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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 1  |  Page : 125-126

Cervicomedullary compression secondary to proliferation of transverse atlantal ligament

1 Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
2 Department of Pathology, West China Hospital, Sichuan University, Chengdu, China

Date of Submission29-Oct-2011
Date of Decision06-Nov-2011
Date of Acceptance18-Nov-2011
Date of Web Publication7-Mar-2012

Correspondence Address:
Chao You
Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.93619

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How to cite this article:
Ma JP, Ma L, You C, Liu JP. Cervicomedullary compression secondary to proliferation of transverse atlantal ligament. Neurol India 2012;60:125-6

How to cite this URL:
Ma JP, Ma L, You C, Liu JP. Cervicomedullary compression secondary to proliferation of transverse atlantal ligament. Neurol India [serial online] 2012 [cited 2021 May 15];60:125-6. Available from:


A 62-year-old man was admitted with progressive extremity weakness and sensory disturbances of one-year duration. Neurological examination revealed moderate weakness of all four extremities with a cervical sensory level. Deep tendon reflex were hyperactive with bilateral up going plantar response. Magnetic resonance imaging (MRI) revealed a retro-atlantoaxial extradural mass, homogenously isointense on T1-weighted sequence and relatively hypo-intense on T2-weighted sequence [Figure 1]. There was no evidence of calcification or spondylosis on computed tomography (CT) and plain radiographs [Figure 2]. Extensive laboratory workup including immunological studies showed no abnormality. C1-2 hemilaminectomy and partial occipital craniectomy were done to expose the lesion. During the operation, a ligament-like mass adherent to the vertebra and dura could clearly be visualized [Figure 3]a. Subtotal resection was performed. Intraoperative frozen histopathological examination confirmed the mass as ligamentous structure [Figure 3]b. Postoperative course was uneventful and there was a rapid improvement of neurologic function in the lower limbs. He was discharged on the seventh postoperative day and he recovered from the neurological deficits during two years' follow-up.
Figure 1: Axial T1-weighted MRI reveals a homogeneous isointense mass around the midline of craniocervical junction region, causing obvious compression to the cervical cord. (b) Sagittal T1-weighted MRI reveals that the mass extends from the foramen magnum to the retro-odontoid area. (c) In sagittal T2-weighted MRI, the mass is relatively low-intense to the neural tissue

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Figure 2: Computed tomography and cervical X radiograph does not detect any sign of calcification or spondylosis

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Figure 3: (a) General observation of resected specimens reveals that the mass is a ligamentous structure with regular shape. (b) Hematoxylin and eosin examination confirms proliferative changes of ligament (H and E, ×200)

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Cervicomedullary compression from lesions arising from the transverse ligament of the  Atlas More Details (TLA) is extremely rare. In this patient, the image founding of proliferative TLA have the following features and characteristics: [1],[2] (1) retro-atlantoaxial extradural mass with obvious anterior cervico-medullary compression; (2) homogeneously isointense to the neural tissue on T1-weighted sequence and relatively hypo-intense on T2-sequence; (3) No contrast enhancement; and (4) no evidence of calcification, bone erosion, bone destruction or spondylosis in cervical X radiograph and CT scan. Histologically, proliferative changes of ligament are observed in the fibrous matrix with no evidence of calcification and salt deposition in the proliferative ligament. The pathophysiology of this condition is totally different from that of calcium pyrophosphate crystal deposition (CPCD) of TLA, the most common reported lesion arising from the TLA. [3],[4] But the exact pathophysiology of this condition and whether proliferation of the TLA will evolve to other pathological changes, such as ossification and canceration, are unclear. [5] Surgery is the only way to treat cervicomedullary compression in this condition. As the proliferative ligament is non-invasive and slowly progressive, the aim of surgery should focus on decompression and protection of the cervicomedullary junction together with mainstreaming atlantoaxial stability. Both preoperative imaging and intraoperative frozen histopathological sections are essential for the definite diagnosis and deciding the scope of resection. As long as the ligamentous structures are confirmed, subtotal resection is sufficient for decompression. However, as the understanding of this disease is very limited, whether there is continued proliferation and increased atlantoaxial instability after surgery are still uncertain.

  References Top

1.Dickman CA, Mamourian A, Sonntag VK, Drayer BP. Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability. J Neurosurg 1991;75:221-7.  Back to cited text no. 1
2.Rhoton AL. The Foramen Magnum. Neurosurgery 2000;Suppl 3;47:158-9.  Back to cited text no. 2
3.Sethi KS, Garg A, Sharma MC, Ahmad FU, Sharma BS. Cervicomedullary compression secondary to massive calcium pyrophosphate crystal deposition in the atlantoaxial joint with intradural extension and vertebral artery encasement. Surg Neurol 2007;67:200-3.  Back to cited text no. 3
4.Assaker R, Louis E, Boutry N, Bera-Louville A, Paul Lejeune J. Foramen magnum syndrome secondary to calcium pyrophosphate crystal deposition in the transverse ligament of the atlas. Spine (Phila Pa 1976) 2001;26:1396-400.  Back to cited text no. 4
5.Kondo S, Onari K, Watanabe K, Hasegawa T, Toguchi A, Mihara H. Hypertrophy of the posterior longitudinal ligament is a prodromal condition to ossification: A cervical myelopathy case report. Spine (Phila Pa 1976) 2001;26:110-4.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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