SPINE Volume 33, Number 19, pp 2066 –2073 ©2008, Lippincott Williams & Wilkins

Occipitocervical Vertical Distraction Injuries
Anatomical Biomechanical, and 3-Tesla Magnetic Resonance Imaging Investigation
K. Zafer Yu ¨ ksel, MD,*† Murvet Yu ¨ ksel, MD,† L. Fernando Gonzalez, MD,‡ Seungwon Baek, MS,* Joseph E. Heiserman, MD,§ Volker K. H. Sonntag, MD,‡ and Neil R. Crawford, PhD*

Study Design. Biomechanical load-to-failure findings correlated with anatomic dissection measurements and intact (prefailure) 3-Tesla (3-T) magnetic resonance images (MRI). Objective. To better understand why the same distractive force to the head can result in occipitoatlantal dislocation (OAD) in some individuals and atlantoaxial dislocation (AAD) in others. Summary of Background Data. Distraction injuries to the cranio-vertebral junction have been studied biomechanically but have not been studied relative to ligamentous anatomic variations. We theorized that morphologic variations in the ligaments should influence the injury pattern during axial distraction. Methods. After obtaining 3-T MRI scans, 10 occiput-C2 specimens were loaded to failure under axial tension. Direct anatomic measurements were also obtained from the distracted and injured specimens. Results. AAD was observed in 7 specimens (mean force Ϯ standard deviation 1229 Ϯ 181 N) at a significantly higher magnitude than OAD, which was observed in 3 specimens (823 Ϯ 127 N; P ϭ 0.009, nonpaired t test). In OAD specimens, the superior cruciate ligament (SCL), which was smaller than the inferior cruciate ligament (ICL), failed. The apical ligament was unidentifiable in these 3 specimens. In 5 of the 7 AAD specimens, the ICL ruptured and was smaller than the SCL. In the remaining 2 specimens, both SCL and ICL ruptured. The apical ligament, which ruptured, was identifiable in all 7 specimens. Conclusion. Axial distraction across the cranio-vertebral junction can produce either OAD or AAD. The SCL and ICL dimensions, alar ligament orientations, and apical ligament presence may affect the injury site. Visualization with 3-T MRI allows better understanding of the injury mechanism and location, which is important clinically in selecting single- or multilevel fixation.

Key words: 3-Tesla, magnetic resonance imaging, biomechanics, alar ligaments, apical ligament. Spine 2008; 33:2066 –2073

From the *Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, ˙ mam U ¨ niversitesi, Kahramanmaras AZ; †Kahramanmaras ¸ Su ¨ tc ¸u ¨ I ¸, Turkey; and Divisions of ‡Neurological Surgery and §Radiology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. Acknowledgment date: July 2, 2007. First revision date: November 8, 2007. Second revision date: February 6, 2008. Acceptance date: April 14, 2008. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Neil R. Crawford, PhD, c/o Spinal Biomechanics, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road; Phoenix, AZ 85013; E-mail: Neil.Crawford@chw.edu

Vertical distraction injuries to the cranio-vertebral junction (CVJ) are grossly unstable and are often associated with significant neurologic or vascular damage.1,2 Occipitoatlantal dislocation (OAD), one common injury associated with vertical distraction, is usually fatal.3 There are many similarities between atlantoaxial dislocation (AAD) and OAD. Both injuries are caused by an enormous distractive force vector that pulls the head vertically. This force separates the skull base from the atlas in the case of OAD or the atlas from the axis in the case of AAD.1 It is unclear whether there is a subtle difference in the orientation of the force vector required to cause OAD versus AAD or whether anatomic variations or dimensions of ligaments and joints dictate the injury pattern that occurs as a result of pure axial distraction. To date, no study has elucidated the physiopathology of OAD versus AAD. The anatomy of the CVJ has been meticulously studied in cadavers, and most of the ligaments in this area have been visualized on magnetic resonance imaging (MRI) examinations in volunteers.4 –9 MRI has also proven useful in assessing the integrity of some of these ligaments in the setting of trauma to this region.8,10 –14 However, MRI has not been used to assess the relative sizes of ligaments of the CVJ in relation to vertical distraction injuries, OAD, and AAD. The aim of this study was to investigate distractive failure loading of the CVJ in vitro and to correlate experimental outcomes with anatomic dissection data and prefailure 3-Tesla (3-T) MRI. The goal of this research is to better understand the biomechanics of distraction injuries of the CVJ, specifically the role of the CVJ ligaments on the injury patterns. We hypothesized that the dimensions and/or arrangement of ligaments would dictate whether OAD or AAD would occur for the same vertical distractive force. Materials and Methods
Ten fresh frozen human osteoligamentous cervical spine specimens (occiput-C2) were used in the study. There were 5 males and 5 females, aged 44 to 61 years (mean, 55 years). Each intact specimen was scanned on a 3-T magnetic resonance (MR) whole-body scanner (Signa Eclipse 3.0T; General Electric Medical Systems, Milwaukee, WI) using an 8-channel head coil

