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Calcium Pyrophosphate Dihydrate Crystal Deposition in and around the Atlantoaxial Joint: Association with Type 2 Odontoid Fractures in Nine Patients¹

¹ From the Departments of Radiology (Y.K., R.D.B., D.J.T., M.N.P., D.R.) and Pathology (P.H.), University of California, San Diego, Veterans Affairs Medical Center, 3350 La Jolla Village Dr, San Diego, CA 92161; the Department of Radiology, Orthopedic Hospital, Los Angeles, Calif (R.M.K.); the Department of Radiology, University of California, San Francisco (L.S.S.); and the Department of Radiology, Hoag Memorial Hospital, Newport Beach, Calif (K.K.C.). Received February 1, 1999; revision requested March 22; revision received October 18; accepted November 1. Supported by Veterans Affairs grant SA-360. Address correspondence to D.R.

PURPOSE: To investigate the histopathologic anatomy of calcium pyrophosphate dihydrate (CPPD) crystal deposition in and around the atlantoaxial joint and the association between CPPD crystal deposition and subchondral cysts, erosions, and fracture involving the odontoid process of the axis.

MATERIALS AND METHODS: One adult cadaver demonstrating calcification in the retro-odontoid area at computed tomography (CT) was selected for further radiography, CT, and magnetic resonance (MR) imaging at the C1-2 level. Anatomic sectioning and histologic evaluations were performed in the specimen. For clinical study, radiographs (n = 5), CT scans (n = 8), and MR images (n = 6) in nine patients (mean age, 74.4 years) with odontoid process fractures and CPPD crystal deposits in and around the atlantoaxial joint were reviewed.

RESULTS: In the cadaveric specimen, radiography and CT demonstrated calcifications in the transverse ligament; histologic evaluation confirmed that these calcifications were CPPD crystal deposits. In all nine patients, radiography (n = 5) and CT (n = 8) also showed calcification in areas adjacent to the odontoid process, which included the transverse ligament. T1- and T2-weighted MR imaging showed a retro-odontoid mass of low signal intensity that compressed the cervical cord in six patients. CT, MR imaging, or both demonstrated subchondral cysts, osseous erosions, or a type 2 odontoid fracture in all patients.

CONCLUSION: CPPD crystal deposition disease involving the C1-C2 articulation can be a clinically important entity that may place affected patients at increased risk of pathologic fracture of the odontoid process.

Index terms: Arthritis, 31.761 • Atlas and axis, fractures, 311.416, 311.761 • Calcium pyrophosphate dihydrate deposition disease (CPPD), 31.761, 319.761 • Fractures, pathologic, 311.416, 311.761 • Ligaments, spinal, 319.761 • Spine, CT, 31.12111 • Spine, MR, 31.121411, 31.12143