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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.

View larger version (119K): [in a new window]   Figure 1a. CPPD crystal deposition in the transverse ligament of a cadaveric specimen. a-c are of sections at approximately the same level; d-f are of a section 4 mm more inferior. (a) Radiograph of the pathologic section shows curvilinear and spotty calcifications (arrow) in the transverse ligament. (b) Transverse CT scan shows a curvilinear calcification (arrow) in the retro-odontoid region. (c) Transverse T1-weighted SE MR image (500/13) shows the transverse ligament with intermediate signal intensity (short arrow). The calcification is shown as a subtle curvilinear low-signal-intensity area (long arrow). (d) Transverse T2-weighted SE MR image (4,000/76) shows low-signal-intensity areas (arrows) in the central portion of the transverse ligament. This section is immediately adjacent to those displayed in a-c and is at the same level as the section displayed in e. (e) Photograph of a pathologic specimen shows whitish CPPD crystal deposits (arrows) in the transverse ligament. (f) Photomicrograph of specimen depicted in e that was obtained from the transverse ligament shows large "lakes" of crystal deposition (arrows) within the ligament. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (108K): [in a new window]   Figure 1b. CPPD crystal deposition in the transverse ligament of a cadaveric specimen. a-c are of sections at approximately the same level; d-f are of a section 4 mm more inferior. (a) Radiograph of the pathologic section shows curvilinear and spotty calcifications (arrow) in the transverse ligament. (b) Transverse CT scan shows a curvilinear calcification (arrow) in the retro-odontoid region. (c) Transverse T1-weighted SE MR image (500/13) shows the transverse ligament with intermediate signal intensity (short arrow). The calcification is shown as a subtle curvilinear low-signal-intensity area (long arrow). (d) Transverse T2-weighted SE MR image (4,000/76) shows low-signal-intensity areas (arrows) in the central portion of the transverse ligament. This section is immediately adjacent to those displayed in a-c and is at the same level as the section displayed in e. (e) Photograph of a pathologic specimen shows whitish CPPD crystal deposits (arrows) in the transverse ligament. (f) Photomicrograph of specimen depicted in e that was obtained from the transverse ligament shows large "lakes" of crystal deposition (arrows) within the ligament. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (123K): [in a new window]   Figure 1c. CPPD crystal deposition in the transverse ligament of a cadaveric specimen. a-c are of sections at approximately the same level; d-f are of a section 4 mm more inferior. (a) Radiograph of the pathologic section shows curvilinear and spotty calcifications (arrow) in the transverse ligament. (b) Transverse CT scan shows a curvilinear calcification (arrow) in the retro-odontoid region. (c) Transverse T1-weighted SE MR image (500/13) shows the transverse ligament with intermediate signal intensity (short arrow). The calcification is shown as a subtle curvilinear low-signal-intensity area (long arrow). (d) Transverse T2-weighted SE MR image (4,000/76) shows low-signal-intensity areas (arrows) in the central portion of the transverse ligament. This section is immediately adjacent to those displayed in a-c and is at the same level as the section displayed in e. (e) Photograph of a pathologic specimen shows whitish CPPD crystal deposits (arrows) in the transverse ligament. (f) Photomicrograph of specimen depicted in e that was obtained from the transverse ligament shows large "lakes" of crystal deposition (arrows) within the ligament. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (135K): [in a new window]   Figure 1d. CPPD crystal deposition in the transverse ligament of a cadaveric specimen. a-c are of sections at approximately the same level; d-f are of a section 4 mm more inferior. (a) Radiograph of the pathologic section shows curvilinear and spotty calcifications (arrow) in the transverse ligament. (b) Transverse CT scan shows a curvilinear calcification (arrow) in the retro-odontoid region. (c) Transverse T1-weighted SE MR image (500/13) shows the transverse ligament with intermediate signal intensity (short arrow). The calcification is shown as a subtle curvilinear low-signal-intensity area (long arrow). (d) Transverse T2-weighted SE MR image (4,000/76) shows low-signal-intensity areas (arrows) in the central portion of the transverse ligament. This section is immediately adjacent to those displayed in a-c and is at the same level as the section displayed in e. (e) Photograph of a pathologic specimen shows whitish CPPD crystal deposits (arrows) in the transverse ligament. (f) Photomicrograph of specimen depicted in e that was obtained from the transverse ligament shows large "lakes" of crystal deposition (arrows) within the ligament. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (149K): [in a new window]   Figure 1e. CPPD crystal deposition in the transverse ligament of a cadaveric specimen. a-c are of sections at approximately the same level; d-f are of a section 4 mm more inferior. (a) Radiograph of the pathologic section shows curvilinear and spotty calcifications (arrow) in the transverse ligament. (b) Transverse CT scan shows a curvilinear calcification (arrow) in the retro-odontoid region. (c) Transverse T1-weighted SE MR image (500/13) shows the transverse ligament with intermediate signal intensity (short arrow). The calcification is shown as a subtle curvilinear low-signal-intensity area (long arrow). (d) Transverse T2-weighted SE MR image (4,000/76) shows low-signal-intensity areas (arrows) in the central portion of the transverse ligament. This section is immediately adjacent to those displayed in a-c and is at the same level as the section displayed in e. (e) Photograph of a pathologic specimen shows whitish CPPD crystal deposits (arrows) in the transverse ligament. (f) Photomicrograph of specimen depicted in e that was obtained from the transverse ligament shows large "lakes" of crystal deposition (arrows) within the ligament. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (133K): [in a new window]   Figure 1f. CPPD crystal deposition in the transverse ligament of a cadaveric specimen. a-c are of sections at approximately the same level; d-f are of a section 4 mm more inferior. (a) Radiograph of the pathologic section shows curvilinear and spotty calcifications (arrow) in the transverse ligament. (b) Transverse CT scan shows a curvilinear calcification (arrow) in the retro-odontoid region. (c) Transverse T1-weighted SE MR image (500/13) shows the transverse ligament with intermediate signal intensity (short arrow). The calcification is shown as a subtle curvilinear low-signal-intensity area (long arrow). (d) Transverse T2-weighted SE MR image (4,000/76) shows low-signal-intensity areas (arrows) in the central portion of the transverse ligament. This section is immediately adjacent to those displayed in a-c and is at the same level as the section displayed in e. (e) Photograph of a pathologic specimen shows whitish CPPD crystal deposits (arrows) in the transverse ligament. (f) Photomicrograph of specimen depicted in e that was obtained from the transverse ligament shows large "lakes" of crystal deposition (arrows) within the ligament. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (110K): [in a new window]   Figure 2. Transverse CT scan obtained in an 84-year-old woman with CPPD crystal deposition disease, atlantoaxial subluxation, and odontoid fracture shows massive calcifications (straight arrow) around the odontoid process of the axis. Atlantoaxial subluxation and erosion of the odontoid process (curved arrow) are seen.

View larger version (156K): [in a new window]   Figure 3a. CT scans obtained in a 72-year-old man with type 2 odontoid fracture sustained after a fall down a step. (a) Transverse CT scan shows small erosions (straight solid arrows) and a subchondral cyst (curved arrow) in the odontoid process. Calcifications (open arrow) around the odontoid process are observed. The anterior median aspect of the atlantoaxial joint space (arrowheads) is narrowed. (b) CT scan reformatted in the sagittal plane shows a type 2 odontoid fracture (long straight arrow) and calcifications (short straight arrows). Gas attenuation (curved arrow) in the anterior aspect of the atlantoaxial joint also is observed.

View larger version (154K): [in a new window]   Figure 3b. CT scans obtained in a 72-year-old man with type 2 odontoid fracture sustained after a fall down a step. (a) Transverse CT scan shows small erosions (straight solid arrows) and a subchondral cyst (curved arrow) in the odontoid process. Calcifications (open arrow) around the odontoid process are observed. The anterior median aspect of the atlantoaxial joint space (arrowheads) is narrowed. (b) CT scan reformatted in the sagittal plane shows a type 2 odontoid fracture (long straight arrow) and calcifications (short straight arrows). Gas attenuation (curved arrow) in the anterior aspect of the atlantoaxial joint also is observed.