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Thickness and width of the tectorial membrane were evaluated between the dens and the clivus on sagittal images. Primarily qualitative anatomic findings about the ligaments . horizontal. Eden Prairie. Various dimensional parameters from MRI scans were evaluated 3 times by 2 reviewers. and the mean values of these measurements were recorded. echo train length ϭ 8. 512 ϫ 224 matrix for axial and coronal. The cranio-caudal height was measured by summing Figure 2. Thickness and width of the apical ligament were defined on sagittal images. and caudo-cranial). axial tensile force was applied. mean failure load between specimens failing as OAD and specimens failing as AAD were compared statistically using a nonpaired 2-tailed Student t test with significance assumed at P Ͻ 0. slice thickness 2 mm interleaved (0 mm skip). Intermediate echo T2-weighted fast spin echo images were obtained in sagittal. anterolateral.Occipitocervical Vertical Distraction Injuries • Yu ¨ ksel et al 2067 Figure 1. C2 was secured to a pot using loops of braided cable routed around the lateral masses of C2 (Figure 1). The failure site and injury pattern were recorded. field of view ϭ 18 cm. Orientation in the axial plane was classified by measuring the angle posteriorly between the 2 ligaments (posterolateral. For the inferior cruciate ligament (ICL) and superior cruciate ligament (SCL). with a field of view of 18 cm. bandwidth 32kHz. The occiput was attached to the base of the servohydraulic test frame and C2 was secured with braided steel cable embedded in a block of polymethylmethacrylate. Failure loads were defined as the maximum load endured before failure. The imaging parameters were 2200/13 milliseconds (TR/TE) for axial. coronal. The width was measured by counting the number of 2-mm-thick sagittal sections on which the ligament could be seen. Applied load was continuously recorded at 2 Hz from a load cell in line with the piston. MN) and C2 was distracted under axial tension until failure at a constant displacement rate of 10 mm per minute. 4 excitations (NEX). MTS Systems Corp. Thickness and cranio-caudal height of the transverse ligaments were also measured in the midportion on MR images. 512 ϫ 320 matrix for sagittal. Testing setup for load to failure. 2200/14 milliseconds (TR/TE) for coronal and sagittal. The fixture was loaded under tension until failure while recording load from a uniaxial load cell (top). and lateral). Thickness (anteroposterior and cranio-caudal diameter) was evaluated on sagittal images in the midportion of the ligament. The occiput was mounted to the base of a uniaxial servohydraulic test frame (858 Mini Bionix. their thickness and width were measured on axial slices. In the coronal view. the heights of all axial images on which the ligament could be seen. The width was calculated by counting the number of 2-mm-thick sagittal sections that showed the membrane. The alar ligaments were characterized by evaluation of their orientation and thickness.05. and axial planes through the CVJ. The thickness was defined as the distance between the posterior dens contour and the tectorial membrane on axial images. Examples of specimens failing as (A) occipitoatlantal dislocation (OAD) or (B) atlantoaxial dislocation (AAD). The distracted and injured specimens were then dissected. To simulate distraction injury of this region.. these ligaments were classified into 3 orientations (cranio-caudal.

