What is the appropriate management for a patient with a C1-C2 (cervical spine) subluxation?

Management of C1-C2 Subluxation

Immediately immobilize the cervical spine with a rigid cervical collar and manual in-line stabilization to prevent neurological deterioration, maintain systolic blood pressure >110 mmHg, and transport directly to a Level 1 trauma center for definitive imaging and treatment. 1, 2

Immediate Stabilization (First Priority)

• Apply a rigid cervical collar with head-neck-chest stabilization immediately upon suspicion of C1-C2 subluxation to limit onset or worsening of neurological deficit 3, 1, 4
• Use manual in-line stabilization (MILS) in conjunction with the rigid collar, as this significantly reduces complications despite the evidence being of low quality 3, 1
• Transport the patient on a rigid backboard with head fixation and vacuum mattress to minimize movement during transfer 2

Hemodynamic Management (Critical for Outcomes)

• Maintain systolic blood pressure >110 mmHg before and during injury assessment to reduce mortality 3, 1, 2
• Target mean arterial pressure ≥70 mmHg continuously during the first week post-injury to limit neurological deterioration 2
• Place an arterial line for continuous accurate blood pressure monitoring 1

Diagnostic Imaging Protocol

• Obtain CT cervical spine without IV contrast as the initial imaging study for all patients with suspected C1-C2 subluxation 4
• Follow with MRI of the cervical spine without IV contrast if ligamentous injury is suspected or to assess spinal cord compression, as MRI is the most appropriate modality for detecting pure ligamentous injuries 4, 5
• Perform CT angiography if vascular injury is suspected (90-100% sensitivity, 98.6-100% specificity) 4

Airway Management (If Required)

If intubation becomes necessary, use the following specific approach:

• Remove the anterior portion of the cervical collar during intubation attempts while maintaining MILS to improve mouth opening and glottic exposure 3, 1, 2
• Use rapid sequence induction with direct laryngoscopy and a gum elastic bougie 3, 1
• Do not use Sellick maneuver as it increases cervical spine movement 3, 1, 2
• Consider videolaryngoscopy over direct laryngoscopy, as it improves first-pass success rates in the presence of cervical immobilization 3
• Have a low threshold for removing MILS if intubation becomes difficult, as MILS worsens glottic view and increases failure rates 3
• Use jaw thrust rather than head tilt plus chin lift if simple airway maneuvers are needed 3, 2

Important caveat: The actual risk of secondary spinal cord injury from airway management is extremely low (0.34% in 1,177 patients), so do not delay necessary airway intervention 3, 2

Definitive Treatment Decision Algorithm

The treatment approach depends on patient age, injury mechanism, and presence of fracture:

For Children Under 13 Years:

• Atlantoaxial dislocation (AAD) without fracture is more common in this age group 6
• These patients are more likely to be neurologically intact 6
• Most require surgical fusion as halo-vest immobilization alone is usually insufficient for AAD without fracture 6

For Adolescents Over 13 Years and Adults:

• Type II odontoid fractures are more common 6
• Higher likelihood of spinal cord injury at presentation 6
• Halo-vest immobilization for 3 months is sufficient for most dens fractures and achieves bony union 6
• Surgical fusion is reserved for failed conservative management or unstable injuries 6

For Inflammatory/Rheumatologic Causes:

• In enthesitis-related arthritis or rheumatoid arthritis with C1-C2 subluxation, prioritize cervical spine protection and rule out spinal cord compression 5, 7
• Control underlying inflammation with non-steroidal anti-inflammatory drugs 5
• Surgical cervical fusion is indicated if conservative management with cervical collar fails or if spinal cord compression is present 5, 7
• Cervical halter traction may be applied only after severe cervical inflammation is excluded 5

Critical Pitfalls to Avoid

• Never leave the cervical collar fully in place during intubation - this significantly worsens glottic visualization and increases failure rates 3, 2
• Do not allow systolic blood pressure to drop below 110 mmHg, as this increases mortality risk 3, 1, 2
• Avoid prolonged rigid collar immobilization beyond 48-72 hours without definitive treatment, as complications rapidly escalate after this timeframe 4
• Do not miss chronic myelopathy from undetected C1-C2 injuries - maintain high clinical suspicion even in delayed presentations 6
• Do not delay transport to a Level 1 trauma center, as this worsens morbidity, mortality, and neurological outcomes 1, 2

Early Complications Prevention

• Begin joint range-of-motion exercises and positioning immediately upon ICU admission to prevent contractures 1
• Implement comprehensive pressure ulcer prevention from the acute phase 2
• Prevent hypothermia aggressively (target core temperature 36-37°C), as each 1°C drop reduces coagulation factor function by 10% 1
• Consider early tracheostomy (<7 days) for upper cervical injuries with significantly decreased vital capacity 1, 2