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Neurosurgery. 2018 Feb 1;82(2):226-231. doi: 10.1093/neuros/nyx194.

C1 Lateral Mass Displacement and Transverse Atlantal Ligament Failure in Jefferson's Fracture: A Biomechanical Study of the "Rule of Spence".

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Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California.
Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California.
Department of Epidemiology and Biostatistics, Loma Linda University, School of Public Health, Loma Linda, California.



Jefferson's fracture, first described in 1927, represents a bursting fracture of the C1 ring with lateral displacement of the lateral masses. It has been determined that if the total lateral mass displacement (LMD) exceeds 6.9 mm, there is high likelihood of transverse atlantal ligament (TAL) rupture, and if LMD is less than 5.7 mm TAL injury is unlikely. Several recent radiographic studies have questioned the accuracy and validity of the "rule of Spence" and it lacks biomechanical support.


To determine the amount of LMD necessary for TAL failure using modern biomechanical techniques.


Using a universal material testing machine, cadaveric TALs were stretched laterally until failure. A high-resolution, high-speed camera was utilized to measure the displacement of the lateral masses upon TAL failure.


Eleven cadaveric specimens were tested (n = 11). The average LMD upon TAL failure was 3.2 mm (±1.2 mm). The average force required to cause failure of the TAL was 242 N (±82 N). From our data analysis, if LMD exceeds 3.8 mm, there is high probability of TAL failure.


Our findings suggest that although the rule of Spence is a conceptually valid measure of TAL integrity, TAL failure occurs at a significantly lower value than previously reported (P < .001). Based on our literature review and findings, LMD is not a reliable independent indicator for TAL failure and should be used as an adjunctive tool to magnetic resonance imaging rather an absolute rule.


Atlantoaxial instability; Atlas fracture; C1 fracture; Jefferson's fracture; Lateral mass overhang; Rule of Spence; Transverse atlantal ligament


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