7 mm on the right and 5.0 mm (Table 1).9) 6.2068 Spine • Volume 33 • Number 19 • 2008 curred was 1229 Ϯ 181 N.4–6.6) * Cranio-caudal Height (mm) 8.0 (0.9) * Thickness (mm) Transverse cruciate ligament 3. Alar ligaments were asymmetrical caudo-cranially in 2 specimens (Figure 6A).2–1. Figure 3.1 (2. N ϭ 7).1) 5.5 (12–16) 6.8–5.009) ultimate strengths of subgroups of specimens failing as occipitoatlantal dislocation (OAD. (mean failure load 823 Ϯ 127 N).9) 5.. The apical ligament was not identifiable on MRI or directly in any of the 3 specimens of the OAD group (Figure 7A).7 (4.7 (4. These mean failure load magnitudes were significantly different (Figure 3. the tectorial membrane was ruptured uniformly at the level of C1.0–1. As predicted. There was avulsion from the occipital condyle in 1 specimen.1 (4.7 mm on the left for OAD specimens (Table 1). this ligament was generally smaller than the ICL (Table 1. The transverse occipital ligament15 was not identifiable on MRI or directly in any of the 3 specimens.9–1. N ϭ 3) or atlantoaxial dislocation (AAD.3 (1. when intact. were obtained.7) Anteroposterior Diameter (mm) 6.2–8. OAD Specimens In the OAD group.2–2.2–3.2 (5.2) 1. Graph showing significantly different (P ϭ 0.5) Thickness (mm) 1.1) 1.0) AAD Group Width (mm) 14.5) Anteroposterior Diameter (mm) 5. P ϭ 0.7) 5.1 (8–12) Cranio-caudal Diameter (mm) 5.9) 5.1 (1.0 (4. The mean tectorial membrane cross-section was 1. the alar ligament shape was symmetrical anteroposteriorly and cranio-caudally.0 (7.0 mm by 15 mm for OAD cases (Table 1).7 (4.2–5.7–3.7) Right alar ligament Left alar ligament *Not identifiable on MRI. i. Mean Ligament Dimensions (Range) From Prefailure MRI OAD Group Structure Tectorial membrane Superior cruciate ligament Inferior cruciate ligament Apical ligament Thickness (mm) 1.9–6. but because of “puckering” on rupture.1 (4.0 (0.9–1.e.5–5. In the OAD group.6–2.0–9. The anatomic measurements of the unruptured ligaments showed consistency with the MRI measurements. The SCL was ruptured in all 3 OAD specimens (Figure 4A).7 (4.0) Cranio-caudal Height (mm) 9.9 mm by 5.5 mm by 5.9 (1.6) 5.3 (4.9–6.6–6.0–8. Results AAD (Figure 2A) was observed in 7 specimens. the mean applied force (Ϯstandard deviation) before failure oc- Table 1.1) 1.9 (4. the crosssectional dimensions of damaged ligaments were expected to exceed the intact dimensions. The mean transverse cruciate ligament cross-section was 3. The mean alar ligament cross-section was 5. Figure 5A). OAD (Figure 2B) was observed in 3 specimens.0–5.9) Width (mm) 15 (14–16) 4.5 (4. The alar ligaments ruptured at the attachment to the occipital condyle unilaterally.009). Error bars show standard deviation.2) 1.0–1.0) Cranio-caudal Diameter (mm) 5. OAD specimens had a more circular sagittal alar ligament cross-section than AAD specimens (Figure 6B).5) 4. Dimensions of ligaments were obtained using an electronic caliper for comparison with measurements from MRI. directly measured cross-sectional sizes of the ruptured ligaments were generally greater than the preinjured MRI measurements of the same ligaments.5) Thickness (mm) 2.5–7. .4 (1.5–4.9 (2.8) 1.0 (4.1 mm by 8.0 (4.5–7. Alar ligaments had anterolateral orientation in 1 of 3 cases or posterolateral orientation in 2 of 3 cases.4 (1.

