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How Common Is the Ponticulus Posticus?

A Computed Tomography Based Analysis of 2917 Patients

Saleh, Ahmed, MD; Gruber, Jilian, BA; Bakhsh, Wajeeh, MD; Rubery, Paul T., MD; Mesfin, Addisu, MD∗,†

doi: 10.1097/BRS.0000000000002400

Study Design. A computed tomography (CT) study of the morphology of the C1 vertebra.

Objective. Is to determine the prevalence of ponticulus posticus (PP) by analyzing CT scans performed on a large, diverse population in the northeast United States. This study also proposes a CT-based classification system both to aid in unifying the description of PP, and to aid in future research.

Summary of Background Data. The prevalence of PP varies from 5% to 68% in published studies. There may be geographic variation in the prevalence of PP. Our objective was to establish the prevalence of PP in the general population, and to develop a comprehensive classification system to describe PP.

Methods. We evaluated cervical spine CT scans performed on patients in the emergency room of a level I trauma center over a 1-year period (January 1, 2014–December 31, 2014). The CT images were evaluated for the presence of a PP, and if present the following demographic data were collected: age, sex, race/ethnicity, and body mass index (BMI). We propose a novel classification system to standardize the description of PP identified on CT scan.

Results. Two thousand, nine hundred and seventeen cervical spine CT scans were reviewed in this study. The prevalence of PP was 22.5%. Men had a higher prevalence of PP than women (53.5% male vs. 46.5% female P ≤ 0.01). When compared with the overall population, African–Americans were more likely to have a PP (P ≤ 0.01), while Caucasian patients were less likely (P ≤ 0.01). The novel classification consisted of a two letter designation for each patient, with the first letter denoting the right sided arch and the second letter the left sided arch. Each side of the arch described as an A, B, or C type. The A type had no presence of a PP, B type had in incomplete PP, and C type had a complete PP. The most common type of a PP was CC encompassing 25% of the patients. The presence of a PP was more common in the left sided arch than the right side (B and C type Left 89.2% vs. B and C type Right 84.7%, P = 0.02).

Conclusion. We found a 22.5% prevalence of PP in 2917 patients undergoing a cervical spine CT. This is the largest study to evaluating the prevalence of PP.

Level of Evidence: 4

Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY

Department of Orthopaedic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY.

Address correspondence and reprint requests to Ahmed Saleh, MD, Maimonides Medical Center, Maimonides Bone and Joint Center, 6010 Bay Parkway, Brooklyn, NY 11204; E-mail:

Received 6 June, 2017

Revised 20 July, 2017

Accepted 2 August, 2017

The manuscript submitted does not contain information about medical device (s)/drug (s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: grants, stocks.

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