title: Occipital condyles congenital dislocation and condylus tertius: an unstable association revealing a new abnormality of the craniocervical junction.
abstract: METHODS
  A case report.
  
  
  OBJECTIVE
  To describe a unique craniocervical junction anomaly and its implications both on mobility and stability of the skull base.
  
  
  BACKGROUND
  Congenital variations in the craniocervical junction (CVJ) are rare and frequently symptomless. Mild traumas may commonly rouse symptoms which help to unveil such anomalies through radiological investigations.
  
  
  METHODS
  A 73-year-old woman developed a monoparesis of the right arm after a mild craniofacial trauma. Neurological examination revealed hyper-reflexia in the upper limbs, confirming the strength impairment in the right one. Radiology showed a post-traumatic bulbo-medullary contusion sustained by a unique and unstable association of the first occipital condyles congenital dislocation ever reported with a rare condylus tertius. The patient underwent posterior decompression and occipitocervical screw-rod fixation and fusion. Clinico-radiological follow-up highlighted a gradual recovery of the neurologic impairment and the posterior decompression with resolution of the spinal cord contusion.
  
  
  RESULTS
  Although apparently stable the hyperostosis and the irregularly shaped condylar surfaces behind the 3-points mechanism of skull base support played a critical role in determining axial instability. The imbalance due to skull-cervical spine malpositioning may consequently trigger a vicious cycle of development of osteophytes leading to spinal cord narrowing with neurologic decline. A surgical strategy providing for posterior decompression and fixation satisfied the need to solve both bulbo-medullary constriction and skull base instability.
  
  
  CONCLUSIONS
  Clinical evidences about CVJ anomalies are lacking and symptoms, when present, tend to be vague. Although extremely rare clinicians should be aware of CVJ variations by engaging to improve their knowledge of imaging anatomy, embryology, CVJ basic craniometry and anatomic relationships. Studies on developmental control genes may offer future perspectives of early diagnosis and targeted treatments.
  
  
  METHODS
  4.
authors.affiliation: *Department of Neurosurgery, Catholic University, 00168 Rome, Italy; and †Department of Spine Surgery, Maggiore Hospital "C.A. Pizzardi", 40100 Bologna, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Lofrese
authors.forename: Federico
authors.initials: F
authors.lastname: De Iure F
authors.forename: Michele
authors.initials: M
authors.lastname: Cappuccio
authors.forename: Luca
authors.initials: L
authors.lastname: Amendola
mesh_terms: D000368:Aged; D001268:Atlanto-Axial Joint / Q000601:surgery*; D001269:Atlanto-Occipital Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D002574:Cervical Vertebrae / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D004204:Joint Dislocations / Q000175:diagnosis / Q000601:surgery*; D009777:Occipital Bone / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome