What is the primary neck MSK concern in children with Down syndrome?

• A. Cervical spondylosis
• B. Torticollis
• C. Atlantoaxial instability
• D. Kyphosis

Answer: (C)

Atlantoaxial instability at the C1–C2 joint is the main neck MSK concern in children with Down syndrome. This vulnerability arises from general ligamentous laxity and potential odontoid (dens) abnormalities, which can allow the atlas to translate excessively on the axis. Even minor neck movements or trauma can then compress the spinal cord, risking neurologic injury. Because instability can be present without obvious symptoms, it’s a critical issue to consider before activities, anesthesia, or any neck manipulation. Watch for neck pain, limited neck motion, new torticollis, or signs of myelopathy like gait changes or changes in reflexes. If suspicion arises, imaging with radiographs (often dynamic flexion-extension views) and MRI as needed helps assess stability and compression, guiding management from activity modification or bracing to surgical stabilization in more severe cases. Other neck issues like torticollis, cervical spondylosis, or kyphosis may occur but are not the primary pediatric DS concern.