Clinical Orthopaedics and Related Research®

, Volume 470, Issue 6, pp 1602–1613 | Cite as

CT and MRI-based Diagnosis of Craniocervical Dislocations: The Role of the Occipitoatlantal Ligament

  • Kristen RadcliffEmail author
  • Christopher Kepler
  • Charles Reitman
  • James Harrop
  • Alexander Vaccaro
Symposium: Complications of Spine Surgery



Craniocervical dislocations are rare, potentially devastating injuries. A diagnosis of craniocervical dislocations may be delayed as a result of their low incidence and paucity of diagnostic criteria based on CT and MRI. Delay in diagnosis may contribute to neurological injury from secondary displacement resulting from instability. The purpose of this study was to define CT and MRI-based diagnostic criteria for craniocervical dislocations to facilitate early injury recognition and stabilization.


Using CT and MRI, we (1) described the bony articular displacements characterize craniocervical injuries; (2) described the ligamentous injuries that characterize craniocervical injuries; and (3) determined whether neurologic injuries were associated with bony or ligamentous injury.


Using a prospectively collected spinal cord injury database, we identified 18 patients with acute, traumatic occipitocervical injuries. We reviewed CT scans and MR images to document the height of the occipitoatlantal and atlantoaxial joints and integrity of craniocervical ligaments. Medical records were reviewed for neurological status. The primary measurements were number of patients with articular displacement, location of bony displacement, and number of patients with ligamentous injury.


Thirteen of 18 patients had displacement outside the normal range. Six patients demonstrated displacement of both occipitoatlantal and atlantoaxial joints, whereas five patients presented with displacement through the atlantoaxial joints only. Two patients had an abnormal basion-dental interval only. Of 17 patients with MR images, the cruciate ligament was injured in 11 patients, indeterminate in four, and intact in two. All five patients with occipitoatlantal articular displacement had injury to the occipitoatlantal capsule. No patient had occipitoatlantal capsular injury without occipitoatlantal articular displacement. Three cases of complete spinal cord injury were found after occipitoatlantal-atlantoaxial dislocations. Three patients with occipitoatlantal-atlantoaxial dislocations were neurologically intact. The five patients with atlantoaxial dislocations and patients without displacement or ligamentous injury were neurologically intact. Five patients had cruciate ligament rupture or indeterminate injury but no joint diastasis.


The occipitoatlantal joint capsules stabilize the occipitoatlantal joint; disruption of the occipitoatlantal capsule may suggest the presence of instability. Based on these findings, we identified two distinct injury patterns: isolated atlantoaxial injuries (Type I) and combined occipitoatlantal-atlantoaxial injuries (Type II). Occipitoatlantal joint capsule integrity differentiated these subsets and Type II injuries had a higher percentage of complete spinal cord injuries on presentation.


