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. 2024 Apr 1;7(14):CASE23664.
doi: 10.3171/CASE23664. Print 2024 Apr 1.

Isolated unilateral alar ligamentous injury: illustrative cases

Benjamin C Reeves  1 , Marcus Valcarce-Aspegren  2 , Stephanie M Robert  1 , Aladine A Elsamadicy  1 , Alexander M Tucker  3 , Phillip B Storm  3 , Michael L DiLuna  1 , Adam J Kundishora  3
Affiliations

Isolated unilateral alar ligamentous injury: illustrative cases

Benjamin C Reeves et al. J Neurosurg Case Lessons. .

Abstract

Background: Isolated unilateral alar ligament injury (IUALI) is a rare and likely underreported occurrence after upper cervical trauma, with only 16 cases documented in the literature to date. Patients generally present with neck pain, and definitive diagnosis is typically made by magnetic resonance imaging (MRI). Unfortunately, likely due in part to its rarity, there are no formal guidelines for the treatment of an IUALI. Furthermore, there is a limited understanding of the long-term consequences associated with its inadequate treatment.

Observations: Here, the authors report on three pediatric patients, each found to have an IUALI after significant trauma. All patients presented with neck tenderness, and two of the three had associated pain-limited range of neck motion. Imaging revealed either a laterally deviated odontoid process on cervical radiographs and/or MRI evidence of ligamentous strain or discontinuity. Each patient was placed in a hard cervical collar for 1 to 2 months with excellent resolution of symptoms. A comprehensive review of the literature showed that all patients with IUALI who had undergone external immobilization with either rigid cervical collar or halo fixation had favorable outcomes at follow-up.

Lessons: For patients with IUALI, a moderate course of nonsurgical management with rigid external immobilization appears to be an adequate first-line treatment.

Keywords: alar ligament; craniocervical junction injury; pediatric; spine trauma.

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Conflict of interest statement

Disclosures Dr. Kundishora reported personal fees from BK Meditech outside the submitted work.

Figures

FIG. 1
FIG. 1
Case 1. Cervical radiograph (A) obtained on presentation, demonstrating lateral deviation of the odontoid process with no associated cervical spine fractures. Axial T2-weighted MRI (B), coronal STIR (C), and sagittal STIR (D) sequences obtained on the day of patient presentation, showing signal intensity within the left alar ligament (white arrows). Flexion (E) and extension (F) cervical radiographs obtained at the 1-month follow-up, demonstrating no signs of dynamic cervical instability.
FIG. 2
FIG. 2
Case 2. Axial (A) and coronal (B) T2-weighted MRI of the cervical spine performed on the day of presentation, with signal intensity observed within the left alar ligament and widening of the left LDAS (white arrows). Follow-up axial (C) and coronal (D) T2-weighted MRI performed 2 months later, demonstrating resolved signal intensity and medialization of the odontoid.
FIG. 3
FIG. 3
Case 3. Coronal STIR image of the cervical spine on the day of presentation (A), demonstrating signal intensity within the right alar ligament (white arrow). Follow-up odontoid (B), flexion (C), and extension (D) cervical radiographs without evidence of bony asymmetry or instability.
See this image and copyright information in PMC

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