{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,7]],"date-time":"2026-04-07T20:18:44Z","timestamp":1775593124811,"version":"3.50.1"},"reference-count":38,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"14","license":[{"start":{"date-parts":[[2024,4,1]],"date-time":"2024-04-01T00:00:00Z","timestamp":1711929600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,4,1]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Isolated unilateral alar ligament injury (IUALI) is a rare and likely underreported occurrence after upper cervical trauma, with only 16 cases documented in the literature to date. Patients generally present with neck pain, and definitive diagnosis is typically made by magnetic resonance imaging (MRI). Unfortunately, likely due in part to its rarity, there are no formal guidelines for the treatment of an IUALI. Furthermore, there is a limited understanding of the long-term consequences associated with its inadequate treatment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>Here, the authors report on three pediatric patients, each found to have an IUALI after significant trauma. All patients presented with neck tenderness, and two of the three had associated pain-limited range of neck motion. Imaging revealed either a laterally deviated odontoid process on cervical radiographs and\/or MRI evidence of ligamentous strain or discontinuity. Each patient was placed in a hard cervical collar for 1 to 2 months with excellent resolution of symptoms. A comprehensive review of the literature showed that all patients with IUALI who had undergone external immobilization with either rigid cervical collar or halo fixation had favorable outcomes at follow-up.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>For patients with IUALI, a moderate course of nonsurgical management with rigid external immobilization appears to be an adequate first-line treatment.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case23664","type":"journal-article","created":{"date-parts":[[2024,4,1]],"date-time":"2024-04-01T15:15:36Z","timestamp":1711984536000},"source":"Crossref","is-referenced-by-count":1,"title":["Isolated unilateral alar ligamentous injury: illustrative cases"],"prefix":"10.3171","volume":"7","author":[{"given":"Benjamin C","family":"Reeves","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marcus","family":"Valcarce-Aspegren","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Weill Cornell Medical College, New York, New York; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephanie M","family":"Robert","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aladine A","family":"Elsamadicy","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander M","family":"Tucker","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Phillip B","family":"Storm","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael L","family":"DiLuna","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adam J","family":"Kundishora","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"4","key":"b1","series-title":"Neuroimaging Clin N Am","first-page":"875","article-title":"Craniocervical junction and cervical spine anatomy","volume":"32","author":"Offiah CE","year":"2022","unstructured":"Offiah CE. Craniocervical junction and cervical spine anatomy.  Neuroimaging Clin N Am. 2022;32(4):875\u2013888."},{"issue":"4","key":"b2","series-title":"Neurospine","first-page":"723","article-title":"Upper cervical spine trauma: WFNS Spine Committee Recommendations","volume":"17","author":"Alves OL","year":"2020","unstructured":"Alves OL, Pereira L, Kim SH, . Upper cervical spine trauma: WFNS Spine Committee Recommendations. Neurospine. 2020; 17(4):723\u2013736."