be an alternative to the routine open surgery procedure.

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 some cases, the bony ridge may also be formed at the level of the vertebral artery emerging from the transverse process of the С1 vertebra (this is ponticulus lateralis). Simultaneous 1-sided formation of ponticulus lateralis and ponticulus posticus is very rare. Data concerning surgical treatment for compression of the vertebral artery owing to ponticulus lateralis are lacking.

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.

• In this patient, surgery was able to help with her pain by removing the compression of the С1 spinal root and alleviating her bow hunter’s syndrome (losing consciousness) when she turned her head.
• The surgeons of this study suggested that this was the first report on the surgical treatment of vertebral artery compression owing to ponticulus lateralis and ponticulus posticus.

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.

• Surgical resection of the ponticulus posticus was performed successfully.
• The patient had satisfactory postoperative relief from localized pain and Barré-Liéou syndrome, but there were no obvious changes in the torticollis and facial asymmetry observed during the 3-month follow-up period.
• The learning observation in this case as presented by the doctors was: “Ponticulus posticus may affect the patient earlier than expected. In such situations, early diagnosis and timely surgical treatment may significantly improve patient’s quality of life and avoid the development of torticollis and face asymmetry.”
• The doctors wrote: “Improvement of torticollis and facial asymmetry would likely be greater if surgery had been performed early.”

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?

• How does a calcified posterior atlanto-occipital ligament develop?
  • We are always intrigued by disorders that occur more in one sex versus the other. Why does Ponticulus Posticus occur more often in women? Is there a hormonal component?  In Ponticulus Posticous, it’s our experience it’s more common in females. One of the main differences between males and females, in general, is females are much more flexible. Does this flexibility lead to calcified ligaments?
• Long-standing instability causing hardening of the ligaments
  • We see ligaments get calcified when there’s been a long-standing instability or hypermobility. The ligaments try to harden as a protective mechanism. The body is so intelligent is if there is something that’s hypermobile or unstable your body will start to harden tissue around that area.
  • Medical science is unclear why people will have Ponticulus Posticus form. Maybe one of the reasons that it’s more common in females is that generally, they do have a bit more hypermobility and their bodies are trying to harden or tighten that area to create stability.

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

• Patients will often ask us, should I get the surgery? Should I have this removed? We then explain to some of the patients that they may have had this condition for years and it never became symptomatic during that time. Now we are seeing the patients because their situation has become symptomatic – and – for many, the problem did not become symptomatic because of the elongated bone, it became symptomatic because of hypermobility in the neck that allowed the bone to move around and compress the artery.
• One way to correct this is to get the neck anatomy back to what it was so that the elongated bone does not press or kink the artery.

Bilateral posterior ponticulus

• This is an example of a patient who had bilateral posterior ponticulus. This is a complicated situation because now both the left and right side vertebral arteries can get kinked or be under tension. The one good thing about this patient’s x-ray is that we can see a good amount of space between the base of the skull and C1. So we would have a good and realistic expectation that we can help this patient and resolve their issues with neck curve correction and Prolotherapy injections to regenerate, tighten, and strengthen those ligaments.

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

• In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and the accompanying symptoms of cervical radiculopathy.
• A before digital motion x-ray at 0:11
• At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
• At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
• At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
• At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
• At 1:14 the previously completely closed neural foramina are now opening normally during motion

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.

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This article was updated on February 25, 2023

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