Odontoid fracture treatment
Evidence
Level lII:isolated Type II odontoid fractures in adults ≥ 50 years age should be considered for surgical stabilization & fusion.
● Level III
○ Nondisplaced type I,II & III fractures may be managed initially with external cervical immobilization, recognizing that type II odontoid fractures have a higher rate of nonunion
○ Type II & III:consider surgical fixation for:
a) dens displacement ≥ 5mm
b) or Type IIA fracture (comminution of fracture)
c) or inability to maintain or achieve alignment with external immobilization
○ For surgical intervention, either an anterior or posterior approach may be used.
Inmobilization
For those not meeting surgical indications, 10–12 weeks of immobilization is recommended. There is no Class I medical evidence comparing immobilization options.
Halo vest: fusion rate =72%, appears superior to a SOMI. If a halo is used, obtain supine and upright lateral C-spine x-rays in the halo. If there is movement at the fracture site, then surgical stabilization is recommended.
Rigid collar: fusion rate = 53%.
In patients who are poor surgical candidates, there is theoretical and anecdotal rationale to consider calcitonin therapy in conjunction with a rigid cervical orthosis.
Odontoid fracture type I treatment
Odontoid fracture type II treatment
Odontoid fracture type III treatment
see Odontoid fracture type III treatment
Mainly 4 treatment strategies of Odontoid fracture treatment are reported, each with distinct pros and contras. Surgically, the two discussed treatments are anterior screw fixation and posterior C1-C2 fusion. Conservatively, the two most reported treatment options are the Halo-vest and the rigid cervical collar.
There is considerable ambiguity regarding optimal management strategies for odontoid fracture in the elderly. 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.
Iyer et al. provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature.
They believe that Odontoid fracture type I and Odontoid fracture type III can be managed in a collar in most cases.
Odontoid fracture type II treatment with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly population must be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunion with close follow-up is an acceptable outcome. If operative management is chosen, a posterior approach is should be chosen when fracture- or patient-related factors make an anterior approach challenging. The high levels of morbidity and mortality associated with odontoid fractures should encourage all providers to pursue medical co-management and optimization of bone health following diagnosis 1).