},{"issue":"2","key":"b3","series-title":"Acta Orthop Belg","first-page":"189","article-title":"Concomitant alar and apical ligament avulsion in atlanto-axial rotatory fixation. Case report and review of the literature","volume":"70","author":"Karray M","year":"2004","unstructured":"Karray M, M\u2019nif N, Mestiri M, Kooli M, Ezzaouia K, Zlitni M. Concomitant alar and apical ligament avulsion in atlanto-axial rotatory fixation. Case report and review of the literature. Acta Orthop Belg. 2004;70(2): 189\u2013192."},{"issue":"5","key":"b4","series-title":"Neurosurgery","first-page":"995","article-title":"Atlanto-occipital dislocation\u2014part 2: the clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children","volume":"61","author":"Pang D","year":"2007","unstructured":"Pang D, Nemzek WR, Zovickian J. Atlanto-occipital dislocation\u2014part 2: the clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery. 2007;61(5):995\u20131015."},{"issue":"2","key":"b5","series-title":"J Forensic Sci","first-page":"556","article-title":"Neck injuries: I. Occipitoatlantal dislocation\u2014a pathologic study of twelve traffic fatalities","volume":"37","author":"Adams VI","year":"1992","unstructured":"Adams VI. Neck injuries: I. Occipitoatlantal dislocation\u2014a pathologic study of twelve traffic fatalities. J Forensic Sci. 1992;37(2):556\u2013564."},{"issue":"11","key":"b6","series-title":"Pediatr Radiol","first-page":"786","article-title":"Occipital condyle fracture and ligament injury: imaging by CT","volume":"26","author":"Bloom AI","year":"1996","unstructured":"Bloom AI, Neeman Z, Floman Y, Gomori J, Bar-Ziv J. Occipital condyle fracture and ligament injury: imaging by CT. Pediatr Radiol. 1996;26(11):786\u2013790."},{"issue":"6","key":"b7","series-title":"Neurochirurgie","first-page":"478","article-title":"Diagnosis and suggested treatment against an isolated unilateral rupture of the alar ligament: concerning one case","volume":"63","author":"Santin MD","year":"2017","unstructured":"Santin MD, Cebula H, Ollivier I, Todeschi J, Baloglu S, Proust F.  Diagnosis and suggested treatment against an isolated unilateral rupture of the alar ligament: concerning one case. Neurochirurgie. 2017;63(6):478\u2013482."},{"key":"b8","series-title":"Chiropr Osteopat","first-page":"20","article-title":"Post-traumatic upper cervical subluxation visualized by MRI: a case report","volume":"15","author":"Demetrious J","year":"2007","unstructured":"Demetrious J. Post-traumatic upper cervical subluxation visualized by MRI: a case report. Chiropr Osteopat. 2007;15:20."},{"issue":"11","key":"b9","series-title":"J Bone Joint Surg Am","first-page":"2713","article-title":"Isolated alar ligament disruption in children and adolescents as a cause of persistent torticollis and neck pain after injury. A report of three cases","volume":"91","author":"Caird MS","year":"2009","unstructured":"Caird MS, Hensinger RN, Vander Have KL, Gelbke MK, Farley FA. Isolated alar ligament disruption in children and adolescents as a cause of persistent torticollis and neck pain after injury. A report of three cases. J Bone Joint Surg Am. 2009;91(11):2713\u20132718."},{"issue":"5","key":"b10","series-title":"J Neurosurg Pediatr","first-page":"541","article-title":"Isolated unilateral rupture of the alar ligament","volume":"13","author":"Wong ST","year":"2014","unstructured":"Wong ST, Ernest K, Fan G, Zovickian J, Pang D. Isolated unilateral rupture of the alar ligament. J Neurosurg Pediatr. 2014;13(5):541\u2013547."},{"key":"b11","series-title":"World Neurosurg","first-page":"e878","article-title":"Unilateral alar ligament injury: diagnostic, clinical, and biomechanical features","volume":"132","author":"Unal TC","year":"2019","unstructured":"Unal TC, Dolas I, Unal OF. Unilateral alar ligament injury: diagnostic, clinical, and biomechanical features. World Neurosurg. 2019; 132:e878\u2013e884."},{"issue":"10","key":"b12","series-title":"World J Radiol","first-page":"357","article-title":"Delayed diagnosis of isolated alar ligament rupture: A case report","volume":"7","author":"Kaufmann RA","year":"2015","unstructured":"Kaufmann RA, Marzi I, Vogl TJ. Delayed diagnosis of isolated alar ligament rupture: A case report. World J Radiol. 2015;7(10):357\u2013360."},{"issue":"6","key":"b13","series-title":"Unfallchirurg","first-page":"555","article-title":"Injuries of the alar ligaments in children and adolescents","volume":"105","author":"Briem D","year":"2002","unstructured":"Briem D, Linhart W, Dickmann C, Rueger JM. Injuries of the alar ligaments in children and adolescents. Article in German. Unfallchirurg. 2002;105(6):555\u2013559."},{"issue":"4","key":"b14","series-title":"Agri","first-page":"265","article-title":"Unilateral isolated alar ligament rupture in an adult female patient","volume":"33","author":"Keskil S","year":"2021","unstructured":"Keskil S, Yuksel U, Karadeniz Bilgili Y, Babacan A. Unilateral isolated alar ligament rupture in an adult female patient. Agri. 2021; 33(4):265\u2013267."},{"issue":"2","key":"b15","series-title":"Spine (Phila Pa 1976)","first-page":"183","article-title":"Functional anatomy of the alar ligaments","volume":"12","author":"Dvorak J","year":"1987","unstructured":"Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine (Phila Pa 1976). 1987;12(2):183\u2013189."},{"issue":"3","key":"b16","series-title":"J Orthop Res","first-page":"452","article-title":"Biomechanics of the craniocervical region: the alar and transverse ligaments","volume":"6","author":"Dvorak J","year":"1988","unstructured":"Dvorak J, Schneider E, Saldinger P, Rahn B. Biomechanics of the craniocervical region: the alar and transverse ligaments. J Orthop Res. 1988;6(3):452\u2013461."},{"issue":"1","key":"b17","series-title":"Radiology","first-page":"133","article-title":"MR morphology of alar ligaments and occipitoatlantoaxial joints: study in 50 asymptomatic subjects","volume":"218","author":"Pfirrmann CW","year":"2001","unstructured":"Pfirrmann CW, Binkert CA, Zanetti M, Boos N, Hodler J. MR morphology of alar ligaments and occipitoatlantoaxial joints: study in 50 asymptomatic subjects. Radiology. 2001;218(1):133\u2013137."},{"issue":"17","key":"b18","series-title":"Spine (Phila Pa 1976)","first-page":"E1062","article-title":"Effect of magnetic resonance imaging field strength on delineation and signal intensity of alar ligaments in healthy volunteers","volume":"37","author":"Lummel N","year":"2012","unstructured":"Lummel N, Sch\u00f6pf V, Bitterling H, . Effect of magnetic resonance imaging field strength on delineation and signal intensity of alar ligaments in healthy volunteers. Spine (Phila Pa 1976). 2012; 37(17):E1062\u2013E1067."},{"issue":"5","key":"b19","series-title":"AJR Am J Roentgenol","first-page":"1003","article-title":"Pediatric craniocervical junction injuries","volume":"196","author":"Junewick JJ","year":"2011","unstructured":"Junewick JJ. Pediatric craniocervical junction injuries. AJR Am J Roentgenol. 2011;196(5):1003\u20131010."},{"issue":"4","key":"b1","series-title":"Neuroimaging Clin N Am","first-page":"875","article-title":"Craniocervical junction and cervical spine anatomy","volume":"32","author":"Offiah CE","year":"2022","unstructured":"Offiah CE. Craniocervical junction and cervical spine anatomy.  Neuroimaging Clin N Am. 2022;32(4):875\u2013888."},{"issue":"4","key":"b2","series-title":"Neurospine","first-page":"723","article-title":"Upper cervical spine trauma: WFNS Spine Committee Recommendations","volume":"17","author":"Alves OL","year":"2020","unstructured":"Alves OL, Pereira L, Kim SH, . Upper cervical spine trauma: WFNS Spine Committee Recommendations. Neurospine. 2020; 17(4):723\u2013736."