View larger version (150K): [in a new window]   Figure 4a. Images obtained in a 56-year-old man with CPPD crystal deposition disease, traumatic type 2 odontoid fracture, and retro-odontoid mass. (a) Transverse CT scan shows calcifications (straight arrow) around the odontoid process. Atlantoaxial joint space narrowing and destructive changes involving the atlas (curved arrow) are observed. (b) CT scan reformatted in the sagittal plane demonstrates periodontoid calcification (short straight arrow), cystic changes in the dens (curved arrow), and a type 2 odontoid fracture (long straight arrow). (c) Sagittal T1-weighted SE MR image (705/15) shows a retro-odontoid mass (arrow) compressing the cervical spinal cord. The signal intensity of the retro-odontoid mass is low compared with that of the spinal cord and bone marrow. (d) On the T2-weighted fast SE MR image (4,282/94), the signal intensity of the retro-odontoid mass (arrow) is low compared with that of the spinal cord and bone marrow. (e) Photomicrograph shows a large crystal deposit (long arrows) as pale nodules with hyalinization bordered by inflammatory cells (short arrow). (Hematoxylin-eosin stain; original magnification, x16.) (f) Photomicrograph obtained by using a polarizing lens demonstrates crystal deposits (arrow) in the lesion. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (119K): [in a new window]   Figure 4b. Images obtained in a 56-year-old man with CPPD crystal deposition disease, traumatic type 2 odontoid fracture, and retro-odontoid mass. (a) Transverse CT scan shows calcifications (straight arrow) around the odontoid process. Atlantoaxial joint space narrowing and destructive changes involving the atlas (curved arrow) are observed. (b) CT scan reformatted in the sagittal plane demonstrates periodontoid calcification (short straight arrow), cystic changes in the dens (curved arrow), and a type 2 odontoid fracture (long straight arrow). (c) Sagittal T1-weighted SE MR image (705/15) shows a retro-odontoid mass (arrow) compressing the cervical spinal cord. The signal intensity of the retro-odontoid mass is low compared with that of the spinal cord and bone marrow. (d) On the T2-weighted fast SE MR image (4,282/94), the signal intensity of the retro-odontoid mass (arrow) is low compared with that of the spinal cord and bone marrow. (e) Photomicrograph shows a large crystal deposit (long arrows) as pale nodules with hyalinization bordered by inflammatory cells (short arrow). (Hematoxylin-eosin stain; original magnification, x16.) (f) Photomicrograph obtained by using a polarizing lens demonstrates crystal deposits (arrow) in the lesion. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (154K): [in a new window]   Figure 4c. Images obtained in a 56-year-old man with CPPD crystal deposition disease, traumatic type 2 odontoid fracture, and retro-odontoid mass. (a) Transverse CT scan shows calcifications (straight arrow) around the odontoid process. Atlantoaxial joint space narrowing and destructive changes involving the atlas (curved arrow) are observed. (b) CT scan reformatted in the sagittal plane demonstrates periodontoid calcification (short straight arrow), cystic changes in the dens (curved arrow), and a type 2 odontoid fracture (long straight arrow). (c) Sagittal T1-weighted SE MR image (705/15) shows a retro-odontoid mass (arrow) compressing the cervical spinal cord. The signal intensity of the retro-odontoid mass is low compared with that of the spinal cord and bone marrow. (d) On the T2-weighted fast SE MR image (4,282/94), the signal intensity of the retro-odontoid mass (arrow) is low compared with that of the spinal cord and bone marrow. (e) Photomicrograph shows a large crystal deposit (long arrows) as pale nodules with hyalinization bordered by inflammatory cells (short arrow). (Hematoxylin-eosin stain; original magnification, x16.) (f) Photomicrograph obtained by using a polarizing lens demonstrates crystal deposits (arrow) in the lesion. