If operative management is chosen, a posterior approach is should be chosen when fracture- or patient-related factors make an anterior approach challenging. In a frail elderly patient, a fibrous nonunion with close follow-up is an acceptable outcome. However, the risks of surgery in an elderly population must be carefully considered on a case-by-case basis. Radiograph of the cervical spine open-mouth view shows a fracture through the base of the odontoid process (arrow) that was not discernible on the lateral. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. We believe that type I and type III odontoid fractures can be managed in a collar in most cases. A treatment algorithm is presented based on the available literature. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. Poor bone health and medical comorbidities contribute to increased surgical risk in this population however, nonoperative management is associated with a risk of nonunion or fibrous union. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly.
Odontoid fracture series#
Our case series serves to illustrate several of the common surgical considerations encountered by spinal surgeons who manage this problem.Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. We present a case series of four young to middle aged patients who presented to our unit with displaced type II odontoid fractures and underwent different surgical stabilization procedures. As a bail out procedure there is still place for the older wiring techniques, such as the modified Gallie fusion augmented by external immobilization or trans-articular screws. As a second line the posterior C1/C2 Harms stabilisation with subsequent hardware removal, or if not possible a posterior C1/C2 Harms arthrodesis, should be the 2nd and 3rd choices entertained. In this group closed fracture reduction and alignment, and a subsequent anterior odontoid screw/s, should be the standard of care where-ever possible. Displaced fractures in younger patients comprise a specific subgroup with their own inherent corner-stone surgical considerations.
Odontoid fracture serial#
In young to middle aged patients non-displaced fractures can be managed conservatively with cervical immobilization and serial imaging. Type III: fracture extends into the body of the axis. Type II: fracture through the base of the dens, at the junction of the odontoid base and the body of C2. Their specific site at the odontoid base is confounded firstly by instability, and secondly by a poor blood supply, which predisposes these injuries not only to secondary neurological deterioration but importantly to non-union. Epidemiology /Etiology Type I: avulsion fracture of the apex. Type II odontoid fractures account for over 2/3ds of odontoid fractures, which overall account for approximately 20% of cervical spine fractures.
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