From the Guidelines
Treatment for upper cervical instability should prioritize a conservative approach, focusing on physical therapy to strengthen neck muscles and temporary immobilization with a cervical collar, while avoiding the routine use of manual in-line stabilization (MILS) during tracheal intubation due to its potential to worsen glottic views and lack of evidence in reducing secondary spinal cord injury 1.
When managing upper cervical instability, it's crucial to consider the potential risks and benefits of different interventions. The use of MILS has been called into question due to its potential to increase the difficulty of tracheal intubation and its limited effectiveness in preventing cervical vertebral movement in the presence of a cervical spine injury 1.
Key considerations in the treatment of upper cervical instability include:
- Physical therapy to strengthen deep cervical flexors and extensors
- Temporary immobilization with a cervical collar, which may be removed during tracheal intubation attempts to minimize movement to the cervical spine 1
- Pain management using NSAIDs, such as ibuprofen or naproxen, and muscle relaxants like cyclobenzaprine for associated muscle spasms
- Activity modification to avoid high-impact activities and positions that exacerbate symptoms
Surgical stabilization through fusion procedures like C1-C2 arthrodesis may be necessary in cases where conservative measures fail or in the presence of neurological deficits or severe instability 1. The primary goal of treatment is to prevent further instability, maintain normal neck function, and minimize the risk of spinal cord compression.
In terms of specific interventions, the removal of the anterior part of a semi-rigid or rigid cervical collar during tracheal intubation attempts can help minimize cervical spine movement 1. Additionally, the use of videolaryngoscopes, such as the Airway Scope, may be beneficial in improving first-pass success rates during tracheal intubation in the presence of cervical spinal immobilization 1.
From the Research
Treatment for Upper Cervical Instability
The treatment for upper cervical instability can vary depending on the cause and severity of the condition. Some of the treatment options include:
- Conservative treatment with a collar or Halo-Vest 2
- Surgical treatment, such as screw fixation, anterior fixation using plates and screws, or posterior fixation using metal wire or wire with bone graft 2
- Physical therapy and bracing 3
- Preoperative 3D CT reconstruction to improve surgical outcomes 3
Surgical Indications
Surgical treatment is often indicated in cases of upper cervical instability, particularly when there is a high risk of spinal cord compression or neurological compromise. The decision to operate is typically based on the severity of the instability and the presence of symptoms such as pain, numbness, or weakness 2.
Diagnostic Criteria
The diagnosis of upper cervical instability is often made based on a combination of clinical evaluation, radiographic imaging, and functional testing. Some of the diagnostic criteria used to evaluate upper cervical instability include:
- Translation, vertical distraction, angulation, rotation, and obliquity of fracture line 4
- Comminution and ligamentous disruption 4
- Integrity of crucial ligaments, such as the transverse ligament and anterior longitudinal ligament 4, 5
Non-Surgical Management
Non-surgical management of upper cervical instability may include physical therapy, bracing, and pain management. This approach is often used in cases where the instability is mild or asymptomatic 3. However, there is limited evidence on the effectiveness of conservative treatment for upper cervical instability, and more research is needed to determine the best course of treatment 3.