Assessment of the internal craniocervical ligaments with a new magnetic resonance imaging sequence: three-dimensional turbo spin echo with variable flip-angle distribution (SPACE)

Purpose Lesions close to the internal craniocervical ligaments are a common problem in patients with whiplash injuries. The aim of this study was to evaluate the morphology and visibility of these ligamentous structures with a new isotropic three-dimensional (3D) turbo-spin-echo (TSE) technique. Materials and Methods MR (MR) images of the cervical spine of 52 healthy subjects (27 women and 25 men; mean age=29 years; age range=18–40 years) were taken with a T2-weighted 3D TSE sequence with variable flip-angle distribution [SPACE (Sampling Perfection with Application optimized Contrasts using different flip-angle Evolution)] at 1.5 T (Magnetom Avanto, Siemens Erlangen, Germany). Two experienced musculoskeletal radiologists read the images independently on a 3D imaging and postprocessing workstation. The visibility and morphology of the alar ligaments were evaluated on a five-point scale, and inter-reader correlation was assessed with kappa statistics. Results Both alar ligaments were detected in all subjects. Twenty-eight (53.8%) of the alar ligaments could not be seen within one slice of the standard coronal imaging plane but could adequately be visualized in an oblique reconstruction adapted to the orientation of the ligaments on the axial slices. Inter-reader correlation for visibility on MR imaging (MRI) of the internal craniocervical ligaments was high (left+right side, kappa=0.95). Most (94%) alar ligaments presented symmetrically. In the axial plane, 60% were oriented neutral and 40% had a backward orientation. In the coronal plane, 67% were oriented caudocranially and 33% were oriented horizontally. The shape of the ligaments was parallel in half and was V-shaped in the other half. The alar ligaments had homogeneous low-signal intensity in 56% and heterogeneous low-signal intensity in 44%. The apical ligament of the dens was seen (excellent–good–moderate) in 61% (reader 1) and 52% (reader 2). The tectorial membranes and the transverse ligament of the atlas were shown (excellent–good) in all subjects. Conclusions MRI with acquisition of an isotropic SPACE technique allows high-resolution imaging of the craniocervical ligaments in all orientations. Reconstruction of the image data in the variable orientation of the alar ligaments allowed for excellent depiction within one slice such that partial volume artifacts that hamper image analysis can be eliminated.