Clinical Anatomy 15:148 –151 (2002)

Median (Third) Occipital Condyle

P.V.V. PRASADA RAO*
Department of Anatomy, University of Zimbabwe, Harare, Zimbabwe

Abnormalities of the craniovertebral junction, most of which are associated with the occipital
bone, are of interest not only to anatomists but also to clinicians because many of these
deformities produce clinical symptoms. The occipital bone in humans is formed by the fusion
of the sclerotomes corresponding to the roots of the hypoglossal nerve. In lower vertebrates,
the cranial half of the first cervical sclerotome forms a separate bone between the atlas and
occipital bone, the proatlas; in man it may contribute to anomalous structures around the
foramen magnum. One such structure, a median occipital condyle, which exhibited an
articular facet for the odontoid process, was observed in an adult male skull at the anterior
margin of the foramen magnum. This anomaly is discussed in light of available literature.
Clin. Anat. 15:148 –151, 2002. © 2002 Wiley-Liss, Inc.

Key words: median occipital condyle; condylus tertius; proatlas; occipital bone;
foramen magnum

INTRODUCTION a median occipital condyle or condylus tertius at the

anterior border of the foramen magnum in an adult
The craniovertebral junction includes the occipital male skull as well as pertinent embryology.
bone and its foramen magnum as well as the atlas and
axis, and anomalies associated with this region are of
anatomic and clinical interest. The occipital bone is MATERIALS AND METHODS
the major site of these variations (Oetteking, 1923).
The author examined the human skull remains of
Anatomists and embryologists have studied the nor-
the Zimbabwe Museum of Human Sciences. Most of
mal and abnormal development of this region
the remains were fragments of cranial bones and only
(Kladetzky, 1956; Putz, 1975) as well as clinicians
skulls with an intact cranial base showing the foramen
(McRae, 1960; Menezes et al., 1980). Radiologically,
magnum were selected for this study. A total of 153
abnormal development of this area has been docu-
skulls were examined for the presence of abnormal
mented infrequently (Lombardi, 1961; Dunsker et al.,
bony structures around the foramen magnum. One
1980). The diagnosis, identification and classification
skull, in which a median occipital condyle was iden-
of such abnormalities, however, are of practical signif-
tified, was characterized for age and gender (Bass,
icance because they may produce clinical symptoms
1987).
that are treatable by orthopedic or neurosurgical
means. Abnormalities of this area can be classified as
congenital, inflammatory, acquired, or traumatic, oc- RESULTS
curring either alone or in combination (VanGilder and
Menezes, 1985). Patients may present with a myriad A median occipital condyle, projecting inferiorly
of abnormal neurological signs and symptoms. The and anteriorly from the inferior surface of the clivus,
clinician’s awareness of these craniovertebral disor- just anterior to the foramen magnum, was observed in
ders will aid in the correct diagnosis and appropriate an adult male skull (Fig. 1). The broadest portion of
treatment. this process was at its base, from which it tapered to its
In contrast to the “assimilation of the atlas,” “man-
ifestation of an occipital vertebra” has received con- *Correspondence to: Dr. P.V.V. Prasada Rao, Department of Anat-
siderably less attention (Oetteking, 1923). Hadley omy, University of Zimbabwe, PO Box MP 167, Harare, Zimba-
(1948) was the first to diagnose the manifestation of an bwe. E-mail: prasada@gaul.uz.ac.zw
occipital vertebra radiologically. This study describes Received 29 December 2000; Revised 6 August 2001

© 2002 Wiley-Liss, Inc.


