Traction should be aborted if respiratory difficulties or new neurologic signs or symptoms develop. Review of serial radiographs may indicate a need to redirect the force vector applied by the Gardner-Wells tongs. Lesions that are reduced by cervical traction are then stabilized posteriorly. This is particularly true in the presence of a pannus causing spinal cord compression. Postoperatively, the patient is immobilized in a Philadelphia collar and observed with serial radiographs.
Immobilization is maintained until evidence of fusion is demonstrated radiographically.
A lateral plain radiograph of the cervical spine best visualizes the rostral migration of the dens into the foramen magnum. Regardless of the presence or absence of symptoms, virtually all patients who have radiographic evidence of cranial settling should undergo surgical stabilization. As in atlantoaxial subluxation, closed reduction using cervical traction should be attempted first. Unlike isolated atlantoaxial subluxation, posterior stabilization in cranial settling should extend rostrally to the occiput. Postoperatively, the patient is immoblilized in a Minerva jacket and observed with serial radiographs.