What is the management of C1/C2 rotational subluxation?

Management of C1/C2 Rotational Subluxation

The management of C1/C2 rotational subluxation depends critically on timing: acute cases (≤1 week) should undergo immediate closed reduction with skull traction followed by immobilization, while chronic cases (>1 month) typically require surgical fusion, with the intermediate period (1-4 weeks) representing a critical window where closed reduction may still succeed but becomes progressively less likely. 1

Initial Assessment and Imaging

Diagnosis requires CT imaging with three-dimensional reconstruction to clearly demonstrate the rotatory displacement and identify associated fractures. 2

• Begin with three-view cervical spine radiographs (AP, lateral, and odontoid views), though these have only 54.3% sensitivity for cervical injuries 3
• Plain radiographs may show disruption of the spinolaminar line at C1-2, bony overlapping of the lateral joint, and soft tissue swelling 2
• CT with sagittal and 3D reconstruction is essential and provides definitive diagnosis, with the combination of plain films and thin-cut CT having a false negative rate of less than 0.1% 3
• MRI should be obtained when neurological deficits are present, spinal cord compression is suspected, or to evaluate the posterior ligamentous complex 3
• CT angiography should be considered if vertebral artery injury is suspected, particularly with fractures involving the transverse foramen or C1-C3 fractures 3

Treatment Algorithm Based on Chronicity

Acute Subluxation (≤1 Week)

Closed reduction with skull traction and derotation should be attempted first to preserve C1-2 motion. 2

• Apply skull traction with gradual weight increase (typically starting at 5-10 pounds and increasing cautiously) 2
• Perform derotation maneuvers under fluoroscopic guidance 2
• If closed reduction is successful, immobilize with halo vest fixation for 3 months 2
• Monitor closely for neurological changes during reduction attempts 2

Subacute Subluxation (1-4 Weeks)

Attempt closed reduction, but have a lower threshold for proceeding to surgical intervention if reduction fails or is incomplete. 1

• Cervical halter traction may be applied after severe cervical inflammation is excluded 4
• If closed reduction fails after reasonable attempts, proceed to surgical fusion 1

Chronic Subluxation (>1 Month) or Failed Closed Reduction

Surgical fusion is required, with the specific technique depending on the ability to achieve reduction and anatomical constraints. 5, 6

Primary Surgical Approach: Posterior C1-C2 Fusion with Reduction

• C1 lateral mass screws combined with C2 translaminar screws or pedicle screws allow for instrumented reduction and fusion 5
• Apply small amount of distraction through the screw construct to open the C1-C2 articulation 5
• Perform open reduction of the rotatory subluxation 5
• This technique preserves some motion below C2 compared to occipitocervical fusion 5

Alternative Surgical Approach: When C1 Fixation is Impossible

If C1 lateral mass screw placement is not feasible (degenerative changes, revision setting, or anatomical constraints), use occipital and C2/C3 fixation for instrumented reduction. 6

• This technique sacrifices more motion but remains viable when C1 fixation is impossible 6
• Particularly useful in rheumatoid arthritis patients or revision settings 6

Special Considerations

Associated Fractures

When C1-C2 rotatory subluxation occurs with dens fractures or C2 articular facet fractures, closed reduction should still be attempted first. 2

• Even complex injuries with type III dens fractures and bilateral C2 articular facet fractures can be successfully managed with closed reduction and halo vest immobilization 2
• Successful closed reduction preserves C1-2 motion and avoids surgical morbidity 2

Inflammatory Arthropathies (ERA, Rheumatoid Arthritis)

Cervical spine protection and ruling out spinal cord compression should be prioritized, in addition to controlling underlying inflammation. 4

• All patients require NSAIDs for inflammation control 4
• Cervical collar protection is essential, particularly in patients with sacroiliitis 4
• Despite cervical collar use, some patients develop persistent ankylosis and may require surgical fusion 4
• Early recognition is critical to reduce complications 4

Critical Pitfalls to Avoid

• Do not delay diagnosis: Low incidence in adults leads to missed or delayed diagnosis with worse outcomes 1
• Do not apply cervical halter traction without first excluding severe cervical inflammation 4
• Do not assume neurologically intact patients have stable injuries: Careful radiological assessment is mandatory 2
• Time is the enemy: The interval between injury and reduction directly correlates with prognosis and treatment complexity 1
• Do not abandon closed reduction prematurely in acute cases: Even complex injuries with multiple fractures may reduce closed 2