Can atlanto-axial dislocation in a 2-month-old infant heal naturally and how long does it take for the cartilage and vertebrae to recover?

Atlanto-Axial Dislocation in a 2-Month-Old Infant: Natural Recovery and Healing Timeline

Atlanto-axial dislocation in a 2-month-old infant does NOT recover naturally and requires immediate medical intervention with immobilization and likely surgical stabilization to prevent permanent neurological damage or death. This is a potentially catastrophic injury that demands urgent orthopedic or neurosurgical evaluation 1, 2.

Critical Understanding of the Injury

Atlanto-axial dislocation in infants represents a severe disruption of the ligamentous structures between C1 and C2 vertebrae. Unlike simple subluxations that may reduce spontaneously, true dislocations indicate complete ligamentous failure and atlantoaxial instability 3, 4.

Why Natural Healing Does NOT Occur

• Ligamentous disruption is permanent: The transverse ligament and other supporting soft tissues, once torn or severely stretched, do not spontaneously heal to restore stability 2, 5
• Persistent instability remains: Even if torticollis or neck pain improves, the underlying atlantoaxial instability persists without intervention 4
• Progressive deformity develops: Untreated cases lead to fixed rotatory deformity and potential spinal cord compression 3, 4

Immediate Management Algorithm

Step 1: Emergency Stabilization

• Immediate cervical immobilization is mandatory upon diagnosis 2, 5
• Prompt intubation may be necessary if neurological compromise is present 2
• Consider intravenous steroids in the emergency setting, as this appears to facilitate survival in traumatic cases 2

Step 2: Diagnostic Confirmation

• MRI is the preferred imaging modality when spinal cord involvement or ligamentous injury is suspected 1
• Three-dimensional CT can establish the diagnosis and classify the dislocation type 3, 5
• Plain radiographs have significant limitations in 2-month-old infants due to incomplete ossification and normal variants 1

Step 3: Treatment Decision

For reducible dislocations with early presentation (within 1-2 weeks):

• Cervical immobilization with appropriate orthosis 3
• Intensive physiotherapy under close monitoring 3
• Serial imaging to confirm maintained reduction 3

For irreducible dislocations or those presenting after 6 weeks:

• Surgical intervention is required 3, 4
• Posterior occipitocervical fusion (occiput to C2) is the definitive treatment 2, 5
• In infants, specialized techniques using occipital keel, C2 pedicle screws, and sublaminar fixation may be necessary 6

Healing Timeline (With Appropriate Treatment)

Conservative Management Success (Rare in True Dislocations)

• Only applicable if diagnosed within 1-2 weeks and the dislocation is reducible 3
• Immobilization period: typically 6-12 weeks with serial monitoring 3
• Success rate is low for true dislocations; most require surgery 4

Surgical Fusion Timeline

• Bony fusion occurs in 4-6 months postoperatively in pediatric patients 5, 6
• Solid fusion is achieved in approximately 97% of cases with appropriate surgical technique 4
• Early stabilization (within weeks of injury) provides the best neurological outcomes 2, 5

Critical Pitfalls to Avoid

Do not assume spontaneous resolution: Unlike developmental hip dysplasia where 60-80% of abnormalities resolve spontaneously 7, atlanto-axial dislocation does NOT self-correct 3, 4.

Do not delay referral: Every day of delay increases the risk of:

• Fixed rotatory deformity requiring more extensive surgery 4
• Progressive neurological deterioration 2, 5
• Permanent spinal cord injury 2

Do not rely on clinical improvement alone: Torticollis or neck pain may improve while underlying instability persists, leading to false reassurance 4.

Consider non-accidental trauma: In any infant under 5 years with cervical spine trauma, child abuse must be considered as a possible etiology 1.

Prognosis and Long-Term Outcomes

• With early surgical intervention: Most patients achieve solid fusion and functional outcomes, though neurological impairment may persist in up to 50% of cases with associated spinal cord injury 5
• Without treatment: Progressive deformity, chronic pain, and risk of catastrophic neurological injury or death 3, 4
• Postoperative complications: Hydrocephalus is the most common complication, occurring in approximately 29% of cases 5

The bottom line: A 2-month-old infant with atlanto-axial dislocation requires immediate orthopedic or neurosurgical consultation, as this injury will not heal naturally and delays in treatment significantly worsen outcomes 3, 2, 5.