In our clinical work, we often meet young parents from all over the world who come to us with a pile of imaging data, not their own, but their precious son or daughter’s, about “atlantoaxial subluxation”. In fact, they have basically traveled all over the country and consulted with various famous orthopedic professors. The root cause of this phenomenon is the fear of the atlantoaxial spine, also known as C1 and C2, which is often associated with paralysis and death. So they go to one hospital and then another, giving their time, energy and money to the Ministry of Transportation. I think it is important to use a more layman’s approach so that the people, not the professionals, understand the diagnosis and treatment of atlantoaxial subluxation in children. The atlantoaxial spine in the atlantoaxial subluxation we are talking about is the first cervical vertebra (C1) and the pivot is the second cervical vertebra (C2) in a very high position. As the atlantoaxial spine is dislocated forward or backward, it can directly irritate and compress the upper cervical medulla. The causes of atlantoaxial subluxation in adults are congenital, mainly due to dysgenesis of the atlanto-denticle and/or incompetence of the transverse atlantoaxial ligament, and traumatic, often a violence leading to subluxation. In children, the most common causes are upper respiratory tract infections and trauma to the head and neck. Some people may ask: Why is atlantoaxial subluxation more common in adults than in children? In fact, the atlantoaxial plane corresponds to a very wide spinal canal, and the spinal cord has room to compensate for the degeneration. Therefore, children often do not show symptoms of spinal cord compression, and only when they are 30-40 years old, they gradually develop numbness, weakness and unsteadiness in their limbs, and then they will go to the doctor. Delayed diagnosis of atlantoaxial dislocation in children is mainly due to children’s inability to express themselves, parents’ lack of knowledge, or the inexperience of the doctors who see them, who often treat them as “falling pillow”, resulting in atlantoaxial instability. The clinical manifestations are mainly sloping neck, neck pain and limited movement. The appearance of a fixed sloping neck with the head tilted to one side and the chin turned to the opposite side is an essential clinical manifestation of atlantoaxial dislocation. Longer duration of the disease is often followed by asymmetrical facial development and the gradual appearance of numbness, weakness, unstable walking and easy falling of the limbs. Imaging is the main basis for the diagnosis of atlanto-axial dislocation, and the atlanto-axial gap is shown on radiographs, with a gap of no more than 3 mm in normal adults and 5 mm in children. CT 3D reconstruction of the occipital neck and MRI plain scan of the cervical spine can help diagnose the type, cause and degree of compression of dislocations, such as free dentition and rheumatoid arthritis. In clinical practice, many patients take a cervical spine opening film and say that the dentate process is asymmetrical with the block spacing on both sides, and the vast majority of doctors diagnose it as “atlantoaxial subluxation”. This is especially true when there is a dispute, such as when two children fall after pushing or pulling each other. In my case, I do not attach much importance to the cervical open radiographs, mainly because this unequal spacing may be a normal developmental variation, or it may be due to the improper angle of the open radiographs, which has no diagnostic significance. Once a child is labeled as “atlantoaxial subluxation”, it will cast a psychological shadow on him and cast a shadow on the whole family. The end result is that the psychological damage is much greater than the physical trauma. Treatment conservative treatment: usually use the occipital jaw belt Glisson traction, traction weight is mostly 1.5kg-2kg, traction when you can pad a small round pillow behind the neck, such as with no patterned towel rolled into a round pillow placed on the back of the neck, due to the body proportions of small children, the head is relatively large, often need to shoulder padding, corrected the forward tilt of the head. You also need to massage the pillow neck muscles from time to time, the skin of small children is particularly delicate and prone to pressure sores. Some parents are afraid to massage because of fear, in fact, it is not necessary, traction under gentle massage is still very safe. The traction process also requires a review of the film, traction reset and then the head, neck and chest brace fixed. Surgical treatment: atlantoaxial fusion, avoid occipitocervical fusion as far as possible. In clinical practice, we do not use titanium cable fixation (Brooks or Gallie) whenever possible and opt for atlantoaxial pedicle screw fixation fusion. There are three main reasons for this: 1) the titanium cable fixation method is not very stable after all, and there is a certain amount of micromovement; 2) since the bone of the atlantoaxial spine in children is relatively soft, too much force cannot be used after using the titanium cable, otherwise the cutting force will increase, which will easily cause atlantoaxial fractures and lead to surgical failure; 3) during the resetting process, the titanium cable is far from being as strong as the pedicle screw, and the resetting effect is not ideal.