Fig. 1. Inferior surface of the
skull showing the median occipital
condyle at the anterior margin of
the foramen magnum and its artic-
ular facet.
termination. On each side, bony buttresses extended
anteriorly from the anterior margins of the occipital
condyles, the left of which was more prominent. The
anomalous process had a length of 0.65 cm; at its base
the process had an anteroposterior diameter of 0.75 cm
and a transverse diameter of 0.6 cm. It exhibited an
articular facet on its posterior surface 2 mm postero-
superior to its tip and 2 mm anteroinferior to the
anterior border of the foramen magnum (Fig. 1). The
pharyngeal tubercle was observed as a slight projec-
tion 0.7 cm anterior to the median occipital condyle. A
low bony ridge extended between the median occip-
ital condyle and pharyngeal tubercle in the median
plane. No other major abnormalities were found
around the foramen magnum of the other 152 speci-
mens. The atlas and axis associated with this skull
were not available.
DISCUSSION
In a review of radiologic findings in syringomyelia
and syringobulbia, McRae (1953) reported that 38% of
the patients had bony abnormalities in the region of
the foramen magnum. In a study of radiographs, Lom-
bardi (1961) observed such anomalies in 19 of 4,000
cases (0.47%). Lombardi (1961) also mentioned that
Sauser had observed craniovertebral anomalies in five
of 1,119 skulls (0.44%). Lombardi (1961) reported the
occurrence of a third condyle in six of 4,000 X-rays.
Menezes et al. (1980) also reported two cases of ab-
Median Occipital Condyle 149
normal clivus-odontoid articulation in children and
suggested that it may represent a “third occipital con-
dyle” or condylus tertius.
The median occipital condyle is normally described
as having a narrow base and a broader inferior surface,
which bears an articular facet for the apex of the
odontoid process or, more rarely, the anterior arch of
the atlas (Lombardi, 1961; Shapiro and Robinson,
1976). In the case presented here, the median occip-
ital condyle was broader at its base and tapered toward
its inferior surface. The median occipital condyle var-
ies in length (0.65 cm in this case); Hadley (1948)
mentioned that a third condyle with a length of 13–14
mm had been reported in the literature.
Prescher (1990) mentioned that Meckel was the
first to describe the condylus tertius in 1815 as a bony
process projecting downward in the midline from the
inferior aspect of the basiocciput along the anterior
margin of the foramen magnum. Hadley (1948) pro-
posed that the third condyle may develop from an
ossification center within the cruciate ligament. Lom-
bardi (1961) noted that Kollmann considered the third
condyle to be a result of the incomplete regression of
the hypochordal arch of the occipital vertebra or proat-
las. Putz (1975) described an isolated condylus tertius
located at the anterior margin of the foramen mag-
num, which articulated with the apex of the dens. In
an anatomical specimen, the differential diagnosis can
very easily be made, as the false condylus tertius
possesses a fine channel at its base because the pro-
150 Rao
cesses basilares are not completely fused in the mid-
line at their bases; radiologically, differentiation be-
tween a true and false condylus tertius can be
impossible (Prescher, 1990).
The occipital bone is formed by fusion of the four
sclerotomes corresponding to the three primary roots
of the hypoglossal nerve (Sensenig, 1957). In some
lower vertebrates, such as reptiles, the cranial half of
the first cervical sclerotome remains as a separate
bone, the proatlas, between the occiput and atlas
(Shapiro and Robinson, 1976). In man, the neural arch
of the proatlas divides into anterior and posterior seg-
ments (Ganguly and Roy, 1964). The anterior seg-
ment forms the occipital condyles whereas the poste-
rior segment forms a portion of the rostral articular
facets of the atlas. The dorsal portion of the lateral
masses of the atlas and the tip of the dens also arise
from the proatlas (McRae and Barnum, 1953; VanG-
ilder and Menezes, 1983). The body and neural arches
of the axis develop from the second cervical scle-
rotome, whereas most of the dens develops from the
first cervical sclerotome, except the tip, which devel-
ops from the proatlas (McRae and Barnum, 1953).
Failure of fusion of the tip of the dens to the rest of
the dens results in an ossiculum terminale (Hadley,
1948), in which case there is normally a small round
defect at the tip of the dens in which the ossicle rests
(Wollin, 1963). Some form of bony accentuation
around the margin of the foramen magnum that may
represent a vertebralization of the proatlas is not un-
