In vitro upper cervical spine kinematics: Rotation with combined movements and its variation after alar ligament transection.

Previous studies indicate that maximum upper cervical axial rotation occurs only through a combination of transverse, frontal, and sagittal plane motions. This study explores the relationship between transection of the alar ligament and combined upper cervical axial rotation movements. Ten cryopreserved upper cervical spines were manually mobilized in bilateral axial rotation and two different motion combinations with simultaneous motion in the three anatomical planes: rotation in extension (extension + axial rotation + contralateral lateral bending) and rotation in flexion (flexion + axial rotation + ipsilateral lateral bending). These three motions were performed before and after right alar ligament transection. The occiput-axis axial rotation was measured using an optical motion capture system while measuring the applied load. With intact alar ligament, the axial rotation in flexion showed the lowest range of motion (right, R: 9.81 ± 3.89°; left, L: 15.54 ± 5.89°). Similar results were found between the other two mobilizations: axial rotation (R: 33.87 ± 6.64°; L: 27.99 ± 6.90°) and rotation in extension (R: 35.15 ± 5.97°; L: 28.96 ± 6.47°). After right alar ligament transection, rotation in flexion (particularly in left rotation) showed the largest increase in motion: rotation in flexion (R: 13.78 ± 9.63°; L: 23.04 ± 5.59°), rotation in extension (R: 36.39 ± 7.10°; L: 31.71 ± 7.67°), and axial rotation (R: 38.50 ± 9.47°; L: 31.59 ± 6.55°). Different combinations of movements should be evaluated when analyzing the maximum axial rotation of the upper cervical spine, as axial rotation alone and rotation in extension showed a larger range of motion than rotation in flexion. After unilateral alar ligament injury, rotation to the non-injured side in flexion demonstrates the most movement increase.