CLINICAL STUDIES

Injuries Involving the Transverse Atlantal Ligament:

Classification and Treatment Guidelines Based upon
Experience with 39 Injuries

Curtis A. Dickman, M.D.,

Karl A. Greene, M.D., Ph.D.,
Volker K.H. Sonntag, M.D.
Division of Neurological Surgery, Barrow Neurological Institute,
St. Joseph's Hospital and Medical Center, Phoenix, Arizona

C O M P R E H E N S IV E A N A T O M IC A N D clinical analyses of 39 patients w ith injuries involving the transverse atlantal

ligament or its osseous insertions w ere performed to assess the m orphology of the injured ligam ents and the patients'
capacity to heal. Injuries of the upper cervical spine w ere screened w ith plain radiographs, thin-section computed
tomography, and magnetic resonance imaging studies. The injuries w ere 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 tw o types of injuries had distinctly
different clinical characteristics that w ere useful for determ ining treatm ent. Type I injuries w e re incapable of bealing
satisfactorily w ithout internal fixation; they should be treated w ith early surgery. Type II injuries, w h ich rendered the
transverse ligament physiologically incom petent even though the ligament substance was not torn, should be treated
initially w ith a rigid cervical orthosis, because they had a 7 4 % success rate nonoperatively. Surgery should be
reserved for patients w ith Type II injuries that have nonunion w ith persistent instability after 3 to 4 m onths of
im m obilization. Type II injuries had a 2 6 % rate of failure of im m obilization; therefore, close m onitoring is needed
to detect patients w ho w ill require delayed operative intervention. (Neurosurgery 38:44-50, 1996)
Key words: Atlantoaxial instability, Atlas fracture, Cervical fractures, Cervical spine injury, Spinal instability, Transverse atlantal ligament

lthough the transverse atlantal ligament is not visible

A
on plain radiographs, its integrity is inferred from
these studies. A widened mobile atlantodental interval
implies that the transverse atlantal ligament is disrupted or
incompetent. However, such studies do not permit direct
evaluation of the ligament structure.
Acute traumatic disruptions of the transverse atlantal liga­
ment have not been comprehensively studied (3,4, 7, 9 ,1 0 ,1 4 ,
21, 23). Although a few studies have examined the in vitro
biomechanics and pathophysiology of injuries to the trans­
verse ligament (8, 9, 15, 25-27, 30), no pathological or ana­
tomic studies have assessed whether there are subtypes of
transverse ligament injuries that are capable of healing.
This report is the first clinical series that documents the in
vivo pathoanatomy of injuries involving the transverse atlan­
tal ligament. This clinical experience was used to formulate a
clinical classification scheme to guide treatments based upon
the extent of the injury to both the osseous and ligamentous
structures of the upper cervical spine.
P A T IE N T S A N D M E T H O D S
The diagnostic imaging studies of patients admitted to our
institution with injuries of the upper cervical spine between
1988 and 1995 were reviewed. Thirty-nine patients (12 female
patients and 27 male patients) with acute traumatic injuries
involving the transverse atlantal ligament or its osseous in­
sertion were identified. The mechanisms of injury included
automobile accidents (n = 18), automobile-pedestrian colli­
sions (n = 5), motorcycle accidents (n = 3), bicycle accidents
(n = 2), falls (n = 8), sports-related injuries (n = 2), and a
horseback-riding accident (n = 1).
Patients were excluded if they exhibited other abnormali­
ties that affected the upper cervical spine, if follow-up could
not be obtained, or if they had penetrating spinal injuries,
rheumatoid arthritis, connective tissue diseases, metabolic
bone diseases, ankylosing spondylitis, D ow n's syndrome, or
other congenital or acquired abnormalities of the cranioverte-
bral junction. Only patients with acute trauma to the upper

