Injuries Involving the Transverse Atlantal Ligament: Classification and Treatment Guidelines Based upon Experience with 39 Injuries

Abstract

Comprehensive anatomic and clinical analyses of 39 patients with injuries involving the transverse atlantal ligament or its osseous insertions were performed to assess the morphology of the injured ligaments and the patients' capacity to heal. Injuries of the upper cervical spine were screened with plain radiographs, thin-section computed tomography, and magnetic resonance imaging studies. The injuries were classified as disruptions of the substance of the ligament (Type I injuries, n = 16) or as fractures and avulsions involving the tubercle for insertion of the transverse ligament on the C1 lateral mass (Type II injuries, n = 23). These two types of injuries had distinctly different clinical characteristics that were useful for determining treatment. Type I injuries were incapable of healing satisfactorily without internal fixation; they should be treated with early surgery. Type II injuries, which rendered the transverse ligament physiologically incompetent even though the ligament substance was not torn, should be treated initially with a rigid cervical orthosis, because they had a 74% success rate nonoperatively. Surgery should be reserved for patients with Type II injuries that have nonunion with persistent instability after 3 to 4 months of immobilization. Type II injuries had a 26% rate of failure of immobilization; therefore, close monitoring is needed to detect patients who will require delayed operative intervention.

Motion-preserving reduction and fixation of C1 Jefferson fracture using a C1 lateral mass screw construct

“…The integrity of the TAL is the most important factor in determining the method of treatment. 6,13 Spence et al 14 reported a lateral mass spread >6.9 mm implied a disruption of the TAL. More recently, it has been proposed that MRI is a more sensitive indicator of TAL disruption than the ''rule of Spence.''…”

“…[1][2][3] There is a high prevalence of concomitant fractures of the second cervical vertebra. 4,5 The unstable Jefferson fracture of C1 is a C1 burst fracture with concomitant injury of the transverse atlantal ligament.…”

“…4,5 The unstable Jefferson fracture of C1 is a C1 burst fracture with concomitant injury of the transverse atlantal ligament. 6,7 Whether an unstable Jefferson fracture of C1 should be treated surgically or non-surgically is controversial. Non-surgical treatment of displaced Jefferson burst fractures confers high rates of non-union and neurologic sequelae can arise due to cranial settling at C0-2.…”

Nonoperative Treatment of an Unstable Jefferson Fracture Using a Cervical Collar

“…Dickman et al [2,3] classified transverse ligament injuries into two main types, which have two distinctly different treatment outcomes. Type I injuries are intrasubstance ruptures of the transverse ligament that are incapable of healing and because of instability are believed by most to require surgery.…”

Clinical Application of a Revised Screw Technique via the C1 Posterior Arch and Lateral Mass in the Pediatric Population

“…The American Academy of Neurological Surgeons recommends that the rigid collar be used to reduce the cervical injury for the first 4 weeks and, if unsuccessful, immobilization should be continued [18]. Both Dickman et al [19] and Lo et al [20] showed that a cervical orthosis collar or halo device can be successfully used for AAI induced by the transverse atlantal ligament. When considering perioperative complications, many authors also recommend conservative management in patients with Down syndrome and for asymptomatic patients with AAI [21,22].…”