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Type II odontoid fractures in the elderly: an evidence-based narrative review of management

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Abstract

Considerable controversy exists regarding the optimal management of elderly patients with type II odontoid fractures. There is uncertainty regarding the consequences of non-union. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. The objective of the study was to evaluate the published literature and determine the current evidence for the management of type II odontoid fractures in elderly. A search of the English language literature from January 1970 to date was performed using Medline and the following keywords: odontoid, fractures, cervical spine and elderly. The search was supplemented by cross-referencing between articles. Case reports and review articles were excluded although some were referred to in the discussion. Studies in patients aged 65 years with a minimum follow-up of 12 months were selected. One-hundred twenty-six articles were reviewed. No class I study was identified. There were two class II studies and the remaining were class III. Significant variability was found in the literature regarding mortality and morbidity rates in patients treated with and without halo vest immobilisation. In recent years several authors have claimed satisfactory results with anterior odontoid screw fixation while others have argued that this may lead to increased complications in this age group. Lately, the posterior cervical (Goel–Harms) construct has also gained popularity amongst surgeons. There is insufficient evidence to establish a standard or guideline for odontoid fracture management in elderly. While most authors agree that cervical immobilisation yields satisfactory results for type I and III fractures in the elderly, the optimal management for type II fractures remain unsolved. A prospective randomised controlled trial is recommended.

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References

  1. Aebi M, Etter C, Coscia M (1989) Fractures of the odontoid process. Treatment with anterior screw fixation. Spine 14:1065–1070

    Article  CAS  PubMed  Google Scholar 

  2. Anderson LD, D’Alonzo RT (1974) Fractures of the odontoid process of the axis. J Bone Joint Surg Am 56:1663–1674

    CAS  PubMed  Google Scholar 

  3. Andersson S, Rodrigues M, Olerud C (2000) Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly. Eur Spine J 9:56–59

    Article  CAS  PubMed  Google Scholar 

  4. Apfelbaum RI, Lonser RR, Veres R, Casey A (2000) Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg 93:227–236

    CAS  PubMed  Google Scholar 

  5. Appuzo ML, Heiden JS, Weiss MH, Ackerson TT, Harvey JP, Kurze T (1978) Acute fractures of the odontoid process. An analysis of 45 cases. J Neurosurg 48(1):85–91

    Article  Google Scholar 

  6. Bednar DA, Parikh J, Hummel J (1995) Management of type II odontoid process fractures in geriatric patients: a prospective study of sequential cohorts with attention to survivorship. J Spinal Disord 8:166–169

    Article  CAS  PubMed  Google Scholar 

  7. Berlemann U, Schwarzenbach O (1997) Dens fractures in the elderly: results of anterior screw fixation in 19 elderly patients. Acta Orthop Scand 68:319–324

    Article  CAS  PubMed  Google Scholar 

  8. Bohler J (1982) Anterior stabilization for acute fractures and non-unions of the dens. J Bone Joint Surg Am 64:18–27

    CAS  PubMed  Google Scholar 

  9. Bohler J (1986) Operative treatment of injuries to cervical spine. Orthop Rev 15(1):58–59

    CAS  PubMed  Google Scholar 

  10. Bohlmann HH (1979) Acute fractures and dislocations of the cervical spine: an analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg 61:1119–1142

    Google Scholar 

  11. Börm W, Kast E, Richter HP et al (2003) Anterior screw fixation in Type II odontoid fractures: is there a difference in outcome between age groups. Neurosurgery 52:1089–1094

    Article  PubMed  Google Scholar 

  12. Clark CR, White AA III (1985) Fractures of the dens. A multicenter study. J Bone Joint Surg Am 67:1340–1348

    CAS  PubMed  Google Scholar 

  13. Coyne TJ, Fehlings MG, Wallace MC et al (1995) C1–C2 posterior cervical fusion: long-term evaluation of results and efficacy. Neurosurgery 37:688–793

    Article  CAS  PubMed  Google Scholar 

  14. Crockard A, Heilman A, Stevens J (1993) Progressive myelopathy secondary to odontoid fractures: clinical, radiographic and surgical features. Neurosurgery 78:579–586

    Article  CAS  Google Scholar 

  15. Currier BL, Todd LT, Maus TP, Fisher DR, Yamzemski MJ (2003) Anatomic relationship of the internal carotid artery to the C1 vertebra: a case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 28:E461–E467

    Article  PubMed  Google Scholar 

  16. DeVivo MJ, Kartus PL, Stover SL, Rutt RD, Fine PR (1987) Seven-year survival following spinal cord injury. Arch Neurol 44:872–875

    CAS  PubMed  Google Scholar 

  17. Dickman CA, Sontagg VK (1998) Posterior C1-C2 Transarticular screw fixation for atlantoaxial arthrodesis. Neurosurgery 43(2):275–280