44 Neurosurgery, Vol. 38,No. 1, January 1996


cervical spine, without other abnormalities of this region,
were included for analysis. Children under the age of 14 years
were excluded because of imm ature skeletal features. No
upper age limit was set. The patients' mean age was 28 years
(range, 14-74 yr).
All patients were evaluated by plain radiography, thin-
section computed tomography (CT), and high-resolution
magnetic resonance imaging (MRI). Full radiographic cervical
spine series were obtained, including anteroposterior, lateral,
oblique, open-mouth views, and, when clinically appropriate,
flexion-and-extension views. Thin-section computed tomo­
graphic scans were obtained with 1-mm cuts from the top of
the occipital condyles to the C 2 -C 3 interspace. Additional
spinal levels were studied when clinically indicated. MRI
studies were performed with a Signa GE 1.5-Tesla magnetic
resonance unit. High-resolution, multiplanar images were ob­
tained. Surface coils were used to improve the anatomic res­
olution. Thin slices (2-3 mm), oriented parallel to the C l ring,
were obtained to delineate the transverse ligament. Several
different pulse sequences were used, including fast spin-echo,
gradient-echo, T1 -weighted, and T2-weighted images. The
details of the MRI parameters and the characteristics of the
normal and disrupted transverse ligaments were reported
elsewhere (5).
The morphological patterns of injuries to the bones and
ligaments were recorded, using anatomic diagrams traced
from patients' imaging studies. The patterns of injury were
reviewed with respect to the patient's clinical presentation,
operative and nonoperative treatments, and outcome. Fol­
low-up data were obtained from hospital medical records,
outpatient office charts, clinical examinations, reviews of ra­
diographic studies, and telephone interviews.
RESULTS
At admission, 1 patient had a complete C l level quadriple-
gia and died shortly thereafter, 1 patient had a mild quadri-
paresis, and the other 37 patients were neurologically intact.
The injuries were classified according to the extent of osseous
and ligamentous injuries. Type I injuries were disruptions of
the substance of the transverse atlantal ligament, without an
osseous component. Type II injuries were fractures or avul­
sions involving the tubercle for insertion of the transverse
atlantal ligament on the C l lateral mass, without disruption of
the ligament substance. These two types of injuries had dis­
tinctly different clinical characteristics and treatment out­
comes. The two major types of transverse ligament injuries
were further subdivided for analysis (Fig. 1).
Type I injuries
Sixteen patients had torn, disrupted transverse atlantal lig­
aments (Type I injuries), 15 of whom had a widened atlanto-
dental interval (mean interval, 8 mm; range, 2 -1 4 mm). All 16
patients exhibited instability (i.e., mobile anteroposterior sub-
N e u ro s u rg e ry , Vol. 38, No. 1, January 1996
Transverse Atlantal Ligament Injuries
FIG U R E 1. Classification of injuries to the transverse atlantal
ligament. Type I injuries disrupt the ligament substance in its
midportion ( IA ) or at its periosteal insertion (IB). Type II
injuries disconnect the tubercle for insertion of the trans­
verse ligament from the C l lateral mass involving a commi­
nuted C l lateral mass (IIA) or avulsing the tubercle from an
intact lateral mass ( IIB ) (reprinted with permission from Bar­
row Neurological Institute).
luxations of C l) on plain radiographs. All had MRI evidence
of ligament disruption with loss of continuity of the ligament,
high-signal intensity in the ligament, or blood separating the
ligament from its insertion. Two patterns of ligament disrup­
tions occurred; they were midsubstance ligament tears (Type
IA, n = 7) or osteoperiosteal disruptions (Type IB, n = 9) (Fig.
2, A and B).
Of the 16 patients with Type I injuries, one was the patient
who died at admission. Four patients (25%) had a concurrent
cervical fracture. Of those four, two had odontoid fractures,
one had an atlas burst fracture (four-part ring fracture), and
one had fractures of the odontoid process of C2 and the
posterior arch of C l. Because of the unique aspects of their
cases, the patients with odontoid fractures and a disrupted
transverse ligament have been described elsewhere (13). None
of the 15 surviving patients healed with nonoperative treat­
ment; all required surgery to restore permanent atlantoaxial
stability. Nine patients failed to heal spontaneously or with a
cervical orthosis. Six patients presented after a delay in diag­
nosis with severe neck pain and subacute or chronic atlanto­
axial instability (range, 2 -6 mo). Three patients who were