Cruciate Ligament Ligamentous Injury Occipital Condyle American Spinal Injury Association Craniocervical Junction 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    American Spinal Injury Association. Available at: Accessed August 27, 2011
  2. 2.
    Bambakidis NC, Feiz-Erfan I, Horn EM, Gonzalez LF, Baek S, Yuksel KZ, Brantley AG, Sonntag VK, Crawford NR. Biomechanical comparison of occipitoatlantal screw fixation techniques. J Neurosurg Spine. 2008;8:143–152.PubMedCrossRefGoogle Scholar
  3. 3.
    Bellabarba C, Mirza SK, West GA, Mann FA, Dailey AT, Newell DW, Chapman JR. Diagnosis and treatment of craniocervical dislocation in a series of 17 consecutive survivors during an 8-year period. J Neurosurg Spine. 2006;4:429–440.PubMedCrossRefGoogle Scholar
  4. 4.
    Chang W, Alexander MT, Mirvis SE. Diagnostic determinants of craniocervical distraction injury in adults. AJR Am J Roentgenol. 2009;192:52–58.PubMedCrossRefGoogle Scholar
  5. 5.
    Deliganis AV, Baxter AB, Hanson JA, Fisher DJ, Cohen WA, Wilson AJ, Mann FA. Radiologic spectrum of craniocervical distraction injuries. Radiographics. 2000;20:S237–250.PubMedGoogle Scholar
  6. 6.
    Dickman CA, Locantro J, Fessler RG. The influence of transoral odontoid resection on stability of the craniovertebral junction. J Neurosurg. 1992;77:525–530.PubMedCrossRefGoogle Scholar
  7. 7.
    Dziurzynski K, Anderson PA, Bean DB, Choi J, Leverson GE, Marin RL, Resnick DK. A blinded assessment of radiographic criteria for atlanto-occipital dislocation. Spine. 2005;30:1427–1432.PubMedCrossRefGoogle Scholar
  8. 8.
    Feiz-Erfan I, Gonzalez LF, Dickman CA. Atlantooccipital transarticular screw fixation for the treatment of traumatic occipitoatlantal dislocation. Technical note. J Neurosurg Spine. 2005;2:381–385.CrossRefGoogle Scholar
  9. 9.
    Gonzalez LF, Fiorella D, Crawford NR, Wallace RC, Feiz-Erfan I, Drumm D, Papadopoulos SM, Sonntag VK. Vertical atlantoaxial distraction injuries: radiological criteria and clinical implications. J Neurosurg Spine. 2004;1:273–280.PubMedCrossRefGoogle Scholar
  10. 10.
    Gonzalez LF, Klopfenstein JD, Crawford NR, Dickman CA, Sonntag VK. Use of dual transarticular screws to fixate simultaneous occipitoatlantal and atlantoaxial dislocations. J Neurosurg Spine. 2005;3:318–323.PubMedCrossRefGoogle Scholar
  11. 11.
    Grabb BC, Frye TA, Hedlund GL, Vaid YN, Grabb PA, Royal SA. MRI diagnosis of suspected atlanto-occipital dissociation in childhood. Pediatr Radiol. 1999;29:275–281.PubMedCrossRefGoogle Scholar
  12. 12.
    Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC, Mielke DH. Guidelines for the management of acute cervical spine and spinal cord injuries. Clin Neurosurg. 2002;49:407–498.PubMedGoogle Scholar
  13. 13.
    Harris JH Jr. Missed cervical spinal cord injuries. J Trauma. 2002;53:392–393.PubMedCrossRefGoogle Scholar
  14. 14.
    Horn EM, Feiz-Erfan I, Lekovic GP, Dickman CA, Sonntag VK, Theodore N. Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates. J Neurosurg Spine. 2007;6:113–120.PubMedCrossRefGoogle Scholar
  15. 15.
    Jung JY, Yoon YC, Kwon JW, Ahn JH, Choe BK. Diagnosis of internal derangement of the knee at 3.0-T MR imaging: 3D isotropic intermediate-weighted versus 2D sequences. Radiology. 2009;253:780–787.PubMedCrossRefGoogle Scholar
  16. 16.
    Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17:627–637.PubMedGoogle Scholar
  17. 17.
    La Marca F, Zubay G, Morrison T, Karahalios D. Cadaveric study for placement of occipital condyle screws: technique and effects on surrounding anatomic structures. J Neurosurg Spine. 2008;9:347–353.PubMedCrossRefGoogle Scholar
  18. 18.
    Pang D, Nemzek WR, Zovickian J. Atlanto-occipital dislocation—part 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;61:995–1015; discussion 1015.Google Scholar
  19. 19.
    Panjabi MM, Thibodeau LL, Crisco JJ 3rd, White AA 3rd. What constitutes spinal instability? Clin Neurosurg. 1988;34:313–339.PubMedGoogle Scholar
  20. 20.
    Payer M, Luzi M, Tessitore E. Posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. Acta Neurochir (Wien). 2009;151:223–229; discussion 229.CrossRefGoogle Scholar
  21. 21.
    Payer M, Sottas CC. Traumatic atlanto-occipital dislocation: presentation of a new posterior occipitoatlantoaxial fixation technique in an adult survivor: technical case report. Neurosurgery. 2005;56(Suppl):E203; discussion E203.PubMedCrossRefGoogle Scholar
  22. 22.
    Radcliff KE, Ben-Galim P, Dreiangel N, Martin SB, Reitman CA, Lin JN, Hipp JA. Comprehensive computed tomography assessment of the upper cervical anatomy: what is normal? Spine. 2010;10:219–229.CrossRefGoogle Scholar
  23. 23.
    Rao G, Arthur AS, Apfelbaum RI. Circumferential fracture of the skull base causing craniocervical dislocation. Case report. J Neurosurg. 2002;97(Suppl):118–122.PubMedGoogle Scholar
  24. 24.
    Rojas CA, Bertozzi JC, Martinez CR, Whitlow J. Reassessment of the craniocervical junction: normal values on CT. AJNR Am J Neuroradiol. 2007;28:1819–1823.PubMedCrossRefGoogle Scholar
  25. 25.
    Sim E, Vaccaro AR, Berzlanovich A, Schwarz N, Sim B. In vitro genesis of subaxial cervical unilateral facet dislocations through sequential soft tissue ablation. Spine. 2001;26:1317–1323.PubMedCrossRefGoogle Scholar
  26. 26.
    STROBE Guidelines. Available at: Accessed August 27, 2011.
  27. 27.
    Traynelis VC, Marano GD, Dunker RO, Kaufman HH. Traumatic atlanto-occipital dislocation. Case report. J Neurosurg. 1986;65:863–870.Google Scholar
  28. 28.
    Tubbs RS, Grabb P, Spooner A, Wilson W, Oakes WJ. The apical ligament: anatomy and functional significance. J Neurosurg. 2000;92(Suppl):197–200.PubMedGoogle Scholar
  29. 29.
    Werne S. Spontaneous atlas dislocation. Acta Orthop Scand. 1955;25:32–43.PubMedCrossRefGoogle Scholar
  30. 30.
    Werne S. Spontaneous dislocation of the atlas as a complication in rheumatoid arthritis. Acta Rheumatol Scand. 1956;2:101–107.PubMedGoogle Scholar
  31. 31.
    Werne S. Studies in spontaneous atlas dislocation. Acta Orthop Scand Suppl. 1957;23:1–150.PubMedGoogle Scholar
  32. 32.
    Werne S. The possibilities of movement in the craniovertebral joints. Acta Orthop Scand. 1959;28:165–173.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Kristen Radcliff
    • 1
    • 4
    Email author
  • Christopher Kepler
    • 1
  • Charles Reitman
    • 2
  • James Harrop
    • 3
  • Alexander Vaccaro
    • 1
  1. 1.Rothman InstituteThomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Department of Orthopedic SurgeryBaylor College of MedicineHoustonUSA
  3. 3.Department of NeurosurgeryThomas Jefferson UniversityPhiladelphiaUSA
  4. 4.Egg Harbor TownshipUSA

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