Stabilizing Ligaments | Upper Cervical Spine | Occiput-C2

What is the Atlanto-Occipital Joint?

The atlanto-occipital joint (O-C1) is formed by the occipital condyles and the upper articular facets of C1. These paired joints each look like a saddle and both are stabilized by multiple ligaments and the articular capsules of O-C1.

The O-C1 joint is responsible for the most flexion/extension of any vertebral segment with 25 degrees of motion. There is a small amount of rotation (5 degrees) that also occurs here.

The basion is the front edge of the foramen magnum and the opisthion is the rear edge, important bony contact points for the stabilizing ligaments of this joint.

The stability of the atlanto-occipital joint stems from multiple structures. The aforementioned joint capsules of the O-C1 joint create substantial stability. The other ligaments are noted here from front to back.

How the Atlanto-Occipital Helps with Neck Stabilization

The anterior atlanto-occipital membrane (a continuation of the anterior longitudinal ligament) attaches from the anterior arch of the atlas to the anterior aspect of the basion (the front of the foramen magnum). This ligament works to prevent excessive neck extension.

The twin alar ligaments attach from the lateral aspect of the odontoid process (dens of C2) to the medial occipital condyles on either side. These ligaments limit flexion and rotation at the atlanto-occipital joint.

The apical ligament attaches from the tip of the odontoid process (C2) to the basion. It is sandwiched between the alar ligaments and the cruciate ligament complex. This ligament is not significant and does not contribute to the stability of O-C1.

The cruciate ligament complex is just posterior to the odontoid process originating from the back of the dens. The whole ligament complex looks like a cross (cruciate). The superior band stabilizes the odontoid to the basion. The transverse band (better know as the transverse ligament) is the strongest portion of the cruciate ligament complex and loops around the odontoid, attaching to the lateral masses of the atlas. This ligament is the most important stabilizer of C1-2. The inferior band is a continuation of the superior band and connects to the body of C2.

The tectorial membrane is an extension of the posterior longitudinal ligament and lies posterior to the cruciate ligament complex. This ligament attaches from the dens to the anterior foramen magnum. Due to its position, this ligament limits both excessive flexion and extension.

Jumping to the back of the spinal canal, the posterior atlanto-occipital membrane attaches from the occipital bone to the posterior arch of the atlas. It is a continuation of the ligamentum flavum and a homolog of the anterior occipital membrane.

The ligamentum nuchae is a continuation of the supraspinous ligament and spans from the posterior occiput to the spinous process of C1. This ligament serves to limit excessive neck flexion.

Related Links

(Click to Enlarge) Alar ligaments attach from the odontoid to the condyles of the skull. Large arrow odontoid, small arrows alar ligaments.

(Click to Enlarge) Tectorial membrane arrow points to membrane continulation of PLL.

(Click to Enlarge) Transverse ligament top down of odontoid. Large arrow and ligament small arrows.

Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Stabilizing Ligaments of the Upper Cervical Spine (Occiput-C2)

What is the Atlanto-Occipital Joint?

How the Atlanto-Occipital Helps with Neck Stabilization

Related Links

About the Author: Donald Corenman, MD, DC

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