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Atlanto-axial Injury

Case Detail

Anatomy: Brain-Spine
Joseph Junewick, MD FACR
Diagnostic Category: Trauma
Created: over 11 years ago
Updated: over 10 years ago
Tags: PEDS
Modality/Study Types: CT MR
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6 year old restrained rear seated passenger involved in a motor vehicle accident with front-end damage complaining of suboccipital pain. No cervical spine tenderness or neurological deficit.

Case Images


Atlanto-axial Injury


CT – Axial and sagittal and coronal reformatted images demonstrate widened predental space (anterior atlantodental interval) with rotary subluxation of C1 and C2 (note the asymmetry of the lateral masses of C1 relative to C2) and avulsion fracture of the anterior tubercle of C1.

MR – Perfomed 2 days after initial injury. Sagittal T1, FSE2 and IR and axial FSE2 images of the cervical spine demonstrate precervical and suboccipital edema, synovial fluid in the predental joint, posterior translation of the dens, and disruption of the apico-clival ligament with hemorrhage.


The atlantodental interval is largely maintained the transverse atlantal ligament which extends along the posterior aspect of the dens from one lateral mass of C1 to the other. Ligaments of lesser importance include the alar, apical, and cruciform.

Injury of the transverse atlantal ligament is rare, usually associated with a Jefferson fracture or C1 lateral mass fracture, resulting in “rotary dissociation”. The mechanism of injury is unclear but likely related to a combination of several forces (rotation, flexion, lateral tilt and axial loading).

Fracture of the anterior arch of C1 is related to hyperextension of the spine with avulsion by the longus colli muscles.

This type of injury is painful and occasionally associated with fixed torticollis but not necessarily with neurologic deficit.


Harris JH and Mirvis SE. The Radiology of Acute Cervical Spine Trauma, 3rd Edition (1996).

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