    Article  CAS  PubMed  Google Scholar 

  18. Doherty BJ, Heggeness MH, Esses SI (1993) A biomechanical study of odontoid fractures and fracture fixation. Spine 18:178–184

    Article  CAS  PubMed  Google Scholar 

  19. Dunn ME, Seljeskog EL (1986) Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery 18:306–310

    Article  CAS  PubMed  Google Scholar 

  20. Ebraheim NA, Misson JR, Xu R, Yeasting RA (2000) The optimal transarticular c1–2 screw length and the location of the hypoglossal nerve? Surg Neurol 53(3):208–210

    Article  CAS  PubMed  Google Scholar 

  21. Ekong CE, Schwartz ML, Tator CH et al (1981) Odontoid fracture: management with early mobilization using the halo device. Neurosurgery 9:631–637

    Article  CAS  PubMed  Google Scholar 

  22. Fassett DR, Harrop JS, Maltenfort M et al (2007) Mortality rates in geriatric patients with spinal cord injuries. J Neurosurg Spine 7(3):277–281

    Article  PubMed  Google Scholar 

  23. Frangen TM, Zilkens C, Muhr G, Schinkel C (2007) Odontoid fractures in the elderly: dorsal C1/C2 fusion is superior to halo-vest immobilization. J Trauma 63:83–89

    Article  PubMed  Google Scholar 

  24. Gallie WE (1939) Fractures and dislocations of the cervical spine. Am J Surg 3:495–499

    Article  Google Scholar 

  25. Glaser JA, Whitehill R, Stamp WG, Jane JA (1986) Complications associated with the halo-vest. A review of 245 cases. J Neurosurg 65:762–769

    Article  CAS  PubMed  Google Scholar 

  26. Goel A, Leheri V (1994) Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir 129:47–53

    Article  CAS  Google Scholar 

  27. Goel A, Desai KI, Muzumdar DP (2002) Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 51:1351–1357

    Article  PubMed  Google Scholar 

  28. Grauer JN, Shafi B, Hilibrand AS et al (2005) Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J 5:123–129

    Article  PubMed  Google Scholar 

  29. Graziano G, Jaggers C, Lee M et al (1993) A comparative study of fixation techniques for Type II fractures of the odontoid process. Spine 18:2383–2387

    Article  CAS  PubMed  Google Scholar 

  30. Greene KA, Dickman CA, Marciano FF, Drabier J, Drayer BP, Sonntag VK (1994) Transverse atlantal ligament disruption associated with odontoid fractures. Spine 19:2307–2314

    CAS  PubMed  Google Scholar 

  31. Hadley MN, Browner CM, Liu SS et al (1988) New subtype of acute odontoid fractures (type IIA). Neurosurgery 22:67–71

    CAS  PubMed  Google Scholar 

  32. Hadley MN, Dickman CA, Browner CM et al (1989) Acute axis fractures: a review of 229 cases. J Neurosurg 71:642–647

    Article  CAS  PubMed  Google Scholar 

  33. Hagen S (1999) CBO memorandum: projections of expenditures for long-term care services for the elderly. Congressional Budget Office, Washington, DC

  34. Hanigan WC, Powell FC, Elwood PW et al (1993) Odontoid fractures in elderly patients. J Neurosurg 78:32–35

    Article  CAS  PubMed  Google Scholar 

  35. Harms J, Melcher RP (2001) Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 26:2467–2471

    Article  CAS  PubMed  Google Scholar 

  36. Harrop JS, Sharan AD, Przybylski GJ (2000) Epidemiology of spinal cord injury after acute odontoid fractures. Neurosurg Focus 8(6):e4

    CAS  PubMed  Google Scholar 

  37. Harrop JS, Przybylski GJ, Vaccaro AR et al (2000) Efficacy of anterior odontoid screw fixation in elderly patients with Type II odontoid fractures. Neurosurg Focus 8(6):e6

    CAS  PubMed  Google Scholar 

  38. Hart R, Saterbak A, Rapp T, Clark C (2000) Nonoperative management of dens fracture nonunion in elderly patients without myelopathy. Spine 25(11):1339–1343

    Article  CAS  PubMed  Google Scholar 

  39. Horn E, Theodore N, Feiz-Erfan I, Lekovic GP, Dickman C, Sonntag VKH (2006) Complications of halo fixation in the elderly. J Neurosurg Spine 5:46–49

    Article  PubMed  Google Scholar 

  40. Irwin AN, Arthur M, Mullins RJ, Hart RA (2004) Variations in injury patterns, treatment and outcome for spinal fractures and paralysis in adult versus geriatric patients. Spine 29:796–802

    Article  PubMed  Google Scholar 

  41. Jackson AP, Haak MH, Khan N, Meyer PR (2005) Cervical spine injuries in the elderly: acute postoperative mortality. Spine 30:1524–1527

