{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T06:36:57Z","timestamp":1769063817682,"version":"3.49.0"},"reference-count":25,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["SPI"],"published-print":{"date-parts":[[2016,6]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>The rule of Spence is inaccurate for assessing integrity of the transverse atlantal ligament (TAL). Because CT is quick and easy to perform at most trauma centers, the authors propose a novel sequence of obtaining 2 CT scans to improve the diagnosis of TAL impairment. The sensitivity of a new CT-based method for diagnosing a TAL injury in a cadaveric model was assessed.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>Ten human cadaveric occipitocervical specimens were mounted horizontally in a supine posture with wooden inserts attached to the back of the skull to maintain a neutral or flexed (10\u00b0) posture. Specimens were scanned in neutral and flexed postures in a total of 4 conditions (3 conditions in each specimen): 1) intact (n = 10); either 2A) after a simulated Jefferson fracture with an intact TAL (n = 5) or 2B) after a TAL disruption with no Jefferson fracture (n = 5); and 3) after TAL disruption and a simulated Jefferson fracture (n = 10). The atlantodental interval (ADI) and cross-sectional canal area were measured.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>From the neutral to the flexed posture, ADI increased an average of 2.5% in intact spines, 6.25% after a Jefferson fracture without TAL disruption, 34% after a TAL disruption without fracture, and 25% after TAL disruption with fracture. The increase in ADI was significant with both TAL disruption and TAL disruption and fracture (p &lt; 0.005) but not in the other 2 conditions (p &gt; 0.6). Changes in spinal canal area were not significant (p &gt; 0.70).<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>This novel method was more sensitive than the rule of Spence for evaluating the integrity of the TAL on CT and does not increase the risk of further neurological damage.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2015.9.spine13807","type":"journal-article","created":{"date-parts":[[2016,2,26]],"date-time":"2016-02-26T15:04:27Z","timestamp":1456499067000},"page":"903-909","source":"Crossref","is-referenced-by-count":14,"title":["Comparison of CT versus MRI measurements of transverse atlantal ligament integrity in craniovertebral junction injuries. Part 2: A new CT-based alternative for assessing transverse ligament integrity"],"prefix":"10.3171","volume":"24","author":[{"given":"Luis","family":"Perez-Orribo","sequence":"first","affiliation":[{"name":"Spinal Biomechanics Laboratory and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Samuel","family":"Kalb","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura A.","family":"Snyder","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Forrest","family":"Hsu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Devika","family":"Malhotra","sequence":"additional","affiliation":[{"name":"Spinal Biomechanics Laboratory and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard D.","family":"Lefevre","sequence":"additional","affiliation":[{"name":"Spinal Biomechanics Laboratory and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ali M.","family":"Elhadi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anna G. 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S.","family":"Newcomb","sequence":"additional","affiliation":[{"name":"Spinal Biomechanics Laboratory and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicholas","family":"Theodore","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Neil R.","family":"Crawford","sequence":"additional","affiliation":[{"name":"Spinal Biomechanics Laboratory and"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"key":"b1-spine13807","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"291","DOI":"10.1227\/NEU.0b013e3182011262","article-title":"The craniovertebral junction area and the role of the ligaments and membranes","volume":"68","author":"Debernardi","year":"2011"},{"key":"b2-spine13807","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1097\/00006123-199601000-00012","article-title":"Injuries involving the transverse atlantal ligament: classification and treatment guidelines based upon experience with 39 injuries","volume":"38","author":"Dickman","year":"1996"},{"key":"b3-spine13807","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"221","DOI":"10.3171\/jns.1991.75.2.0221","article-title":"Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability","volume":"75","author":"Dickman","year":"1991"},{"key":"b4-spine13807","series-title":"Skeletal Radiol","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1007\/s002560050476","article-title":"Magnetic resonance imaging in the evaluation of ligament injuries","volume":"28","author":"Farooki","year":"1999"},{"key":"b5-spine13807","series-title":"J Neurosurg Spine","doi-asserted-by":"publisher","first-page":"273","DOI":"10.3171\/spi.2004.1.3.0273","article-title":"Vertical atlantoaxial distraction injuries: radiological criteria and clinical implications","volume":"1","author":"Gonzalez","year":"2004"},{"issue":"2 Suppl","key":"b6-spine13807","series-title":"J Neurosurg","first-page":"139","article-title":"Complex atlantoaxial fractures","volume":"91","author":"Guiot","year":"1999"},{"key":"b7-spine13807","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"31","DOI":"10.1227\/00006123-198807000-00007","article-title":"Acute traumatic atlas fractures: management and long term outcome","volume":"23","author":"Hadley","year":"1988"},{"key":"b8-spine13807","series-title":"J Clin Neurosci","doi-asserted-by":"publisher","first-page":"695","DOI":"10.1016\/j.jocn.2010.08.033","article-title":"Motion-preserving reduction and fixation of C1 Jefferson fracture using a C1 lateral mass screw construct","volume":"18","author":"Jo","year":"2011"},{"issue":"3 Suppl","key":"b9-spine13807","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1227\/01.NEU.0000366108.02499.8F","article-title":"Atlas fractures","volume":"66","author":"Kakarla","year":"2010"},{"key":"b10-spine13807","series-title":"J Spinal Disord Tech","doi-asserted-by":"publisher","first-page":"402","DOI":"10.1097\/01.bsd.0000177959.49721.3b","article-title":"Management of acute traumatic atlas fractures","volume":"18","author":"Kontautas","year":"2005"},{"key":"b11-spine13807","series-title":"Neuroradiology","doi-asserted-by":"publisher","first-page":"617","DOI":"10.1007\/s00234-002-0799-6","article-title":"MRI assessment of the alar ligaments in the late stage of whiplash injury\u2014a study of structural abnormalities and observer agreement","volume":"44","author":"Krakenes","year":"2002"},{"key":"b12-spine13807","series-title":"Neuroradiology","doi-asserted-by":"publisher","first-page":"585","DOI":"10.1007\/s00234-003-1036-7","article-title":"MRI of the tectorial and posterior atlantooccipital membranes in the late stage of whiplash injury","volume":"45","author":"Krakenes","year":"2003"},{"key":"b13-spine13807","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1097\/00007632-198805000-00002","article-title":"Fractures of the atlas: classification, treatment and morbidity","volume":"13","author":"Landells","year":"1988"},{"key":"b14-spine13807","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"1532","DOI":"10.1097\/BRS.0b013e3181f550a6","article-title":"The incidence of noncontiguous spinal fractures and other traumatic injuries associated with cervical spine fractures: a 10-year experience at an academic medical center","volume":"36","author":"Miller","year":"2011"},{"issue":"10 Suppl","key":"b15-spine13807","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"S466","DOI":"10.1097\/00007632-199110001-00002","article-title":"Experimental study of atlas injuries. 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