initially treated with an orthosis (two patients with odontoid
fractures and the patient with an isolated atlas fracture) for 12
to 20 weeks developed persistent instability that required
surgery. These three patients were treated with a halo brace
(n = 2) or a sternal occipital mandibular immobilization brace
(n = 1) for cervical immobilization. The remaining six patients
were treated with acute surgery within 2 weeks of their injury,
because it was presumed that their injuries could not heal
45
46 Dickman et al.
FIG U RE 2. Gradient-echo MRI studies of Type IA (A,
arrows) and Type IB (B, arrows) injuries. C, the normal trans­
verse atlantal ligament appears on axial gradient-echo mag­
netic resonance images (TR, 733 ms; TE, 18 ms; flip angle, 20
degrees; slice, 3 mm) as a homogenous, continuous, thick,
low-signal intensity structure (a rrow h ead ) that extends
between the medial portions of the lateral masses of C1. The
ligament is contrasted anteriorly by the high-signal intensity
of the synovium, which surrounds the odontoid, and posteri­
orly by the high-signal intensity of the cerebrospinal fluid.
without internal fixation. All 15 surgically treated patients
with Type I injuries developed an osseous union. All were
treated with C 1-C 2 fixation with wires or cables and autolo­
gous grafts (6); six patients also had transarticular screws
placed for rigid internal fixation.
All four patients with Type I ligament injuries with con­
comitant fractures of C l or C2 had an osteoperiosteal failure
Neurosurgery, Vol. 38, No. 7, January 1996
of the transverse ligament (Type IB). These injuries were all
clinically unstable and manifested by an inability to maintain
satisfactory alignment in a halo brace, recurrent subluxations,
fracture nonunion, delayed instability, and failure to heal
with cervical immobilization. One elderly patient with frac­
tures of C l and C2 was unable to tolerate a halo brace and was
treated with early surgery (13).
Type II injuries
Twenty-three patients had tubercle avulsions or bone frac­
tures that disconnected the tubercle for the transverse liga­
ment insertion from the lateral mass of C l (Type II injury).
These injuries rendered the transverse ligament physiologi­
cally incompetent, even though the ligamentous substance
was not disrupted.
Twenty-two of these patients (96%) had an associated atlas
fracture— typically comminuted fractures of the lateral mass
of C l (Type IIA) (Fig. 3, A and B). Two patients (9%) had
tubercle-avulsion injuries without comminuted fractures of
the involved C l lateral mass (Type IIB). One patient with a
tubercle avulsion had a fracture of the contralateral C l lateral
mass (Fig. 3C).
All 23 patients with Type II injuries were initially managed
nonoperatively using a Philadelphia collar (n = 7) or a halo
brace (n = 16). After an average of 13 weeks of treatment with
an orthosis (range, 12-16 wk), six patients (26%) had non­
union with persistent atlantoaxial instability that required
surgical treatment. Four of these nonunions had comminuted
C l lateral mass fractures (Type IIA). Both of the Type IIB
injuries with tubercle avulsions developed nonunion. Among
the six nonunions, four patients were initially treated with a
halo brace and two wore a Philadelphia collar. Their surgical
treatment consisted of C 1 -C 2 fixation (n = 4) or occipitocer­
vical fixation (n = 2). Occipitocervical fixation was reserved
for patients with concurrent fractures of the C l posterior arch
that precluded adequate fixation to C l.
Diagnostic imaging of transverse ligam ent pathological
findings
The pathoanatomy of injuries to the transverse atlantal
ligament and its osseous insertions was correlated with how
well the plain radiographic studies detected the pathological
findings of the transverse atlantal ligament (Fig. 4, A and B).
Plain radiographs alone were relatively insensitive for detect­
ing injuries of the transverse ligament. The amount of Cl
lateral mass displacement on open-mouth radiographs of C l
and C2 was a poor predictor of a disrupted ligament. When
only atlas fractures were considered, 61% of injuries were
missed if a 7.0-mm criteria was used to presume an injury to
the transverse atlantal ligament after an atlas fracture ("Sp en ­
ce's rule") (30). Of the 23 atlas fractures, only 9 (39%) of the
associated incompetent transverse ligaments would have
been detected. This 7.0-mm rule does not accurately predict
the status of the transverse atlantal ligament after an atlas
fracture (Fig. 4A). Based on the normal atlantodental interval
of 3.0 mm or less, 10 of the 39 patients (26%), primarily
patients with Type IIA injuries, would have been judged as
 Transverse Atlantal Ligament Injuries 47

