Review Question - QID 219589

In geriatric patients (age > 80), mortality and morbidity are thought to be high regardless of what treatment is employed.

Odontoid fractures account for 10-15% of all cervical fractures and involve the C2 vertebra. They most commonly occur in the elderly, secondary to hyperflexion or hyperextension mechanisms. They have traditionally been classified based on the location of the fracture, with type II fractures occurring through the waist of the odontoid and portending the worst prognosis concerning continued pain/nonunion. CT is the study of choice in these cases, and MRI is only necessary in specific cases where neurologic symptoms are present. Treatment depends on the degree of fracture displacement, fracture pattern, and patient characteristics, namely age. In geriatric patients older than 80, no benefit has been demonstrated with surgical management compared to nonsurgical, and the current recommendation remains a hard cervical collar as these patients do not tolerate halo vest immobilization well. Unfortunately, regardless of the treatment chosen, there is a high degree of morbidity and mortality in the geriatric population with this injury pattern.

De Bonis et al. published a multicenter study on the functional outcomes of 147 elderly patients treated for odontoid fractures. Sixty-seven were treated conservatively, and 80 underwent surgery. They noted that two different outcome scores (Modified Rankin Scale & Charlson Comorbidity Index) were independently predictive for functional outcome and treatment disability, with C1-2 posterior fusion and occipital-cervical stabilization being associated with worse outcomes. They concluded that surgery showed no advantages in the geriatric population concerning functional outcomes.

Lofrese et al. postulated whether fracture healing was truly the goal in cases of type II odontoid fractures in elderly patients. They studied 50 geriatric patients and treated them all with a rigid cervical collar. They found that 24/50 reached a stable union, while 26 had a stable non-union with dynamic cervical spine radiographs. There were no differences in outcome scores between the stable union/nonunion groups. Based on these results, they favor hard collar immobilization as the preferred treatment method in this population.

Sarode and Demetriades published a meta-analysis comparing surgical and nonsurgical management of type II odontoid fractures in the elderly. They noted that mortality rates did not favor surgical or nonsurgical management at short—or long-term points. They note, however, that in the 12 studies included, there was significant heterogeneity and poor methodological quality.

Incorrect Answers:
Answer 2: Screw fixation is not ideal in cases where there is displacement and has not been proven superior to fusion in this geriatric population.
Answer 3: Halo vest immobilization is poorly tolerated by the geriatric population, and rigid cervical collar stabilization is preferred.
Answer 4: Smoking is a risk factor for nonunion regardless of treatment choice and does not necessarily affect the decision to perform surgery.
Answer 5: MRI is not routinely required in this population as associated nerve impingement is uncommon, and the CT scan typically details the fracture quite well.