Nonoperative management of odontoid fractures: A review of 59 cases
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
References (62)
- et al.
Incidence of traumatic spinal cord lesions
Journal of Chronic Diseases
(1975) - et al.
The epidemiology of fractures and fracture-dislocations of the cervical spine
Injury
(1992) - et al.
Fractures of the odontoid: a laboratory and clinical study of mechanisms
Orthopedic Clinics of North America
(1978) - et al.
Fractures of the dens – the results of non-rigid immobilization
Injury
(1988) - et al.
Cervical spine fractures in the elderly
Surgical Neurology
(1997) Fracture of the dens in the aged
Surgical Neurology
(1984)- et al.
Management of acute odontoid fractures with single-screw anterior fixation
Neurosurgery
(1999) - et al.
Experience of posterior surgery in atlanto-axial instability
Spine
(1984) - et al.
Contemporary management of adult cervical odontoid fractures
Orthopedics
(2000) - et al.
Factors influencing the outcome of cervical spine injuries
Journal of Trauma
(1988)
Cervical injuries suffered in automobile crashes
Journal of Neurosurgery
Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature
Journal of Bone and Joint Surgery
Fractures of the dens. A multicenter study
Journal of Bone and Joint Surgery
Odontoid fractures, with special reference to the elderly patient
Clinical Orthopaedics and Related Research
Choice of treatment of odontoid fractures
Journal of Neurosurgery
Management of fractures of the dens (odontoid process)
Journal of Bone and Joint Surgery
Fractures of the C-2 vertebral body
Journal of Neurosurgery
Acute axis fractures: a review of 229 cases
Journal of Neurosurgery
Fractures of the odontoid process of the axis
Journal of Bone and Joint Surgery
Posttraumatic atlantoaxial instability: the fate of the odontoid process fracture in 46 cases
Journal of Trauma
Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features
Journal of Neurosurgery
Non-union of the odontoid process. An experimental investigation
Clinical Orthopaedics and Related Research
Myelopathy caused by atlanto-axial dislocation
Journal of Neurosurgery
Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly
European Spine Journal
Functional outcome of surgically and conservatively managed dens fractures
Spine
Acute axis fractures. Analysis of management and outcome in 340 consecutive cases
Spine
Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures
Journal of Trauma
The contemporary treatment of odontoid injuries
Spine
Nonoperative management of Types II and III odontoid fractures: the Philadelphia collar versus the halo vest
Neurosurgery
Nonoperative management of dens fracture nonunion in elderly patients without myelopathy
Spine
Evidence-based management of type II odontoid fractures
Clinical Neurosurgery
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Nonoperative management of C-2 dens fractures: Single center experience and review of the literature
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Treatment of Odontoid Fractures in the Aging Population
2017, Neurosurgery Clinics of North AmericaCitation Excerpt :Conservative management for odontoid fractures most commonly consists of rigid external fixation—with either a hard cervical collar or halo immobilization. These options are sometimes chosen in the elderly because of concerns for operative morbidity in this fragile population.28 This risk must be counterbalanced with the higher rates of nonunion with external immobilization alone.29
The selection of core International Classification of Functioning, Disability, and Health (ICF) categories for patient-reported outcome measurement in spine trauma patients—results of an international consensus process
2016, Spine JournalCitation Excerpt :Also, clinician-based neurological classifications [20,21] were frequently used. This is in line with many studies from all over the world reporting neurological status as a strong determinant of outcome in spine trauma and the intensity of pain experienced by the patient as an outcome measure [22–27]. Interestingly, the most relevant ICF categories identified in the expert survey related to the same issues [15].
Application of the Canadian C-Spine Rule during early clinical evaluation of a patient presenting in primary care with a C2 fracture following a motor vehicle collision: A case report
2015, International Journal of Osteopathic MedicineCitation Excerpt :A similar decision making process was suggested by the Neck Pain Task Force statement.21 Conservative treatment with a cervical collar was prescribed as suggested by several studies on odontoid fractures who are deemed stable on initial evaluation.30–33 Implementation of the Canadian C-Spine Rule in outpatient clinics can be very helpful for avoiding unnecessary imaging and, in the meanwhile, guaranteeing safe practice.
Current controversies in nonoperative management of Type II odontoid fractures in the elderly
2014, Seminars in Spine SurgeryCitation Excerpt :However, the purpose of their study was to suggest that elderly patients with lesser displaced fractures can be appropriately treated with a cervical collar. Rizk et al.23 demonstrated similar findings with no morbidity associated with cervical collar treatment of Type II odontoid fractures in 22 patients. Muller et al.12 confirmed that stable Type II odontoid fractures could be treated successfully with rigid cervical collars.
Age increases the risk of immediate postoperative dysphagia and pneumonia after odontoid screw fixation
2014, Clinical Neurology and NeurosurgeryCitation Excerpt :Another consideration is the decision of whether to operate on type II odontoid fractures in the first place. A recent study by Rizk et al. [34] examined the success of cervical orthosis alone on non-myelopathic patients with type II odontoid fractures. The study found that 43 of 59 patients were treated successfully with a cervical orthosis alone, thus removing the potential morbidity of surgery.