Nonoperative management of odontoid fractures: A review of 59 cases

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Abstract

Objectives

Surgical treatment of odontoid fractures is recommended by many surgeons to prevent sudden neurologic injury or progressive myelopathy. Less aggressive approach to the treatment of odontoid fractures has been advocated by some authors especially in the elderly population. Very few reports have followed up patients’ outcomes following conservative treatment of odontoid fractures. Here we evaluate the clinical and radiographic results of patients without myelopathy treated without surgery for an odontoid type fracture.

Patients and methods

101 patients with traumatic odontoid fracture admitted to the Pennsylvania State Hershey Medical Center between 1998 and 2008. Fractures were defined using a CT scan according to the Anderson–D’Alonzo Classification. Conservative treatment was pursued in appropriately selected patients.

Results

Fifty-nine patients were selected to be treated in a cervical collar. Sixteen patients failed using radiographic evidence and continued neck pain. Fourteen patients went on to be surgically stabilized. The other two patients opted to continue with cervical orthosis and regular clinical evaluations. The Forty-three remaining patients had stable imaging studies and with no other complaints. None of the patients developed myelopathy symptoms during the follow-up period.

Conclusions

Our results indicate that a select group of patients with odontoid fracture who are deemed stable on initial evaluation in a cervical orthosis may be effectively managed non-operatively. None of the patients who were managed conservatively had clinical worsening during the period of management. The decision to proceed with surgical treatment was based on failure of resolution of neck pain or worsening or concerning instability on imaging studies. However in many patients, even elderly patients in a surgical risks are greater, many odontoid fractures can be safely managed in a cervical orthosis.

Introduction

Odontoid fractures account for 9–20% of cervical spine fractures [1], [2], [3], [4], [5], [6]. However, due to the high level of potentially fatal neurological injury associated with these fractures, the exact incidence is not well known [7], [8], [9], [10], [11]. The incidence of odontoid fractures has a bimodal distribution with increased incidence in younger patients with high energy injuries and older patients with lower energy injuries. Odontoid fractures are the most common individual cervical spine fractures for persons aged ≥70 years. Furthermore, for individuals over 80 years of age, C2 fractures are the most common of all traumatic spinal fractures [12]. The mechanism of injury leading to dens fractures typically involves either hyperextension, or hyper flexion. Fractures classified as “type II” by the Anderson and D’Alonzo classification are the most common type, comprising 65–74% [8], [13], [14], [15]. While, type II and III fractures of the odontoid have the highest nonunion rates of odontoid fractures with incidence as high as 32% and 13% respectively [8]. Spinal cord injury is infrequent in those patients who survive such fractures [7], [8], [9], [15], [16]. The most dangerous risk of ongoing instability at the atlantoaxial junction is a progressive neurological injury [16], [17], [18], [19], [20]; however, disabling or problematic pain may also result from continued pathological movement. This has been used as grounds by many physicians to pursue stabilization regardless of myelopathy [8], [11], [16], [17], [19].

On the other hand, the higher incidence of anesthetic risk and diminished bone quality in the elderly, making fusion much more challenging and less likely to be achieved, argues against surgical intervention [21], [22], [23], [24]. To date there have been very few reports of nonsurgical treatment of odontoid process fractures using only cervical collars [21], [22], [25], [26], [27], [28], [29]. Here we present of series of nonsurgically treated odontoid fractures using cervical collars.

Section snippets

Materials and methods

A retrospective review was performed to identify patients over age 17 at the Hershey Medical Center, Pennsylvania State University, with acute dens fractures. A chart review was performed evaluating records from the period of December 1999 through December of 2008. Exclusion criteria included patients with myelopathic signs and symptoms at the time of diagnosis, previous attempted cervical arthrodesis, or surgical intervention. All living patients were contacted and asked to return for clinical

Results

We identified one hundred and one patients with an odontoid fracture on admission. Forty-nine patients were female and 52 were male. The average age was 65.3 years. The range varied between 17 years and to 98 years old with a standard deviation of 26 years and a median of 76 years. Fourteen patients died during initial hospitalization or after discharge secondary to other injuries sustained during the traumatic event. Sixteen patients who were initially treated non-operatively were lost to

Discussion

Our work shows that in a select group of patients with odontoid fractures, following a thorough evaluation, and close follow up nonsurgical management in a cervical orthosis could be a viable option with minimal morbidity and mortality. Sixteen out of the initial 59 patients treated non-operatively failed this management. Failure was based on persistent neck pain or cervical instability present on follow up imaging. None of the patients suffered any morbidity. These results confirm the lack of

Conclusion

In summary, the literature lacks class I or II evidence favoring one treatment option over another. What can be deduced is that younger less displaced fractures seem to have a higher fusion rate. Older patients have higher complication rates when treated surgically or in a Halo vest [24].

Our results indicate that a select group of patients with odontoid fracture who are deemed stable on initial evaluation in a cervical orthosis may be effectively managed non-operatively. None of the patients

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