Citation, DOI, disclosures and article data
At the time the article was created Rishi Agrawal had no recorded disclosures.View Rishi Agrawal's current disclosures
Atlanto-axial subluxation is a disorder of C1-C2 causing impairment in rotation of the neck. The anterior facet of C1 is fixed on the facet of C2. It may be associated with dislocation of the lateral mass of C1 on C2.
Atlanto-axial subluxations are often associated with high energy traumas, with higher occurrence among children and young adults 6.
There are several ways in which a subluxation can occur:
rotatory subluxation, known as atlantoaxial rotatory fixation (AARF) is characterized into four different types according to the Fielding and Hawkins classification 3:
type I: the atlas is rotated on the odontoid with no anterior displacement
type II: the atlas is rotated on one lateral articular process with 3 to 5 mm of anterior displacement
type III: comprises rotation of the atlas on both lateral articular processes with anterior displacement greater than 5 mm
type IV: rotation and posterior displacement of the atlas
lateral subluxation 4
In a non-traumatic setting, flexion and extension views may be performed. The expected distance between the anterior arch of C1 and the dens in the fully flexed position should be <3 mm in an adult (~5 mm in a child) 5.
Also, the anterior translocation of the atlas causes the posterior arch of C1 to become anterior to the spinolaminar line 7.
In a vertical subluxation, the dens is often above the McGregor line by over 8 mm in men and 9.7 mm in women.
On CT, C1 is not oriented in line with the head. The head may be pointed anteriorly, C1 is turned. If this is a fixed defect, C2 is rotated in conjunction with C1.
Possible differential considerations on imaging include:
- 1. Lustrin ES, Karakas SP, Ortiz AO et-al. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics. 23 (3): 539-60. doi:10.1148/rg.233025121 - Pubmed citation
- 2. Rojas CA, Hayes A, Bertozzi JC et-al. Evaluation of the C1-C2 articulation on MDCT in healthy children and young adults. AJR Am J Roentgenol. 2009;193 (5): 1388-92. doi:10.2214/AJR.09.2688 - Pubmed citation
- 3. Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am. 1977;59 (1): 37-44. J Bone Joint Surg Am (abstract) - Pubmed citation
- 4. Reynolds MD. Lateral subluxation of atlanto-axial joint. Ann. Rheum. Dis. 1980;38 (5): 499. Free text at pubmed - Pubmed citation
- 5. Yang S, Boniello A, Poorman C, Chang A, Wang S, Passias P. A Review of the Diagnosis and Treatment of Atlantoaxial Dislocations. Global Spine J. 2014;4(3):197-210. doi:10.1055/s-0034-1376371 - Pubmed
- 6. Riascos R, Bonfante E, Cotes C, Guirguis M, Hakimelahi R, West C. Imaging of Atlanto-Occipital and Atlantoaxial Traumatic Injuries: What the Radiologist Needs to Know. Radiographics. 2015;35(7):2121-34. doi:10.1148/rg.2015150035 - Pubmed
- 7. Atlantooccipital Dislocation. Imaging in Spine Surgery. 2017;:160-1. doi:10.1016/b978-0-323-48554-8.50077-4