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Atlantoaxial Subluxation

By Alfred J. Cianflocco, MD, FAAFP, Director, Primary Care Sports Medicine, Cleveland Clinic Sports Health, Department of Orthopaedic Surgery, Cleveland Clinic

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(C1–C2 Subluxation)

Atlantoaxial subluxation is misalignment of the 1st and 2nd cervical vertebrae, which may occur only with neck flexion.

Atlantoaxial subluxation can result from major trauma or can occur without trauma in patients with rheumatoid arthritis, juvenile idiopathic arthritis, or ankylosing spondylitis.

Atlantoaxial subluxation is usually asymptomatic but may cause vague neck pain, occipital headache, or occasionally intermittent (and potentially fatal) cervical spinal cord compression.


  • Plain x-rays

  • MRI if cord compression suspected

Atlantoaxial subluxation is usually diagnosed with plain cervical x-rays; however, flexion views may be required to show intermittent subluxation. Views during flexion, as tolerated by the patient, show dynamic instability of the entire cervical spine. If x-rays are normal and subluxation is still suspected, MRI, which is more sensitive, should be done. MRI also provides the most sensitive evaluation of spinal cord compression and is done immediately if cord compression is suspected.


  • Treatment of symptoms

  • Cervical immobilization

  • Surgery

Indications for treatment include pain, neurologic deficits, and potential spinal instability. Treatment includes symptomatic measures and cervical immobilization, usually beginning with a rigid cervical collar. Surgery may be needed to stabilize the spine.

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