What is the treatment for rotary subluxation of C1/C2 (cervical spine)?

Treatment of Rotary Subluxation of C1/C2

For acute traumatic C1-C2 rotatory subluxation, attempt closed reduction with cervical traction within 24 hours of injury; if this fails due to locked facets or if the subluxation is chronic (>1 month), proceed to surgical open reduction and C1-C2 fusion. 1, 2

Initial Management Algorithm

Acute Cases (<1 week from injury)

• Immediate cervical immobilization is essential to prevent neurological deterioration, though avoid prolonged rigid collar use as this can worsen outcomes 3

• Attempt closed reduction with cervical traction as the first-line treatment within 24 hours of presentation 1, 4

  • Skull traction with gradual derotation should be applied 4
  • Success rates are highest when attempted early (within days of injury) 2
  • If reduction is successful, maintain with halo vest fixation for 3 months 4

• Proceed directly to surgery if:

  • Closed reduction fails within 24 hours (indicates locked facet) 1
  • Neurological deficits are present 3
  • Associated unstable fractures exist (dens fracture, C2 facet fractures) 4

Chronic Cases (>1 month duration)

• For chronic irreducible subluxation with C2 facet deformity on 3D CT, attempt "remodeling therapy" before considering fusion 5

  • This involves careful closed manipulation followed by halo fixation 5
  • The C2 facet deformity sign on 3D CT is the key clinical index for this approach 5
  • Follow-up imaging at 2-3 months should demonstrate remodeling of the facet deformity 5
  • This preserved cervical rotation in 12/12 pediatric patients with chronic subluxation at 42-month follow-up 5

• If remodeling therapy fails or osseous fusion has occurred, proceed to surgical C1-C2 fusion 5

Surgical Approach

When surgery is indicated, perform open reduction and internal fixation using the Harms technique (C1-C2 lateral mass screws with rod fixation) 1

• This is the standard approach for irreducible cases with locked facets 1
• Surgical management successfully restored cervical mobility and resolved torticollis in adult traumatic cases 1

Critical Imaging Requirements

• Obtain 3D CT reconstruction to identify C2 facet deformity, which is a risk factor for recurrent subluxation 5
• MRI is indicated when neurological deficits are present or spinal cord compression is suspected 3
• Plain radiographs alone are insufficient for complete evaluation, missing up to 15% of injuries 6

Special Considerations

Inflammatory Arthritis (ERA) Cases

• Non-surgical management with cervical collar protection is preferred for enthesitis-related arthritis patients with sacroiliitis 7
• Cervical halter traction may be applied only after severe cervical inflammation is excluded 7
• Control underlying inflammation with NSAIDs and disease-modifying therapy 7

Key Pitfall to Avoid

The time between injury and reduction is the single most important prognostic factor 2. Delayed diagnosis leads to poor outcomes because:

• Chronic cases (>1 month) develop facet deformities that prevent simple reduction 5
• Many adult cases are not related to clear trauma, leading to diagnostic delays 2
• Early recognition within days allows successful closed reduction in most cases 4