In only one of the AAD specimens was the transverse occipital ligament15 visible (Figure 8). P ϭ 0.e. all had symmetrical (left and right) caudo-cranial orientation (Figure 6A). The superior band of the cruciate ligament (black arrow) is intact but the inferior band (white arrow) is ruptured. In 1 specimen the alar ligamants were intact bilaterally.17 There is a paucity of biomechanical studies in the literature regarding the mechanisms of cervical trauma occurring in victims suffering from OAD and AAD.5 mm2) than in OAD specimens (20. The mean alar ligament crosssection was 6. Figure 6B). AAD specimen. OAD specimen. the . dimensions of the ruptured ligaments after biomechanical Figure 4.16. the tectorial membrane was ruptured at C2 or near the base of the dens. Discussion Injury to the upper cervical spine occurs frequently in fatal motor vehicle accidents. which are usually difficult to clearly identify in scans from lower field strength MR. Alar ligaments had posterolateral orientation in 6 of 7 cases or horizontal orientation in 1 of 7 cases.9 mm by 5. Figure 5B).22) and the mean crosssectional area of the ICL was smaller in AAD specimens (16. Most of the biomechanical studies in this field are related to biomechanics of occipitocervical fixation.Occipitocervical Vertical Distraction Injuries • Yu ¨ ksel et al 2069 ligament was ruptured in the middle partially in the right and totally in the left.2 mm by 5.9 mm by 9. Before injury. However.1 mm (Table 1). In 5 of these 7 specimens. Posterior view of the cranio-vertebral junction in representative OAD and AAD specimens. The apical ligament was identifiable on MRI in all 7 AAD specimens. The apical ligament was ruptured in 6 specimens in this group. AAD was the predominant injury type. Note the puckered.3 mm2.5 mm (Table 1). morbidity. with higher load recorded during the distraction test than was required for OAD.1 mm (Table 1. particularly among pedestrians and motorcyclists.16 Distraction injuries that result in cranio-cervical separation may be unilateral or bilateral and may occur between the occiput and C1. nontensile appearance of this band. Higher-field-strength whole-body MR systems provide various benefits. Under the same testing conditions.3 mm on the left side in AAD specimens (Table 1). Although rare. the high resolution of higher-field-strength MR systems proved especially useful in understanding trauma mechanisms to the CVJ because of the ability to distinguish the small ligaments of this region. Figure 7B). particularly for MRI of small joints. The superior band of the cruciate ligament (black arrow) is ruptured. or both. between C1 and C2. The damaged tectorial membrane is resected. P ϭ 0. but there was a fracture of the odontoid tip. AAD specimens had a more ovoid sagittal alar ligament cross-section than OAD specimens. For AAD specimens. The mean tectorial membrane cross-section was 1.0 mm on the right side and 6. A.0 mm by 5. B. AAD Specimens In all 7 specimens representing AAD. The AAD group had larger anteroposterior and smaller cranio-caudal alar ligament diameter than the OAD group (i. and delayed neurologic deterioration. The inferior band of the cruciate ligament (white arrow) is intact. The increased signal-to-noise ratio may allow imaging with improved spatial resolution for musculoskeletal applications.28). Note that the superior band of the cruciate ligament is more prominent than the inferior band. The mean apical ligament cross-section was 1.8 mm2. the ICL was ruptured (Figure 4B) but the SCL was intact.6 mm2) than in OAD specimens (21. the ICL was generally smaller than the SCL (Table 1. distraction injuries of the CVJ are usually of critical clinical importance because of high mortality. including increased signal-to-noise ratio and probably better diagnostic performance compared with magnets working at lower field strengths.0 mm by 14. in 1 specimen the ligament was avulsed from the odontoid tip. Anatomic dissection measurements of the postbiomechanical testing and unruptured ligaments usually correlated well with MRI measurements. the mean transverse cruciate ligament cross-section was 2. This study is the first to address the failure pattern encountered in occipitocervical distraction injuries. In 1 specimen of this group. The alar ligaments were ruptured in the middle in 5 specimens bilaterally. In the remaining 2 specimens both the SCL and ICL were ruptured..18 In this study. The mean cross-sectional area of the SCL was larger in AAD specimens (25.

