From the Guidelines
The treatment of atlantoaxial subluxation should prioritize posterior C1-C2 fusion for moderate to severe cases with neurological symptoms or instability, as it provides the most effective stabilization of the joint and minimizes the risk of secondary spinal cord injury 1.
Overview of Atlantoaxial Subluxation Treatment
The management of atlantoaxial subluxation is multifaceted and depends on the severity of the subluxation, the presence of neurological symptoms, and the underlying cause. For mild cases without neurological deficits, conservative management may be sufficient, but for more severe cases, surgical intervention is often necessary to prevent long-term neurological damage.
Conservative Management
Conservative management includes the use of a cervical collar for immobilization, although the evidence suggests that rigid or semi-rigid collars may not be effective in limiting cervical spinal movement and could potentially increase the risk of difficult tracheal intubation 1. Pain management with NSAIDs (such as ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) and muscle relaxants like cyclobenzaprine (5-10mg three times daily) for 1-2 weeks can help alleviate symptoms. Physical therapy focusing on gentle neck strengthening exercises should be initiated once acute pain subsides.
Surgical Intervention
For moderate to severe cases with neurological symptoms or instability, posterior C1-C2 fusion is the recommended surgical approach. This procedure stabilizes the joint using screws, rods, and bone grafts, providing the most effective means of preventing further subluxation and minimizing the risk of secondary spinal cord injury. In cases of rheumatoid arthritis-related subluxation, disease-modifying antirheumatic drugs should be optimized as part of the treatment plan.
Airway Management Considerations
When airway management is required, videolaryngoscopy is preferred over direct laryngoscopy due to its superiority in minimizing cervical spine movement and reducing the risk of secondary spinal cord injury 1. The use of manual in-line stabilization (MILS) during tracheal intubation is not recommended as it may worsen glottic view and has limited evidence supporting its efficacy in reducing the risk of secondary spinal cord injury 1.
Post-Surgical Care
Post-surgery, patients require 6-12 weeks of restricted neck movement and regular follow-up imaging to assess fusion. Prompt treatment is essential as untreated severe atlantoaxial subluxation can lead to spinal cord compression, resulting in permanent neurological damage or even death. The decision between conservative and surgical management should be made by a spine specialist after thorough clinical and radiological evaluation.