Odontoid fracture type II treatment

• Comparison of Mechanical Stress on Implants in Anterior Single and Double Screw Fixation of Odontoid Fractures in a Finite Element Model
• Masseter Sarcopenia and Mortality After Type II Odontoid Fractures in the Elderly: A 5-Year Follow-Up Study
• Comparative Effectiveness of Conservative Management Versus Surgical Fixation in Acute Type II Odontoid Fractures
• Traumatic posterior atlantoaxial dislocation based on imaging of the anterior arch-odontoid process-transverse ligament complex: a retrospective cohort study
• Hounsfield unit measurements to predict odontoid fracture union in elderly patients: post-hoc subgroup analysis from an international prospective comparative study
• Traumatic odontoid fracture - Proposal of a treatment algorithm
• The AO Spine Upper Cervical Injury Classification System (AO UCIC) - An Umbrella Review of Traumatic Axis Injuries Factors that May Affect Treatment Decision
• Safety of non-osseous union of type II odontoid fractures-a multi-institutional cohort study

Odontoid fracture type II treatment become increasingly common in the aging population.

Treatment remains controversial. No agreement has been reached after many attempts to identify factors that will predict which type II fractures are most likely to heal with immobilization and which will require operative fusion.

Critical review of the literature reveals a paucity of well designed studies. A wide range of nonunion rates with immobilization alone (5–76%) is quoted: 30% is probably a reasonable estimate for overall nonunion rate, with 10% nonunion rate for those with displacement <6 mm. Possible key factors in predicting nonunion include:

1. degree of displacement: probably the most important factor

a) some authors feel that displacement >4 mm increases nonunion

b) some authors use ≥6 mm as the critical value, citing a 70%nonunion rate60 in these regardless of age or direction of displacement

2. age:

a) children <7 yrs old almost always heal with immobilization alone

b) some feel that there is a critical age above which the nonunion rate increases, and the following ages have been cited: age >40 yrs (possibly ≈ doubling the nonunion rate),76 age >55 yrs,77 age >65 yrs,78 yet others do not support increasing age as a factor.

Establishing a clear treatment paradigm for octogenarians hampered by a literature replete with level III articles.

see Odontoid fracture type II conservative treatment.

Odontoid fracture type II Surgery.

Odontoid fracture type II treatment in the Elderly

A direct anterior submandibular retropharyangeal approach with open reduction and fixation (ORIF) using a customized variable screw placement (VSP) plate was used to realign and fix the fracture fragments in compression mode under direct vision. Twenty patients of type-II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior variable screw position (VSP) plate and screw fixation and eight amongst them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws.

All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow-up has been for 3 years.

Anterior retropharyangeal approach allows direct fracture fragment realignment under vision with an opportunity to fix in compression mode using the VSP plate, which ensures early fusion across the type-II odontoid fracture. Any associated instability can be treated by additional bilateral anterior transarticular screws. The approach is simple and safe without any risk to the vertebral arteries and biomechanically appealing ¹⁾.

In the study by Graffeo et al., the authors evaluated 111 patients over the age of 79 (average age: 87) with type II odontoid fractures undergoing nonoperative (94 patients) vs. operative intervention (17 total; 15 posterior and 2 anterior). They studied multiple variables and utilized several scales [abbreviated injury scale (AIS), injury severity score (ISS), and the Glasgow coma scale (GCS)] to determine the outcomes of nonoperative vs. operative management.

Graffeo et al. concluded that there were no significant differences between nonoperative and operative management for type II odontoid fractures in octogenarians. They found similar frequencies of additional cervical fractures, mechanisms of injury, GCS of 8 or under, AIS/ISS scores, and disposition to “nonhome” facilities. Furthermore, both appeared to have increased mortality rates at 1-year post injury; 13% during hospitalization, 26% within the first post-injury month, and 41% at 1 year.

In the editorial by Falavigna, his major criticism of Graffeo's article was the marked disparity in the number of patients in the operative (17 patients) vs. the nonoperative group (94 patients), making it difficult to accept any conclusions as “significant”. He further noted that few prior studies provided level I evidence, and that most, like this one, were level III analyses that did not “significantly” advance our knowledge as to whether to treat octogenarians with type II odontoid fractures operatively vs. nonoperatively ²⁾.

Twenty-one of 22 patients who underwent posterior C1-C2 temporary fixation of an odontoid fracture achieved fracture healing and regained motion of the atlantoaxial joint. The functional outcomes of these 21 patients were compared with that of a control group, which consisted of 21 randomly enrolled cases with posterior C1-C2 fixation and fusion. The differences between the 2 groups in the visual analog scale score for neck pain, neck stiffness, Neck Disability Index, 36-Item Short Form Health Survey, and time to fracture healing were analyzed.

Significantly better outcomes were observed in the temporary-fixation group for visual analog scale score for neck pain, Neck Disability Index, and neck stiffness. The outcomes in the temporary-fixation group was superior to those in the fusion group in all dimensions of the 36-Item Short Form Health Survey. There were no significant differences in fracture healing rate and time to fracture healing between the 2 techniques.

Functional outcomes were significantly better after posterior C1-C2 temporary fixation than after fusion. Temporary fixation can be used as a salvage treatment for an odontoid fracture with an intact transverse ligament in cases of failure of, or contraindication to, anterior screw fixation ³⁾.

Data of twenty patients who underwent posterior temporary-fixation due to Anderson-D'Alonzo type II odontoid fractures with intact transverse ligament were retrospectively reviewed. Another twenty patients undergoing anterior screw fixation were randomly selected as the control group. The range of motion (ROM) in rotation of C1-C2 measured on functional computed tomography (CT) scan and outcomes evaluated by the visual analog scale (VAS) for neck pain, neck stiffness, patient satisfaction, and neck disability index (NDI) were compared between two groups at the final follow-up.

At the final follow-up, 19 cases in each groups achieved facture healing. Total C1-C2 ROM in rotation on both sides in the posterior temporary-fixation group was 32.4 ± 12.5°, smaller than 40.0 ± 13.0 in the anterior fixation group. However, there was no statistical difference between two groups. And there was no significant difference between two groups in functional outcomes evaluated by VAS for neck pain, neck stiffness, patient satisfaction and NDI.

Posterior temporary-fixation can spare the motion of C1-C2 and achieve same good clinical outcomes as anterior screw fixation in the treatment of Anderson-D'Alonzo type II odontoid fractures. It was an ideal alternative strategy to anterior screw fixation ⁴⁾.