common (Lombardi, 1961). In birds, the anterior arch
of the proatlas may fuse with the anterior margin of
the foramen magnum forming a third or median oc-
cipital condyle (Wollin, 1963). On the other hand, if
segmentation fails to occur, atlanto-occipital fusion
results (Hadley, 1948; McRae, 1953; McRae and Bar-
num, 1953). The most interesting feature of cranio-
vertebral abnormalities is their diversity. Thus, an
occipital vertebra and an atlanto-occipital fusion rep-
resent the opposite ends of a continuum (Shapiro and
Robinson, 1976).
Because the third condyle lies in the midsagittal
plane, it may limit rotation of the head. Because of its
articulation with the tip of the odontoid process,
movement may also be limited by the restraining
action of the joint capsule and other ligamentous
structures, especially the cruciate ligament, anterior
and posterior longitudinal ligaments, and tectorial
membrane.
Most of the time, manifestations of the occipital
vertebra have no clinical significance. None of Lom-
bardi’s (1961) patients had any complaints attributable
to the median occipital condyles, but when well-de-
veloped, they may limit the mobility of the head.
When a third condyle is present, the attachments and
location of the apical and alar ligaments of the dens, as
well as their role in limiting movement and stability of
the craniovertebral region, is not known. Because the
articulation with the odontoid process was not located
at the tip of the third condyle in the present case,
flexion and extension movements of the head on the
atlas may have been limited by associated ligamen-
tous tissue. The abnormal osseous formations that
originate from the arches of the proatlas, when fused
with the base, may narrow the foramen magnum and
cause compressive neurological symptoms (Lombardi,
1961).
In several cases cited by VanGilder and Menezes
(1985) multiple anomalies were present. The bony
deformity by itself may be sufficient to cause pressure
on the upper cervical spinal cord during movements of
the head and neck. The clinical presentation is de-
pendent on bony or mechanical compression of the
neural axis at the cervicomedullary junction, and the
associated abnormalities of the nervous system (Spill-
ane et al., 1957). Dysgenesis of the odontoid process
(os odontoideum and ossiculum terminale) may be
associated with displacement of the distal segment of
the dens rostrally or instability of the atlanto-axial
joint (secondary to an incompetent cruciate ligament)
and compression at the cervicomedullary junction
(Wollin, 1963; Menezes et al., 1980). Symptoms of os
odontoideum can range from vague discomfort to
gradually developing partial or complete quadripare-
sis. An os odontoideum may cause sudden death from
cord damage due to minor trauma to the weakened
atlanto-axial complex (Fielding and Griffin, 1974).
VanGilder and Menezes (1983) reported post-trau-
matic posterior invagination of an unfused odontoid
process in two patients, resulting in ventral cervicome-
dullary compromise. McRae (1953) also observed a
marked gliding of the atlas on the axis (range 5–25
mm) during flexion and extension of the neck in cases
with os odontoideum (these movements occurred at
the atlanto-axial joints instead of at the atlanto-occip-
ital joints). Compromise of neural structures at the
cervicomedullary junction results in symptoms and
signs involving cervical roots, cranial nerves, brain-
stem and spinal cord dysfunction, and vascular insuf-
ficiency (Menezes et al., 1980). Cranial subluxation of
the odontoid process due to rheumatoid arthritis
causes severe and chronic occipito-cervical pain due to
entrapment of the first and second cervical roots (Sla-
tis et al., 1989). Patients may exhibit myelopathy pre-
senting with different degrees of weakness in the
upper or lower extremities, and motor myelopathy
may include quadriparesis that is attributed to repet-
itive trauma to the pyramidal tracts and chronic com-

pression of neural structures at the cervicomedullary
junction (Menezes et al., 1980). Brainstem signs in-
cluded nystagmus and respiratory symptoms. Vascular
symptoms included syncope, vertigo, an altered level
of consciousness and transient visual field loss because
of excessive stretching or angulation of vertebral or
anterior spinal arteries (Michie and Clark, 1968).
ACKNOWLEDGMENTS
Thanks to the Regional Director of the Zimbabwe
Museum of Human Sciences for permitting me to
study its skull collection, Mr. B. Magadzike for his
cooperation, Prof. L.F. Levy for his valuable sugges-
tions in the preparation of this manuscript, and Ms. C.
Ganyani for typing the manuscript.
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