The transverse ligament of the atlas is the strong horizontal band of the cruciform ligament, connecting the medial aspect of the two lateral masses of C1 behind the dens. It is the strongest ligament of the craniovertebral junction and the primary restraint against atlantoaxial subluxation.
Holds the dens firmly against the anterior arch of C1, preventing posterior displacement of the dens into the spinal cord. The normal atlantodental interval (ADI) of less than 3mm in adults reflects intact transverse ligament function.
Rupture of the transverse ligament produces atlantoaxial instability — the ADI exceeds 3mm on flexion radiographs. Causes include high-energy trauma, rheumatoid arthritis pannus eroding the ligament, Down syndrome ligamentous laxity, and os odontoideum. Surgical stabilisation by C1-C2 fusion (Goel-Harms or Brooks-Jenkins technique) is required for symptomatic instability.
Complete transverse ligament failure producing ADI >3mm, dynamic cord compression risk, and required surgical C1-C2 fusion.
Inflammatory pannus from rheumatoid arthritis destroying the transverse ligament producing atlantoaxial instability and risk of sudden neurological deterioration.
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