},{"issue":"2","key":"b3","series-title":"Acta Orthop Belg","first-page":"189","article-title":"Concomitant alar and apical ligament avulsion in atlanto-axial rotatory fixation. Case report and review of the literature","volume":"70","author":"Karray M","year":"2004","unstructured":"Karray M, M\u2019nif N, Mestiri M, Kooli M, Ezzaouia K, Zlitni M. Concomitant alar and apical ligament avulsion in atlanto-axial rotatory fixation. Case report and review of the literature. Acta Orthop Belg. 2004;70(2): 189\u2013192."},{"issue":"5","key":"b4","series-title":"Neurosurgery","first-page":"995","article-title":"Atlanto-occipital dislocation\u2014part 2: the clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children","volume":"61","author":"Pang D","year":"2007","unstructured":"Pang D, Nemzek WR, Zovickian J. Atlanto-occipital dislocation\u2014part 2: the clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery. 2007;61(5):995\u20131015."},{"issue":"2","key":"b5","series-title":"J Forensic Sci","first-page":"556","article-title":"Neck injuries: I. Occipitoatlantal dislocation\u2014a pathologic study of twelve traffic fatalities","volume":"37","author":"Adams VI","year":"1992","unstructured":"Adams VI. Neck injuries: I. Occipitoatlantal dislocation\u2014a pathologic study of twelve traffic fatalities. J Forensic Sci. 1992;37(2):556\u2013564."},{"issue":"11","key":"b6","series-title":"Pediatr Radiol","first-page":"786","article-title":"Occipital condyle fracture and ligament injury: imaging by CT","volume":"26","author":"Bloom AI","year":"1996","unstructured":"Bloom AI, Neeman Z, Floman Y, Gomori J, Bar-Ziv J. Occipital condyle fracture and ligament injury: imaging by CT. Pediatr Radiol. 1996;26(11):786\u2013790."},{"issue":"6","key":"b7","series-title":"Neurochirurgie","first-page":"478","article-title":"Diagnosis and suggested treatment against an isolated unilateral rupture of the alar ligament: concerning one case","volume":"63","author":"Santin MD","year":"2017","unstructured":"Santin MD, Cebula H, Ollivier I, Todeschi J, Baloglu S, Proust F.  Diagnosis and suggested treatment against an isolated unilateral rupture of the alar ligament: concerning one case. Neurochirurgie. 2017;63(6):478\u2013482."},{"key":"b8","series-title":"Chiropr Osteopat","first-page":"20","article-title":"Post-traumatic upper cervical subluxation visualized by MRI: a case report","volume":"15","author":"Demetrious J","year":"2007","unstructured":"Demetrious J. Post-traumatic upper cervical subluxation visualized by MRI: a case report. Chiropr Osteopat. 2007;15:20."},{"issue":"11","key":"b9","series-title":"J Bone Joint Surg Am","first-page":"2713","article-title":"Isolated alar ligament disruption in children and adolescents as a cause of persistent torticollis and neck pain after injury. A report of three cases","volume":"91","author":"Caird MS","year":"2009","unstructured":"Caird MS, Hensinger RN, Vander Have KL, Gelbke MK, Farley FA. Isolated alar ligament disruption in children and adolescents as a cause of persistent torticollis and neck pain after injury. A report of three cases. J Bone Joint Surg Am. 2009;91(11):2713\u20132718."},{"issue":"5","key":"b10","series-title":"J Neurosurg Pediatr","first-page":"541","article-title":"Isolated unilateral rupture of the alar ligament","volume":"13","author":"Wong ST","year":"2014","unstructured":"Wong ST, Ernest K, Fan G, Zovickian J, Pang D. Isolated unilateral rupture of the alar ligament. J Neurosurg Pediatr. 2014;13(5):541\u2013547."},{"key":"b11","series-title":"World Neurosurg","first-page":"e878","article-title":"Unilateral alar ligament injury: diagnostic, clinical, and biomechanical features","volume":"132","author":"Unal TC","year":"2019","unstructured":"Unal TC, Dolas I, Unal OF. Unilateral alar ligament injury: diagnostic, clinical, and biomechanical features. World Neurosurg. 2019; 132:e878\u2013e884."