23 Our findings revealed that this ligament was missing in 30% of our adult cadaveric specimens. the superior band has a relatively smaller cross-section than the inferior band. In the OAD group.23. different authors describe the alar ligaments differently because of different orientations and configurations encountered and the presence of connections between the occipital bone. than in the OAD group.21. The tectorial membrane can be distinguished from the cruciate ligaments by its hypointense. However. consistent with Tubbs et al. signal. the apical ligament can be examined in trauma patients using 3-T MRI to confirm the injury mechanism and to decide on fixation strategy possibilities.1 Gonzalez et al1 theorized a set of possibilities for different injury patterns resulting from pure axial distraction of the CVJ. in which the apical ligament was missing. such as small sample size and the findings that there were also differences between OAD and AAD specimens in the orientation of alar ligaments and in the relative dimensions of the cruciate ligaments. It is hypothesized that different types of distraction injuries of the ligamentous complex of the CVJ are caused by a similar mechanism. Clinically. all specimens in which the apical ligament was absent were in the OAD group. Failure load magnitude was also significantly higher in the AAD group. The alar ligaments are short ligaments that extend upward from the lateral aspects of the apex of the dens to the medial-inferior aspect of the occipital condyles. testing were generally greater than their MRI-measured values. and the dens.19 –21 They limit the rotational movement in this region of the spine.6. there is evidence that the apical ligament may indeed contribute to CVJ stability more than was thought previously. Clinically. . The apical ligament may influence the stability and strength of the CVJ and the distraction injury mechanism. in OAD specimens. slightly darker. the superior band has a relatively larger cross section than the inferior band. The odontoid process (white arrowhead).2070 Spine • Volume 33 • Number 19 • 2008 Figure 5. alar ligaments (black arrowheads) and body of the axis (asterisk) are also visible. The tectorial membrane (small black arrows) is in close proximity to the superior and inferior bands of the cruciate ligament. the alar ligaments always had symmetrical (left and right) caudo-cranial orientation. In the AAD group. however. Also.5. the alar ligaments were often asymmetrical caudo-cranially whereas in AAD specimens.19.24 Tubbs et al23 reported that this ligament was missing in 20% of the adult specimens studied.19 In the literature.22 Our results revealed that the orientation and shape of the alar ligaments seem to be related to the mechanism of the distraction injury and trauma pattern: in OAD specimens. Axial MRI slices demonstrating relative crosssectional dimensions of the superior and inferior bands of the cruciate ligament (between large black arrows) in OAD and AAD specimens. the atlas. it is important for the surgeon to recognize that a variety of alar ligament orientations can be considered “normal” and to recognize changes to the orientation and configuration of these structures on high-resolution MRI. in which the apical ligament was prominent.23 Interestingly. the alar ligaments had a more ovoid cross-section than in AAD specimens. They also claimed that the apical ligament contributes little to cranio-cervical stability.11. This difference can be explained by the loss of the tensile orientation of the ligament after rupture and “puckering” of the ligament. It is difficult to draw a definitive conclusion about the importance of the apical ligament from these findings because of other confounding factors.15. They stated that if all vertically compressive ligaments (apical. The apical ligament is a thin midline ligament that extends from the apex of the dens into the anterior wall of the foramen magnum between the alar ligaments. MRI measurements were therefore considered more anatomically accurate.

In a specimen that was to fail as AAD. possibly because of the small numbers studied. B. No apical ligament is identifiable. alar. Simultaneous failure of C0 –C1 and C1–C2 (OAD with simultaneous AAD) was also hypothesized. As seen on sagittal MRI. alar ligaments course in a more caudo-cranial orientation on the right (arrowheads) and a horizontal orientation on the left (arrows) in a specimen representing OAD. OAD: Superior and inferior bands of the cruciate ligament (black arrows) are seen as band-like low-signal intensity structures. Sagittal MRI of representative specimens from OAD and AAD groups. in specimens that were to fail as AAD. and tectorial membrane) and articular capsules are sectioned. the SCL was found to be relatively smaller than the ICL. On coronal MRI. in specimens that were to fail as OAD. This type of injury was not observed in our set of cadaveric specimens. alar ligament cross-section was typically round (arrows). whereas in AAD specimens the SCL was found to be relatively larger than the ICL. The apical ligament is also clearly visible (white arrow). if the vertical segment of the cruciate ligament inferior to the transverse ligament fails. Our results support this hypothesis: in OAD specimens. then axial tension should cause OAD. then axial tension should cause AAD. B. the superior and inferior bands of the cruciate ligament are visible (black arrows). AAD: as with OAD. Conversely.Occipitocervical Vertical Distraction Injuries • Yu ¨ ksel et al 2071 Figure 6. Our findings revealed that relative dimensions of the superior band and inferior band of the cruciate ligament. the left and right orientations were typically symmetrical (arrows). . MRI demonstrating alar ligament orientations in representative specimens from OAD and AAD groups. Figure 7. A. alar ligament cross-section was typically ovoid (arrows). or because loading was applied in a slow controlled fashion. and if the vertical portion of the cruciate ligament is ruptured above the transverse ligament. A.

