Objective Indirect Assessment of Transverse Ligament Competence Using Quantitative Analysis of 3-Dimensional Segmented Flexion-Extension Computed Tomography Scan

Objective: Assessment of transverse ligament (TL) competence in patients with suspected atlantoaxial instability is performed via indirect radiograph measurements or direct TL visualization on magnetic resonance imaging (MRI). Interpretation of these images can be limited by unique patient anatomy or imaging technique variability. We report a novel technique for evaluating TL competence using flexion-extension computed tomography (feCT) scan with 3-dimensional (3D) segmentation and quantitative analysis.

Methods: feCT scans of 11 patients were segmented to create 3D surface models. Six patients with atlantoaxial pathology were evaluated for possible instability based on clinical examination and imaging findings. The other 5 patients had no clinical or imaging evidence of atlantoaxial injury. Dynamic atlantodental interval (ADI) was calculated using point-to-point voxel changes between flexion and extension 3D models. Magnitude and direction of ADI changes were quantified and compared with available cervical spine flexion-extension radiograph and/or MRI findings.

Results: In the 5 patients without evidence of atlantoaxial injury, 94.3% of ADI vector changes were <3.0 mm. In the 3 patients with atlantoaxial pathology but TL competence, 92.4% of ADI vector changes were <3.0 mm. In the 3 patients with atlantoaxial pathology and TL incompetence, only 49.1% of ADI vector changes were <3.0 mm. In addition to the significant atlantoaxial subluxation in these 3 patients, there was significant rotational motion compared with the patients with an intact TL.

Conclusions: 3D segmentation and quantitative analysis of feCT scan allow objective indirect assessment of TL integrity. Results are consistent with MRI findings and offer additional biomechanical information regarding the direction and distribution of atlantoaxial motion.