Atlantoaxial Instability (Atlantoaxial Subluxation) Treatment & Management

Updated: May 21, 2021
  • Author: Chris G Koutures, MD, FAAP; Chief Editor: Craig C Young, MD  more...
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Treatment

Acute Phase

Rehabilitation program

Physical therapy

If asymptomatic AAI is detected on screening evaluation of an individual without recent trauma or inflammation, physical therapy may help in teaching patients proper head control and avoidance of extremes of motion or at-risk activities.

Medical issues/complications

The initial management of either traumatic or inflammation-induced AAI depends on the presence and progression of the patient's neurologic symptoms. An experienced neurosurgeon or spinal surgeon should be consulted in most, if not all, cases.

  • Posterior fusion of the upper cervical spine with central cord decompression is indicated in any unstable atlantoaxial joint or in the presence of significant myelopathy. [11] The patient should remain strictly immobilized while awaiting expedient surgical referral and procedures. Surgery is immediately indicated only in cases of irreducible canal compromise or progressive neurologic deterioration. Otherwise, it can be scheduled on a less-emergent basis.Posterior fusion of the upper cervical spine may also be indicated in cases of os odontoideum (nonunion of a previous odontoid fracture) or other forms of odontoid aplasia or hypoplasia.A study by Claybrooks et al reviewed 2 techniques for atlantoaxial fusion. The authors reported that "C1 lateral mass to C2 pedicle (C1LM-C2P) fixation is equivalent to C1 lateral mass to C2 laminar (C1LM-C2L) fixation in flexion/extension and AP translation and superior in lateral bending and axial rotation." [12]

  • Cases of inflammation-related subluxation may require reduction under general anesthesia with subsequent cast fixation or traction under the guidance of an experienced spinal surgeon.

  • Traumatic or inflammation-induced acute AAI that involves stable lesions without any neurologic symptoms may be reduced. The patients may be placed in a halo brace with vest reduction and immobilization for 3 months. [13] Repeat radiographs are necessary after the reduction has been completed; several sources warn that deformity may still be possible, even after reduction.

  • In children with confirmed radiographic evidence of transverse ligament disruption less than 3 weeks old, the likelihood of ligamentous healing increases with halo brace and vest management.

  • In adults, healing of the transverse and alar ligaments is unreliable. Therefore, some authorities do not consider nonoperative management in adults, whereas others favor nonoperative management because of the risk of common surgical complications, the often-incomplete resolution of neurologic symptoms, and the lack of long-term data supporting surgical management.

Surgical intervention

Posterior fusion of asymptomatic individuals with AAI, such as patients with Down syndrome, remains controversial. Although some authorities advocate fusion to reduce the risk of a catastrophic trauma to the spine, others do not recommend fusion if the patient remains asymptomatic.

It is important to note that the incidence of serious cervical spine injury is not increased in patients with Down syndrome and AAI, as compared with other athletic populations. Posterior fusion of the upper cervical spine is mainly indicated in symptomatic individuals.

Consultations

A spinal surgeon or neurosurgeon should be consulted in all cases of acute AAI. In cases of asymptomatic AAI found on screening examination, referral is indicated to confirm the diagnosis and to evaluate possible activity restrictions.

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Recovery Phase

Rehabilitation program

Physical therapy

After prolonged patient immobilization, physical therapy can increase the cervical range of motion and assist the patient in regaining strength deficits due to immobilization. An experienced therapist can also emphasize the need to avoid at-risk activities and extremes of cervical flexion and/or extension.

Surgical intervention

Posterior cervical fusion is indicated in patients who present with a deformity that has been present for longer than 3 months or who present with recurrence after 6 weeks of immobilization. Such fusion can also be considered in the patient with chronic AAI who develops acute symptoms or neurologic compromise.

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Complications

A study examined in-hospital mortality and postoperative major complications in patients undergoing fusion surgery for atlantoaxial subluxation (AAS) and to examine whether the risk of perioperative complications varies between patients with and without rheumatoid arthritis (RA). The study reported that the in-hospital mortality after fusion surgery for AAS was relatively low. However, patients with RA had an increased risk of postoperative complications and massive blood transfusion compared with patients without RA. [14]

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