O = Atlas Fracture

t-
>
CD= Odontoid Fracture

..............................
O = C1-C2 Combination Fracti
A = No Fractures of C1 or C2

O
Total 1Q
o
oo

.
C1 Lateral

1
Mass 9

1
Displacement 8
ooooo

1
(mm) 7
—

ooo o
—

o o
oo
3 H
—
ooo
—

o
0 AAAAAAA ---m i oLfAAAA------------ rp. ----------------------------------------- ■----------------------
Midsubstance Osteoperiosteal Comminuted Tubercle
Ligament Ligament C1 Lateral Avulsions
Disruptions Disruptions Mass Fractures (IIB)
(IA) (IB) (HA)

15
B O = Atlas Fracture
CD = Odontoid Fracture
14 □ = C1-C2 Combination Fract
▲ = No Fractures of C1 or C2
13
12
11
Maximal
10
Atlantodental
Interval 9
(mm) 8 o o
7 oo
6 oo
5 □ oooo o
4 .000..
3 - oo
2 - □ ooooo
1 - oo
0 1-------------------

Midsubstance Osteoperiosteal Comminuted Tubercle

Ligament Ligament C1 Lateral Avulsions
Disruptions Disruptions Mass Fractures (IIB)
(IA) (IB) (HA)

FIG U R E 4. Correlation of plain radiographic findings, with

FIGURE 3. CT studies of Type II injuries. A and
injury with a comminuted C1 latera mass a p e rs is te n t
b j d e on ,ho left. This palien, had nono«,on a > n d £ « ^
C1-C2 instability, despite treatment with mass |S
weeks. C, Type MB injury. The patient s e: fractures of the
disconnected from the C l ring by uni a mpni tubercle
anterior and posterior arch. The transverse
on the patient's right side is avulsed from t s
the C l lateral mass. The avolsed tubercle ts vis.ble as
fragment adjacent to the odontoid.
the pathoanatomy of the injury patterns to the bones and
ligaments, as visualized using CT and M RI. A, the type of lig­
ament injury in relation to the total amount of displacement
of the C1 lateral masses on open-mouth views of C1-C2. If a
7.0-mm criterion is used to presume transverse ligament dis­
ruption, more than half of the unstable atlas fractures would
have been missed. "Spence's 7.0-mm rule" does not accu­
rately predict the status of the transverse atlantal ligament
after an atlas fracture. B, the type of ligament and bone
injury in relation to the maximal atlantodental interval on
preoperative lateral cervical radiographs. If a 3.0-mm cutoff
is used to presume a disrupted transverse atlantal ligament,
10 of the 39 injuries (2 6 % ) would not have been detected.
Less than 1 0% of the Type I injuries but almost 4 0 % of the
Type II injuries would have been missed (reprinted with per­
mission from Barrow Neurological Institute).

and pathological specimens (5, 22). Subsequently, we investi­

normal despite an injury that involved the transverse atlantal
gated the capability of MRI to depict the anatomy and patho­
ligament (Fig. 4 B. )
logical findings of the transverse atlantal ligament in vivo (5)
This ongoing analysis has yielded several new insights re­
D ISC U SS IO N . garding the natural history of injuries of the transverse liga­
This report, which describes a prospective an the ment.
The integrity of the transverse ligament is not only perti­
per cervical spine injuries that began in > verse atlantal
nent to acute ligamentous injuries but is also essential to the
largest reported series of injuries to e normal
ligament. Initially, we examined in vitro and in stability of atlas fractures, degenerative, inflammatory, and

