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Objective Unfamiliarity with the morphometry of the assimilated C1 lateral mass (C1LM) could make screw placement dangerous. In the present study, we defined the morphometric dimensions of the occipitalized C1LM to provide surgeons with valuable information for preoperative planning. Methods Thin-slice computed tomography scanning data from 131 patients with occipitalization of the atlas (OA) and 50 control cases were imported into Mimics software for analysis. The widths and heights of the C1LM were fully measured in the different planes. The ideal inward angulation and the safe maximum cephalic angulation of C1 screw trajectory were evaluated. Results Except for the medial height, all the widths and heights of C1LM were significantly shorter in the OA group than those in the control group. The ideal inward angle (α) was significantly larger in the OA group (23.8° ± 8.3°) than that (15.3° ± 3.8°) in the control group; the corresponding screw length was also significantly longer in the OA group (20.9 ± 2.9 mm). The safe maximum cephalic angles (β) of the screw trajectory did not reach a significant difference between the 2 groups. All the widths and heights were shorter in the females than those in the males. The α angle also did not reach a significant difference between the sexes; however, the β angles in the males (35.9° ± 10.4°) was significantly larger than that in the females (32.0° ± 9.4°). Conclusions Although the hypoplastic C1LM brings limitations to screw insertion to some extent, it is still broad enough to accommodate a screw safely in both female and male patients. Considering the irregularity of the C1LM in patients with OA, the preoperative imaging assessment is critical, and C1LM screw placement should be performed individually. Highlights • The volume of the C1LM with occipitalization is hypoplastic. • The assimilated C1LM is still broad enough to accommodate a screw safely in both female and male patients. • The inward angle of the screw trajectory will be larger in the OA group than that in the control group. • The safe maximum cephalic angle of the screw trajectory was not different between the OA and control groups. • The volume of the C1LM in women is small compared with that in men. [ABSTRACT FROM AUTHOR]

The occipitalization of the atlas (OA) is always associated with multiplanar dislocation and olisthy of the C1 over C2 facets, which may change the anatomical relationship between the internal carotid artery (ICA) and the atlas. The purpose of this current study is to identify the location of the ICA relative to the anterior aspect of the atlas in patients with OA and define the clinical implications for screw placement. We retrospectively reviewed the computed tomography angiography data of 86 patients with OA and 86 control subjects. Several parameters were also measured to quantitatively evaluate the mutual relationship. In the OA group, 25.6% of ICAs were located in area 3 and 74.4% in area 2, whereas the percentages were 57.4% and 42.6%, respectively, in the control group. There were 73 (42.4%) ICAs in which the shortest distance between the dorsal surface of the ICA and the ventral cortex of the atlas was less than 4 mm in the OA group and only 50 (29.1%) in the control group. The ideal angulation of C1 screw trajectory was about 5 degrees more medial in the OA group than that in the control group (P < 0.01). The risk of ICA injury is much higher in OA patients than in non-OA patients during the C1 screw placement. A mean medial angulation about 20 degrees will permit a long and safe screw purchase, but should be individualized. We recommend careful preoperative computed tomography angiography evaluation in all patients before surgery. [ABSTRACT FROM AUTHOR]

Occipitalization of the atlas (OA) often is associated with atlantoaxial dislocation and basilar invagination. The purpose of this study is to determine the biomechanical difference between normal and OA conditions in the craniovertebral junction and to further explore the rationale for development of atlantoaxial dislocation and basilar invagination using the finite element model (FEM). A ligamentous, nonlinear, sliding-contact, 3-dimensional FEM of the occipitoatlantoaxial complex was generated. Validation of the model was accomplished by comparing kinematic predictions with experimental data. We defined the atlantooccipital joint as a tie contact to simulate the OA deformity. The range of motion and the value of the maximum Von Mises stress were compared between the intact and OA models. We found all of the predicted data in the intact FEM fell within 1 standard deviation of the cadaver data for all 6 loadings. The OA simulation significantly reduced the overall range of motion of the occipitoatlantoaxial complex at all loadings. The maximum Von Mises stress was predicted to increase at the transverse ligament and the superior articular facet of the axis for all the flexion, extension, lateral bending, and axial rotation loadings. The OA could result in hypermobility of the atlantoaxial segment and cause overstress in the transverse ligament and the lateral atlantoaxial joints. These changes explain the pathogenesis of atlantoaxial dislocation and basilar invagination associated with OA. Follow-up should be scheduled regularly due to the nature of the dynamic development of atlantoaxial dislocation and basilar invagination. [ABSTRACT FROM AUTHOR]