A geometrical model of vertical translation and alar ligament tension in atlanto-axial rotation

Abstract

Introduction: While allowing the greatest range of axial rotation of the entire spine with 40° to each side, gradual restraint at the extremes of motion by the alar ligaments is of vital importance. In order for the ligaments to facilitate a gradual transition from the neutral to the elastic zone, a complex interaction of axial rotation and vertical translation via the biconvex articular surfaces is essential. The aim of this investigation is to establish a geometrical model of the intricate interaction of the alar ligaments and vertical translatory motion of C1/C2 in axial rotation.

Methods: Bilateral alar ligaments including the odontoid process and condylar bony entheses were removed from six adult cadavers aged 65-89 years within 48 h of death. All specimens were judged to be free of abnormalities with the exception of non-specific degenerative changes. Dimensions of the odontoid process and alar ligaments were measured. Graphical multiplanar reconstruction of atlanto-axial rotation was done in the transverse and frontal planes for the neutral position and for rotation to 40° with vertical translation of 3 mm. The necessary fibre elongation of the alar ligaments in the setting with and without vertical translation of the atlas was calculated.

Results: The mean diameter of the odontoid process in the sagittal plane was 10.6 mm (SD 1.1). The longest fibre length was measured from the posterior border of the odontoid enthesis to the posterior border of the condylar enthesis with an average of 13.2 mm (SD 2.5) and the shortest between the lateral (anterior) border odontoid enthesis and the anterior condylar enthesis with an average of 8.2 mm (SD 2.2). In graphical multiplanar reconstruction of atlanto-axial rotation to 40° without vertical translation of C1/C2, theoretical alar fibre elongation reaches 27.1% for the longest fibres, which is incompatible with the collagenous structure of the alar ligaments. Allowing 3 mm caudal translation of C1 on C2 at 40° rotation, as facilitated by the biconvex atlanto-axial joints, reduces alar fibre elongation to 23.3%.

Conclusion: The biconvex configuration of the atlanto-axial joints is an integral feature of the functionality of upper cervical spine as it allows gradual vertical translation of the atlas against the axis during axial rotation, with gradual tensing of the alar ligaments. Vertical translation on its own, however, does not explain the tolerance of the alar ligaments towards the maximum of 40° of rotation and is most likely synergistic with the effects of the coupled motion of occipitocervical extension during rotation.

Fig. 1

Sagittal section through the atlanto-axial joint revealing the biconvex joint surfaces as demonstrated by Putz and Pomaroli [19]. a Inferior articular surface of atlas. b Articular surface of axis

Fig. 2

Graphical multiplanar reconstruction of axial C0–C2 rotation. Upper image schematic representation of the craniocervical junction in the transverse plane. The neutral position at 0° rotation is superimposed by the position at 40° axial rotation. The right alar ligament shows the position of the alar fibres in the neutral position. The left side of the illustration shows the tensed left alar ligament fibres in the 40° rotated position. The typical fibrocartilage distribution FC is shaded into the right alar ligament. Lower right image Metrically reconstructed frontal of the craniocervical junction in the neutral position in a view from posterior. Lower left image Metrically reconstructed view of the craniocervical junction at 40° axial rotation. The PF crosses the midline of the OP in rotation. The fibre lengths are measured in this position (values depicted above the CE for AF, MF and PF). All fibres are then “dropped” at the CE by 3 mm, simulating vertical translatory motion (not shown). The length of the fibres is redetermined in this position. OP odontoid process, CE condylar enthesis, OE odontoid enthesis, AF anterior fibre, MF midregion fibre, PF posterior fibre, FC fibrocartilage