Review Question - QID 211619

An odontoid fracture with <50% displacement in an elderly patient with significant comorbidities should be considered for non-operative management in a cervical collar.

Treatment recommendations for Type II odontoid fractures vary depending on fracture displacement and patient age. A vascular watershed area predisposes Type II dens fractures to non-union which can lead to persistent pain, displacement, and neurological compromise. Risk for nonunion is based on comorbidities and fracture characteristics. C1-C2 fusion should be considered in elderly patients who are at risk for nonunion and those without medical comorbidities predisposing them to complications. A stable fibrous union may be an adequate goal when treating elderly patients.

Bransford et al. reviewed upper cervical spine trauma. Surgical indications for Type II dens fractures include spinal cord injury, distracted fractures, and irreducible fractures. Relative indications are ≥5 mm, 10° angulation, delayed presentation (>2 wk), risk for nonunion, and inability to tolerate external immobilization. The authors emphasize critical evaluation of the craniocervical complex in traumatized patients. Advanced and dynamic imaging should be scrutinized for evidence of craniocervical dissociation and atlantoaxial dislocation in addition to fractures of the occipital condyle, atlas, and axis.

Hsu et al. reviewed the management of odontoid fractures. They note the management of Type II fractures is controversial and the decision to operate should be made on a case-by-case basis. The authors emphasize the high rate of mortality in the elderly and risk of nonunion. Many advocate for early operative treatment in elderly patients to avoid complications of pseudarthrosis and rigid bracing. Healing rates for Type II dens fractures treated with non-halo orthoses, halo-vest orthoses, odontoid screw, and posterior fusion were 51%, 65%, 82%, and 93%, respectively. The authors recommend C1-C2 fusion for posteriorly displaced unstable Type II patterns and non-operative management for stable patterns.

Molinari et al. compared outcomes of 58 patients treated with either rigid cervical collar (n = 33, average age = 83 years) or posterior fusion (n = 25, average age = 80 years). Those with <50% displacement were treated in a cervical collar while a posterior fusion was performed if displacement was > 50%. Despite better healing and stability in the fusion group, mortality was higher than the group treated in a collar (20% vs 12.5%). Complications in the fusion and collar groups were 24% and 6%, respectively. The authors conclude fracture healing and stability do not correlate with improved outcomes and complication rates are lower in those with lesser-displaced fractures treated with a cervical collar and early mobilization.

Figures A & B demonstrate a minimally displaced Type II dens fracture.

Incorrect Answers:
Answer 2: Halo immobilization is indicated for the treatment of acute Type II dens fractures in young patients with no risk factors for nonunion. This treatment is associated with significant morbidity and mortality in elderly patients.
Answer 3: C1-C2 fusion should be considered in elderly patients who are surgical candidates with displaced Type II dens fractures at increased risk for nonunion.
Answer 4: Anterior odontoid screw osteosynthesis is indicated in acute Type II dens fractures at risk for nonunion with minimal displacement, fracture pattern perpendicular to the screw trajectory, and in patients with a body habitus that allows proper screw trajectory.
Answer 5: Odontoidectomy is indicated for posterior displacement of the dens causing neurological deficits.