"Split atlas" in a trauma and nontrauma patient: two different case reports for a rare congenital malformation

Congenital atlas abnormalities are rare and often asymptomatic findings, accidentally detected in trauma and, more rarely, in nontrauma patients. Rachischisis in both anterior and posterior atlas arches, condition defined as ''split atlas," is extremely uncommon and it may well be confused with fracture. Being able to discriminate between these 2 conditions is an essential step in patient care management. In this article, we report 2 cases of split atlas ascertained in both trauma and nontrauma patients. The first concerning a 54-year-old man fell from a 2 m scaffold, and the second related to a 25-year-old woman suffering from treatment-resistant headaches. Subsequently we proceed to analyse the embryology of these abnormalities, and later to discuss pitfalls, tips and tricks useful to a correct diagnosis, in order to achieve an accurate management of split atlas. Specifically, we outline the crucial radiological features to identify, that are beneficial to an efficient differential diagnosis between congenital atlas abnormalities and fracture. These include smooth corticated margins of the cleft, and <3 mm lateral displacement of C1 lateral masses.