it was at a failure load that was 33% less than the AAD failure load. ● Although OAD occurred less frequently than AAD.1 An additional limitation is that fixation of specimens such that ligamentous failure could be induced exclusively at the upper cervical levels required braided cable to be looped around the lateral masses of C2 (Figure 1). Our findings provide information on which structures might be congenitally absent as opposed to structures that have been damaged. . The transverse occipital ligament (white arrow). Note that the alar ligaments are ruptured bilaterally (black arrows) and the transverse ligament is intact (asterisk). and radiologic data to enhance basic understanding of the spine. orientation of the alar ligaments.9 Therefore. and presence of a prominent apical ligament can influence whether OAD or AAD occurs.27. Klopfenstein JD. dimensions were calculated by summing the number of slices on which a structure could be seen. Currently it is also possible to obtain very high resolution MR images of the cranio-cervical junction with 3-T MRI. aiding in identifying the exact injury mechanism and unstable region. Visualization of the ligaments of the upper cervical spine with 3-T MRI in patients suffering from CVJ trauma can help to better understand the mechanism of injury and can allow the physician to identify and stabilize only the unstable level without compromising the unaffected adjacent levels. and had less ovoid alar ligament configuration. clinically. Further study is needed to better separate these variables and possibly to observe other types of outcomes such as simultaneous OAD and AAD. patients suffering from vertical distraction injury of this region can be examined with 3-T MRI to visualize the numerous ligamentous structures of this region and to identify which ligaments were injured.2072 Spine • Volume 33 • Number 19 • 2008 Figure 8. For example. which makes it difficult to separate variables and assess their relative contributions. Knowledge of the anatomic variations of the ligaments of this area and their relationship to the biomechanics of the injury mechanism can give a further insight to the spinal surgeon and the radiologist who are managing survivors of AAD and OAD. biomechanical. which is a part of the alar ligament. but OAD occurred at a failure load that was 33% less than the AAD failure load. In our series. this experimental procedure might have weakened C1–C2 relative to C0 –C1. J Neurosurg Spine 2005. and presence of a prominent apical ligament appear to affect whether injury occurs at C0 –C1 or at C1– C2. ● The dimensions of the superior and inferior cruciate ligaments.3:318 –23.16 It is likely that such injuries are currently underdiagnosed. Key Points ● Identical axial distraction of the CVJ can produce either OAD (3 of 10 outcomes) or AAD (7 of 10 outcomes). and alar ligament orientation can have a direct influence on the site of the vertical distraction injury. A limitation regarding measurements taken from MR images is that in some directions. some series estimate that up to 20% of all traffic fatalities involve upper cervical spine injuries and 50% of craniocervical injuries are frequently missed at initial imaging. OAD specimens consistently lacked the apical ligament. the precision of these measurements is somewhat more limited than in-plane resolution. presence or absence of the apical ligament. Treatment and fixation strategies can be based on these findings since surgical fixation techniques exist for isolated occipitoatlantal fixation 25. et al. orientation of the alar ligaments.28 This study provides anatomic. skewing the outcomes. One limitation of this study is the small number of specimens tested.26 and isolated atlantoaxial fixation. Conclusion Identical axial distraction of the CVJ can produce either OAD or AAD. had larger inferior than SCLs. References 1. AAD occurred more frequently than OAD. The act of threading these cables through the C1–C2 space damaged the thin ligamentous C1–C2 facet capsules. Crawford NR. Although AAD and OAD are rare. is seen in a specimen representing AAD from a posterior view through the cranio-vertebral junction between the occipital condyles. If there had been at least 1 OAD specimen in which the apical ligament was present but where the other factors held true. ● Excellent visualization of the critical CVJ ligaments is possible with 3-T MRI. The dimensions of the SCL and ICL. Although these capsules are very flexible and are not thought to provide much resistance against distraction. and therefore aiding in the decision-making process of the appropriate stabilization surgery for such patients. then conclusions about the contribution of the apical ligament would be somewhat tempered. Use of dual transarticular screws to fixate simultaneous occipitoatlantal and atlantoaxial dislocations. These findings are also clinically relevant. Gonzalez LF. Because slice spacing was 2 mm.

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