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Nontraumatic Spinal Subluxation

by Sally Pullman-Mooar, MD

Spinal dislocation and subluxation (partial dislocation) are usually due to trauma. For example, atlantoaxial subluxation and spondylolisthesis can result from obvious major trauma, such as a high-speed deceleration injury. However, these disorders can occur with minimal, unrecognized, or no trauma. Rarely, cervical disk disorders can cause nontraumatic spinal subluxation.

Atlantoaxial Subluxation

(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 RA, juvenile RA, 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.

Diagnosis

  • Plain x-rays

  • MRI if cord compression suspected

It is usually diagnosed with plain cervical x-rays; however, flexion views may be required to show intermittent subluxation. Views during flexion, done 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

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.

Spondylolisthesis

Spondylolisthesis is subluxation of lumbar vertebrae, usually occurring during adolescence. It usually results from a congenital defect in the pars interarticularis (spondylolysis).

Spondylolisthesis is usually fixed. It usually involves the L3-L4, L4-L5, or L5-S1 vertebrae. Spondylolisthesis often occurs in adolescents or young adults who are athletes and who have had only minimal trauma; the cause is a lumbar vertebra weakened by a congenital defect in the pars interarticularis. This defect is easily fractured; separation of the fracture fragments causes the subluxation. Spondylolisthesis can also occur with minimal trauma in patients who are > 60 and have osteoarthritis. If mild to moderate (subluxation of 50%), spondylolisthesis, particularly in the young, may cause little or no pain. Spondylolisthesis can predispose to later development of spinal stenosis. If due to major trauma, spondylolisthesis can cause spinal cord compression or other neurologic deficits (see Spinal Cord Compression); these deficits rarely occur.

Spondylolisthesis is staged according to the degree of subluxation of adjacent vertebral bodies:

  • Stage I: 0 to 25%

  • Stage II: 25 to 50%

  • Stage III: 50 to 75%

  • Stage IV: 75 to 100%

Spondylolisthesis is evident on plain lumbar x-rays. The lateral view is usually used for staging. Flexion and extension views may be done to check for instability.

Treatment is usually symptomatic.

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