Review Question - QID 219600

In elderly patients with type III odontoid fractures, halo-vest immobilization (HVI) is associated with high complication rates and an increased risk of early mortality when compared to surgical intervention (Answer 1).

The patient presents with neck pain and a type III odontoid fracture without signs of neurological insult after a ground-level fall. Type III odontoid fractures extend into the cancellous body of C2, providing a large surface area for healing and avoiding the vascular watershed area that can affect the healing of type II fractures. Treatment for type III fractures typically involves non-operative modalities. In elderly patients, the use of HVI is often considered contraindicated due to a high risk of respiratory complications and overall patient morbidity and mortality. Owing to the risks associated with HVI, cervical orthosis immobilization is a standard treatment protocol for elderly patients with type III fractures with good outcomes described in the literature.

Woods et al. performed a matched retrospective cohort study comparing mortality rates in elderly patients with odontoid fractures treated with operative and nonoperative modalities. The average patient age was 82.3 years, and 22 of 75 patients had a type III odontoid fracture. At three months after injury, patients treated nonoperatively with either HVI or cervical orthosis had a significantly higher mortality rate compared to surgery (33.3% versus 8.3%). Patients in the nonoperative cohort who died within three months of presentation had a higher average Charlson Comorbidity Index than any other subset of patients, and there were no differences in mortality rates observed at one and five years after injury. The authors concluded that patient age and comorbidity profile should be taken into account when determining prognosis for elderly patients with odontoid fractures regardless of treatment strategy.

DePasse et al. performed a retrospective cohort study to assess the outcomes of elderly patients with type II odontoid fractures treated with HVI. Mortality rates were similar when comparing HVI with cervical orthosis but significantly increased compared to surgical intervention. They also found a decrease in overall morbidity and mortality associated with HVI compared to historical controls, which was attributed to improved patient selection and attention to respiratory care. The authors concluded that complications and outcomes of HVI can be comparable to cervical orthosis with careful patient selection and vigilant respiratory care.

Iyer et al. conducted a literature review summarizing the management of odontoid fractures in elderly patients. They cited a low hemoglobin level, admission from a nursing home, neurological deficits, and type III fractures as independent predictors of mortality after injury. They discussed historically high rates of respiratory complications in elderly patients treated with HVI compared to cervical orthosis, with fewer investigations reporting comparable complication rates with careful patient selection. The authors concluded that the high rates of morbidity and mortality associated with these injuries in elderly patients warrant aggressive medical co-management and bone health optimization regardless of the utilized treatment strategy.

De Bonis et al. assessed the functional outcomes of odontoid fracture management in elderly patients through a retrospective multicenter study. They compared nonoperative management with either HVI or cervical orthosis to surgical intervention and found no advantages with surgery in terms of functional outcomes. The authors concluded that patient fragility and comorbidities most significantly influenced functional outcomes after injury, and these factors should be considered when determining the most appropriate treatment strategy for individual patients.

Figure A is a coronal CT scan image demonstrating a type III odontoid fracture.

Incorrect Answers:
Answers 2 and 3: Early mortality rates in elderly patients with odontoid fractures treated with HVI are increased compared to those treated with surgery and similar to those treated with cervical orthosis.
Answer 4: Functional outcomes are similar between operative and nonoperative management of odontoid fractures in elderly patients.
Answer 5: Respiratory complication rates in elderly patients with odontoid fractures treated in HVI are historically higher when compared to cervical orthosis. More recent literature has suggested similar complication profiles between the two treatment modalities with careful patient selection and supportive respiratory care.