},{"issue":"10","key":"b12","series-title":"World J Radiol","first-page":"357","article-title":"Delayed diagnosis of isolated alar ligament rupture: A case report","volume":"7","author":"Kaufmann RA","year":"2015","unstructured":"Kaufmann RA, Marzi I, Vogl TJ. Delayed diagnosis of isolated alar ligament rupture: A case report. World J Radiol. 2015;7(10):357\u2013360."},{"issue":"6","key":"b13","series-title":"Unfallchirurg","first-page":"555","article-title":"Injuries of the alar ligaments in children and adolescents","volume":"105","author":"Briem D","year":"2002","unstructured":"Briem D, Linhart W, Dickmann C, Rueger JM. Injuries of the alar ligaments in children and adolescents. Article in German. Unfallchirurg. 2002;105(6):555\u2013559."},{"issue":"4","key":"b14","series-title":"Agri","first-page":"265","article-title":"Unilateral isolated alar ligament rupture in an adult female patient","volume":"33","author":"Keskil S","year":"2021","unstructured":"Keskil S, Yuksel U, Karadeniz Bilgili Y, Babacan A. Unilateral isolated alar ligament rupture in an adult female patient. Agri. 2021; 33(4):265\u2013267."},{"issue":"2","key":"b15","series-title":"Spine (Phila Pa 1976)","first-page":"183","article-title":"Functional anatomy of the alar ligaments","volume":"12","author":"Dvorak J","year":"1987","unstructured":"Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine (Phila Pa 1976). 1987;12(2):183\u2013189."},{"issue":"3","key":"b16","series-title":"J Orthop Res","first-page":"452","article-title":"Biomechanics of the craniocervical region: the alar and transverse ligaments","volume":"6","author":"Dvorak J","year":"1988","unstructured":"Dvorak J, Schneider E, Saldinger P, Rahn B. Biomechanics of the craniocervical region: the alar and transverse ligaments. J Orthop Res. 1988;6(3):452\u2013461."},{"issue":"1","key":"b17","series-title":"Radiology","first-page":"133","article-title":"MR morphology of alar ligaments and occipitoatlantoaxial joints: study in 50 asymptomatic subjects","volume":"218","author":"Pfirrmann CW","year":"2001","unstructured":"Pfirrmann CW, Binkert CA, Zanetti M, Boos N, Hodler J. MR morphology of alar ligaments and occipitoatlantoaxial joints: study in 50 asymptomatic subjects. Radiology. 2001;218(1):133\u2013137."},{"issue":"17","key":"b18","series-title":"Spine (Phila Pa 1976)","first-page":"E1062","article-title":"Effect of magnetic resonance imaging field strength on delineation and signal intensity of alar ligaments in healthy volunteers","volume":"37","author":"Lummel N","year":"2012","unstructured":"Lummel N, Sch\u00f6pf V, Bitterling H, . Effect of magnetic resonance imaging field strength on delineation and signal intensity of alar ligaments in healthy volunteers. Spine (Phila Pa 1976). 2012; 37(17):E1062\u2013E1067."},{"issue":"5","key":"b19","series-title":"AJR Am J Roentgenol","first-page":"1003","article-title":"Pediatric craniocervical junction injuries","volume":"196","author":"Junewick JJ","year":"2011","unstructured":"Junewick JJ. Pediatric craniocervical junction injuries. AJR Am J Roentgenol. 2011;196(5):1003\u20131010."}],"container-title":["Journal of Neurosurgery: Case Lessons"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/7\/14\/article-CASE23664.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/7\/14\/article-CASE23664.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/7\/14\/article-CASE23664.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T14:26:02Z","timestamp":1770301562000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/7\/14\/article-CASE23664.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,1]]},"references-count":38,"journal-issue":{"issue":"14"},"URL":"https:\/\/doi.org\/10.3171\/case23664","relation":{},"ISSN":["2694-1902"],"issn-type":[{"value":"2694-1902","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,4,1]]}}}