Atlantoaxial Instability Treatment & Management

  • Author: Daxes Banit, MD; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: May 13, 2010
 

Medical Care

  • Unless symptoms of spinal cord compression occur, AAI requires no treatment. Once symptoms arise, cervical spine stabilization is indicated until surgical stabilization is performed.
  • In persons with rotatory displacement, the time of presentation dictates the treatment. Most of these patients' conditions resolve spontaneously, and additional care is not sought.
    • Patients presenting with subluxation of less than a week's duration are treated with a soft collar and rest for a week. If close follow-up fails to document reduction, a period of halter traction with analgesics and muscle relaxants is warranted. If this fails, halo bracing can be undertaken.
    • In patients with rotatory displacement for more than 1 month, a period of halo traction for 3 weeks is tried. Usually, 2 types of patients are in this group, those whose subluxation improves with bracing but recurs when bracing stops and those who usually present with a fixed deformity.
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Surgical Care

The treatment goals for persons with AAI are to protect the spinal cord, stabilize the spinal column, decompress neural tissue, and reduce any deformity.

In C1-2 subluxation or dislocation, an ADI of greater than 3 mm indicates injury to the transverse ligament. In most cases, the injury is purely ligamentous and unlikely to heal. Therefore, these injuries usually are treated with posterior C1-2 fusion. If the CT scan revealed a bony avulsion injury as the source of failure, a trial of halo bracing may be tried.

In individuals with rotatory dislocation, the treatment for traumatic injuries is a collar for type I injuries that are regarded as stable subluxations. Type II injuries may be potentially unstable. Type III and IV rotatory displacements that are unstable are treated surgically with a reduction and C1-2 fusion. The techniques of fusion vary from sublaminar wiring techniques like Brooks or Gallie, Halifax clamp, or transarticular screw of Magerl.[17, 18, 19, 20, 21, 5, 22, 23, 24] In situations of associated injuries, extending the fusion to the occiput may be required.

In rotatory displacement from nontraumatic causes, the pediatric population is most susceptible. In a patient with either a fixed deformity or recurrent deformity despite reduction in halo brace, a posterior C1-2 fusion is indicated.

  • Posterior cervical spinal fusion can successfully treat symptomatic AAI in many cases.[25, 26] Surgery has been demonstrated to be most successful for treating patients with ligamentous instability but has demonstrated less success in patients with osseous instability. Best results have been obtained in patients with severe pain and mild myelopathy. Thus, detecting symptoms early is preferable for most successful treatment.
  • It has been demonstrated that surgery is unlikely to reverse clinical symptoms when the spinal cord is compressed by more than 60%. However, surgery is not recommended for individuals without spinal cord involvement due to an unclear natural history of AAI.
  • In individuals with RA, the goals of surgery are to relieve neural compression, relieve pain, and address instability. Indications for surgery include AAS of greater than 8 mm with evidence of cord compression on dynamic flexion-extension view, PADI of 14 mm or less, more than 3.5 mm of subaxial subluxation, or progressive neurologic deficit.[27]
    • With atlantoaxial rotatory subluxation in patients with RA, treatment comprises gradual reduction in halo traction followed with an occiput to C2 fusion. The halo may be incorporated for postoperative bracing.
    • Usually, because of severe osteoporosis in patients with RA, multiple pins are used to improve fixation.
    • In addition, the nature of the subaxial cervical spine should be considered when planning the distal extent of the fusion.
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Consultations

  • Neurologist
  • Neurosurgeon
  • Orthopedic surgeon
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Activity

  • Before participation in sports, evaluations are recommended to detect neurologic involvement.
  • Spinal cord compression can arise or worsen if susceptible patients are subjected to extreme ranges of motion. Special care should be taken to avoid excessive flexion or extension of the neck.
  • Special Olympics, Inc., currently requires that all children with Down syndrome who compete in Special Olympics games have radiographic and neurologic examinations to exclude AAI. Individuals with AAI are restricted from participation in certain activities that may result in cervical spine injury. These include gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, soccer, and certain warm-up exercises.[28]
    • In 1983, the American Academy of Pediatrics Committee on Sports Medicine and Fitness issued a statement in agreement with the recommendations and requirements of the Special Olympics. However, a review of evidence in 1995 caused the committee to rescind their recommendations that all children with Down syndrome should be screened radiographically.[29]
    • Although no indication exists that children with asymptomatic AAI are at increased risk of subluxation or progression to symptomatic AAI or that routine screening by radiographs is necessary, recommendations vary.
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Contributor Information and Disclosures
Author

Daxes Banit, MD  Spine Fellow, Charlotte Orthopedic Specialists, PA

Daxes Banit, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Murrey, MD  Clinical Faculty, Department of Orthopedic Surgery, Carolinas Medical Center; Consulting Surgeon, Presbyterian Orthopedic Hospital; Co-President, OrthoCarolina

Daniel Murrey, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Physician Executives, American Medical Association, North American Spine Society, and North Carolina Medical Society

Disclosure: Nothing to disclose.

Bruce Darden II, MD  Director, Spine Surgery Fellowship, Charlotte Spine Center

Bruce Darden II, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, North American Spine Society, North Carolina Medical Society, Scoliosis Research Society, Southern Medical Association, and Southern Orthopaedic Association

Disclosure: Synthes Consulting fee Speaking and teaching; Synthes Grant/research funds Other; Synthes fellowship support Other; Stryker Royalty Other; Stryker Consulting fee Consulting; Orthovita Ownership interest Consulting

Specialty Editor Board

James F Kellam, MD  Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center

James F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

William O Shaffer, MD  Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association

Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; DePuySpine 2009 Consulting fee Design of Offset Modification of Expedium

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

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The transverse ligament holds the dens against the anterior arch of the atlas.
A midsagittal section of the upper cervical spine. Note the landmarks for measuring the anterior atlantodens interval and the posterior atlantodens interval.
The 4 types of atlantoaxial rotatory subluxation.
 
 
 
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