N e u ro s u rg e ry , Vol. 38, No. /, January 1996

48 Dickman et al.

congenital disorders, and other abnormalities that affect the
craniovertebral junction. The status of the transverse atlantal
ligament is a critical factor to consider in terms of the capacity
of atlas fractures to heal.
Only a few patients in this study were treated with early
surgery; therefore, the substantial number of patients who
had the opportunity to heal with nonoperative treatment with
an orthosis permitted us to assess whether the different types
of injury healed spontaneously without internal fixation.
None of the Type I injuries healed spontaneously, whereas
three-fourths of the Type II injuries healed with an orthosis,
which suggests a new classification scheme and treatment
guidelines for injuries of the transverse atlantal ligament.
Type I injuries should be treated with early surgery, because
they are incapable of healing satisfactorily without internal
fixation. Type II injuries should be initially treated with a
rigid cervical orthosis.
The medical literature that is available in the English lan­
guage supports the conclusion that a Type I injury is incapa­
ble of healing without surgery for internal fixation but that
most Type II injuries heal when treated with an orthosis (Table
I). These studies, however, have several important weak­
nesses. First, all prior studies of injuries of the transverse
ligament have been based on a presumptive diagnosis, re­
flected by a widened atlantodental interval or, for atlas frac­
tures, more than 7-mm displacement of the C l lateral masses.
Typically, however, no CT, MRI, or pathological confirmation
of the diagnoses has been achieved. Second, a large percent of
the patients reported were treated with early surgery because
it was presumed that their injuries were incapable of healing.
Finally, the treatment and outcome in 12 of 71 patients could
not be ascertained from the reports.
The anatomy and physiological status of the transverse
atlantal ligament can be satisfactorily demonstrated in vivo
using CT and MRI in combination with dynamic flexion-and-
extension cervical radiographs. These studies provide com­
plementary information. CT demonstrates bone structure,
whereas MRI demonstrates soft tissue anatomy and plain
radiography detects pathological m ovem ent indicative of lig­
amentous incompetence. The normal transverse ligament has
a homogenous low-signal intensity on gradient-echo mag­
netic resonance images (5, 22). The disrupted ligament ap­
pears as an anatomic discontinuity with high-signal intensity
within the ligament and blood between the separated portions
of the ligament (5, 22).
Our results differ from many reports that have completely
depended upon plain radiographs to identify a transverse
ligament injury (2, 5, 9 , 1 1 , 1 3 , 1 4 , 1 7 , 21, 28). Plain radiographs
alone are inadequate to delineate the morphological pattern of
injury to the transverse ligament but are useful as a screening
tool to detect a possible abnormality. Normal relationships of
the C l lateral masses on open-mouth radiographs or a normal

TABLE 1. Literature Reports of Treatment and Outcome of Transverse Ligament Injuries

Transverse Ligament Healed, Nonunion, Early Treatment and Outcome
Series (Ref No.) Total
Injury Type Stable Unstable Surgery** Unknown

Cone and Turner, 1937 (3) \b 0 25 9 2 36

Corner, 1907 (4)
Dunbar and Ray, 1961 (7)
Fielding et al., 1974 (9)
Fielding et al., 1976 (10)
Greene et al., 1994 (1 3)
Mixter and Osgood, 1910 (23)
Barker et al., 1976 (1) 11A 14 3 3 7 27
Fowler et al., 1990 (11)
Lee and Woodring, 1991 (18)
Levine and Edwards, 1991 (20)
Lipson, 1977 (21)
O'Brien et al., 1977 (24)
Segal et al., 1987 (29)
Spence et al., 1970 (30)
Barker et al., 1976 ( 1) IIB 2 2 1 3 8
FHighland and Salciccioli, 1985 (16)
Kenez et al., 1991 (1 7)
Lee and Woodring, 1991 (18)
Levine, 1983 (19)
Levine and Edwards, 1991 (20)
Segal et al., 1987 (29)
Total 16 30 13 12 71
1For presumed inability to heal. " -------------
1 1 1esunipuvt: uidgviUM
liavj a M ^ uasecj on i
resonance imaging, or pathologic confirmation was obtained.

