The alar ligaments are paired, stout fibrous bands running from the lateral dens to the medial surfaces of the occipital condyles, with some fibres reaching the C1 lateral masses. They are the primary restraints against excessive cranial rotation and lateral bending.
Limit axial rotation of the head to approximately 8 degrees to each side before engaging (beyond the transverse ligament's role). The right alar ligament primarily limits left rotation and vice versa. Also restrain excessive lateral bending.
Alar ligament injury in whiplash produces craniovertebral instability symptoms — upper cervical pain, headache, and neurological symptoms. MRI demonstrates alar ligament signal changes and thickening in acute injury. Surgical craniovertebral stabilisation is reserved for confirmed instability with neurological compromise.
Partial or complete alar ligament disruption in high-energy whiplash producing craniovertebral instability symptoms, assessed by MRI and treated conservatively in most cases.
Clinical examination technique — ipsilateral side bending during anterior atlas stabilisation reveals alar ligament laxity by allowing excess ipsilateral C0-C1 bending.
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