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (163K): [in a new window]   Figure 4d. Images obtained in a 56-year-old man with CPPD crystal deposition disease, traumatic type 2 odontoid fracture, and retro-odontoid mass. (a) Transverse CT scan shows calcifications (straight arrow) around the odontoid process. Atlantoaxial joint space narrowing and destructive changes involving the atlas (curved arrow) are observed. (b) CT scan reformatted in the sagittal plane demonstrates periodontoid calcification (short straight arrow), cystic changes in the dens (curved arrow), and a type 2 odontoid fracture (long straight arrow). (c) Sagittal T1-weighted SE MR image (705/15) shows a retro-odontoid mass (arrow) compressing the cervical spinal cord. The signal intensity of the retro-odontoid mass is low compared with that of the spinal cord and bone marrow. (d) On the T2-weighted fast SE MR image (4,282/94), the signal intensity of the retro-odontoid mass (arrow) is low compared with that of the spinal cord and bone marrow. (e) Photomicrograph shows a large crystal deposit (long arrows) as pale nodules with hyalinization bordered by inflammatory cells (short arrow). (Hematoxylin-eosin stain; original magnification, x16.) (f) Photomicrograph obtained by using a polarizing lens demonstrates crystal deposits (arrow) in the lesion. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (193K): [in a new window]   Figure 4e. Images obtained in a 56-year-old man with CPPD crystal deposition disease, traumatic type 2 odontoid fracture, and retro-odontoid mass. (a) Transverse CT scan shows calcifications (straight arrow) around the odontoid process. Atlantoaxial joint space narrowing and destructive changes involving the atlas (curved arrow) are observed. (b) CT scan reformatted in the sagittal plane demonstrates periodontoid calcification (short straight arrow), cystic changes in the dens (curved arrow), and a type 2 odontoid fracture (long straight arrow). (c) Sagittal T1-weighted SE MR image (705/15) shows a retro-odontoid mass (arrow) compressing the cervical spinal cord. The signal intensity of the retro-odontoid mass is low compared with that of the spinal cord and bone marrow. (d) On the T2-weighted fast SE MR image (4,282/94), the signal intensity of the retro-odontoid mass (arrow) is low compared with that of the spinal cord and bone marrow. (e) Photomicrograph shows a large crystal deposit (long arrows) as pale nodules with hyalinization bordered by inflammatory cells (short arrow). (Hematoxylin-eosin stain; original magnification, x16.) (f) Photomicrograph obtained by using a polarizing lens demonstrates crystal deposits (arrow) in the lesion. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (213K): [in a new window]   Figure 4f. Images obtained in a 56-year-old man with CPPD crystal deposition disease, traumatic type 2 odontoid fracture, and retro-odontoid mass. (a) Transverse CT scan shows calcifications (straight arrow) around the odontoid process. Atlantoaxial joint space narrowing and destructive changes involving the atlas (curved arrow) are observed. (b) CT scan reformatted in the sagittal plane demonstrates periodontoid calcification (short straight arrow), cystic changes in the dens (curved arrow), and a type 2 odontoid fracture (long straight arrow). (c) Sagittal T1-weighted SE MR image (705/15) shows a retro-odontoid mass (arrow) compressing the cervical spinal cord. The signal intensity of the retro-odontoid mass is low compared with that of the spinal cord and bone marrow. (d) On the T2-weighted fast SE MR image (4,282/94), the signal intensity of the retro-odontoid mass (arrow) is low compared with that of the spinal cord and bone marrow. (e) Photomicrograph shows a large crystal deposit (long arrows) as pale nodules with hyalinization bordered by inflammatory cells (short arrow). (Hematoxylin-eosin stain; original magnification, x16.) (f) Photomicrograph obtained by using a polarizing lens demonstrates crystal deposits (arrow) in the lesion. (Hematoxylin-eosin stain; original magnification, x40.)