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Transverse Ligament Rupture


- Discussion:
    - rupture of transverse ligament is destabilizing injury that can occur in isolation or with atlantoaxial subluxation or an atlas fracture;
    - transverse ligament is primary restraint to anterior translation of atlas in relation to the lower cervical spine;
    - transverse lig can fail in midsubstance or avulsion of bone can occur;
    - it has been estimated that a force of about 85 kg is required to rupture the transverse ligament;

- Clinical Presentation:
    - pt can give history of flexion injury and has neck pain, occassionally w/ associated head injury;
    - diffuse motor loss may occur if the pyramidal tract is affected;

- Radiographs:
    - cross table lateral:
    - plain radiographs reveal atlantodental interval (distance between anterior ring of atlas & odontoid process) of at least 4 mm;
          - an anterior shift of C1 on C2 of more than 3-5 mm implies injury to transverse ligament;
          - shift > 5 mm implies injury transverse & alar ligaments;
    - accurate assessment can be made by performing a flexion extension CT scan;
    - CT of C1 is often helpful in further delineating exact displacement of the fragments;
    - traumatic atlas frx: (odontoid view);
          - if lateral masses overhang articular surfaces of axis more than 7 mm, then transverse ligament is likely to be torn;
          - this frx is therefore considered unstable and should be treated in a halo cast or skeletal traction for 3 months;
          - if overhang is < 7 mm, then frx is stable and should be treated in rigid support, such as a cervicothoracic brace, for 3 mo;

- Treatment:
    - can occur thru the midstubstance or thru bony avulsion;
    - bony avulsion:
          - should be documented by CT scan;
          - halo immobilization may be used until healing of the avulsed ligament takes place;
          - once healing is documented, repeat flexion and extension are made to assess transverse ligament competency;
    - midsubstance tears:
          - w/ greater than 5 mm of C1-C2 subluxation, atlantoaxial fusion should be performed