Neurosurgery, Vol. 38, No. 1, January 1996


atlantodental interval on lateral cervical radiographs does not
exclude injury to the transverse ligament. Flexion and exten­
sion radiographs are not advocated in patients with extensive
fractures of C l or C2, even if the atlantodental interval is
normal on static radiographs, because of the risk of neurolog­
ical injury. If instability is suspected based on the pattern of
injury to the bone and ligaments, dynamic radiographs
should be withheld or obtained only with extreme caution.
Treatment recommendations for transverse ligament inju­
ries have been based upon several logical assumptions. First,
the transverse ligament is the major ligamentous stabilizing
component for the atlas. The other C 1 -C 2 ligaments are rela­
tively weak (8, 9, 31). Second, when torn or completely dis­
rupted, the transverse ligament, as with other major ligaments
in the body, is incapable of repair. The original strength and
function of a disrupted ligament cannot be restored (12).
Finally, the transverse ligament is compact, stiff, and inelastic.
It stretches very little; rather, it snaps suddenly as it becomes
disrupted (9, 30).
In conclusion, the treatment of injuries to the upper cervical
spine is based upon the extent of injury to both the ligaments
and the bone structures involved. Disruptions of the sub­
stance of the transverse atlantal ligament (Type I injuries) are
incapable of healing and should be treated with early surgery
for internal fixation. Seventy-four percent of patients with
tubercle fracture or avulsion injuries (Type II injuries) healed
with nonoperative treatment using external immobilization.
Patients with tubercle avulsions (Type IIB injuries) may have
a particularly high risk for nonunion; however, reliable gen­
eralizations cannot be made based on the few patients with
Type IIB injuries available for analysis. Surgery for internal
fixation of Type II injuries is reserved for individuals who
develop nonunion with persistent instability after a reason­
able duration of halo immobilization (i.e., 12-16 wk). We
prefer the halo brace because of its superior ability to mechan­
ically stabilize the cervical spine, compared with other ortho-
ses. Despite treatment with a rigid orthosis, 26% of our pa­
tients with Type II injuries failed to restore their spinal
stability nonoperatively. Therefore, close monitoring is man­
datory to detect patients who require delayed operative treat­
ment.
ackn o w led g m en ts
We thank Dr. Ronald I. Apfelbaum of the Department of
Neurosurgery at the University of Utah in Salt Lake City for
providing two of the clinical cases in this series. We thank
Shelley A. Kick, Ph.D., Editor, Mark Schornak, M.S., Medical
Illustrator, and the Editorial Staff of the Neuroscience Publi­
cations Office at the Barrow Neurological Institute for assis-
tance in the preparation of this article.
Received, May 12, 1995.
Accepted, July 11, 1995.
Reprint requests: Curtis A. Dickman, M.D., Neuroscience Publica­
tions, Barrow Neurological Institute, 350 West Thomas Road, Phoe­
nix, AZ 85013-4496.
N e u ro s u rg e ry , Vol. 38, No. 1, lanuary 1996
Transverse Atlantal Ligament Injuries 49
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the human spine: A systemic approach, in Clinical Biomechanics of
the Spine. Philadelphia, JB Lippincott, 1978, pp 191-276.
CO M M EN TS
This is the single most important analysis of injuries of the
transverse atlantal ligament and their management to have
appeared in the literature. The authors have brilliantly corre­
lated the plain film, computed tomography, and magnetic
resonance imaging findings of this ligamentous disruption
along with the associated bony injuries of the ring of C l. The
new classification they have devised and their suggestions for
management based on this classification are logical and easy
to understand. Based on modern imaging techniques, the
authors convincingly point out that Spence's Rule (only a total
lateral displacement of the lateral masses of C l > 7 mm pro­
duces C 1 -C 2 instability) is invalid.
Their observation that injuries of the transverse atlantal
ligament at its midportion or at its periosteal insertion (Type
I) will result in persistent instability without operative treat­
ment mirrors the situation in the subaxial cervical spine,
where ligamentous injuries of the facet joint most often re­
main unstable despite prolonged external immobilization.
Equally important is their finding that when the bony inser­
tion of the transverse atlantal ligament is disrupted by a
comminuted fracture of the lateral mass or the bony tubercle
where it inserts (Type II), external immobilization in a halo
vest will usually result in bony healing and restoration of
stability. The superb line drawings published with this article
vividly demonstrate the differences between these two inju­
ries.
Paul R. C o o p er
New York , New York
Dickman et al. provide a clear presentation of the definition
and clinical significance of a previously poorly understood
post-traumatic entity, transverse atlantal ligament disruption.
They provide clear illustrations and decisive clinical results. It
is clear that Type I injuries are incapable of healing and
should be treated with surgical fixation, whereas Type II
injuries are reasonably managed by nonoperative means. As
Dickman et al. point out, approximately one-quarter of these
patients will fail nonoperative management and will require
surgical stabilization. I
Dickman et al. provide a clear and meticulous presentation
of a previously poorly described clinical entity. This article
will clearly serve as a "Gold Standard" for the determination
of clinical management algorithms.
E d w ard C. Benzel
Albuquerque , New Mexico

AN N O UN CEM EN T

Future M eetings— Congress of N eurological Surgeons

The following are the planned sites and dates for future annual meetings of the
Congress of Neurological Surgeons:

1996 Montreal, Quebec September 28-October 3

1997 New Orleans, LA September 27-October 2
1998 Seattle, W A October 3-8
1999 Boston, M A October 23-28
2000 San Antonio, TX September 23-28

Neurosurgery, Vol. 38, No. 1, lanuary 1996