    Article  PubMed  Google Scholar 

  42. Jeanneret B, Magerl F (1992) Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 5:464–475

    Article  CAS  PubMed  Google Scholar 

  43. Jenkins JD, Coric D, Branch CL (1998) A clinical comparison of one- and two-screw odontoid fixation. J Neurosurg 89:366–370

    Article  CAS  PubMed  Google Scholar 

  44. Johnson R, Hart D, Simmons E (1977) Cervical orthoses: a study comparing their effectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg Am 59:332–339

    CAS  PubMed  Google Scholar 

  45. Koivikko MP, Kiuru MJ, Koskinen SK, Myllynen P, Santavirta S, Kivisaari L (2004) Factors associated with non-union in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 86:1146–1151

    Article  CAS  PubMed  Google Scholar 

  46. Kuntz C 4th, Mirza SK, Jarell AD, Chapman JR, Shaffrey CL, Newell DW (2000) Type II odontoid fractures in the elderly: early failure of nonsurgical treatment. Neurosurg Focus 8:E7

    Article  PubMed  Google Scholar 

  47. Koller H, Zenner J, Hitzl W, Ferraris L, Resch H, Tauber M, Auffarth A, Lederer S, Mayer M (2009) In vivo analysis of atlantoaxial motion in individuals immobilised with the halo thoracic vest or Philadelphia collar. Spine 34(7):670–679

    Article  PubMed  Google Scholar 

  48. Lennarson PJ, Mostafavi H, Traynelis VC, Walters BC (2000) Management of type II dens fractures: a case-control study. Spine 25:1234–1237

    Article  CAS  PubMed  Google Scholar 

  49. Lieberman IH, Webb JK (1994) Cervical spine injuries in the elderly. J Bone Joint Surg Br 76:877–881

    CAS  PubMed  Google Scholar 

  50. Lind B, Bake B, Lundqvist C, Nordwall A (1987) Influence of halo vest treatment on vital capacity. Spine 12:449–452

    Article  CAS  PubMed  Google Scholar 

  51. Lind B, Nordwall A, Sihlbom H (1987) Odontoid fractures treated with halo-vest. Spine 12:173–177

    Article  CAS  PubMed  Google Scholar 

  52. Maak, Travis G, Grauer, Jonathan N (2006) The contemporary treatment of odontoid injuries. Spine 31(11S):S53–S60

  53. Magerl F, Seeman PS (1986) Stable posterior fusion of the atlas and axis by transarticular screw fixation. In: Kehr P, Weidner A (eds) Cervical spine, vol 1. Springer, Wien, pp 267–278

    Google Scholar 

  54. Maiman DJ, Larson SJ (1982) Management of odontoid fractures. Neurosurgery 11:471–476

    Article  CAS  PubMed  Google Scholar 

  55. Majercik S, Tashjian RZ, Biffl WL, Harrington DT, Cioffi WG (2005) Halo vest immobilization in the elderly: a death sentence? J Trauma 59(2):350–357

    Article  PubMed  Google Scholar 

  56. McBride AD, Mukherjee DP, Kruse RN, Albright JA (1995) Anterior screw fixation of type II odontoid fractures: a biomechanical study. Spine 20:1855–1860

    Article  CAS  PubMed  Google Scholar 

  57. Moscovich R, Crockard H (1990) Myelopathy due to a hypertrophic non-union of the dens: case report. J Trauma 30:222–225

    Article  Google Scholar 

  58. Mouradian WH, Fietti VG, Chochran GVB, Fielding JW, Young J (1978) Fractures of the odontoid: a laboratory and clinical study of mechanism. Orthop Clin North Am 9:985–1001

    CAS  PubMed  Google Scholar 

  59. Muller EJ, Schwinnen I, Fischer K et al (2003) Non-rigid immobilisation of odontoid fractures. Eur Spine J 12:522–525

    Article  PubMed  Google Scholar 

  60. Muller EJ, Wick M, Russe O et al (1999) Management of odontoid fractures in the elderly. Eur Spine J 8:360–365

    Article  CAS  PubMed  Google Scholar 

  61. Olerud C, Andersson S, Svensson B, Bring J (1999) Cervical spine fractures in the elderly: factors influencing survival in 65 cases. Acta Orthop Scand 70:509–513

    Article  CAS  PubMed  Google Scholar 

  62. Paradis G, Janes J (1973) Posttraumatic atlantoaxial instability: the fate of the odontoid process fracture in 46 cases. J Trauma 13:359–366

    Article  CAS  PubMed  Google Scholar 

  63. Pepin JW, Bourne RB, Hawkins RJ (1985) Odontoid fractures, with special reference to the elderly patient. Clin Orthop Relat Res 193:178–183

    PubMed  Google Scholar 

  64. Perry J, Nickel VL (1959) Total cervical-spine fusion for neck paralysis. J Bone Joint Surg Am 41:37–60

    PubMed  Google Scholar 

  65. Platzer P, Thalhammer G, Sarahrudi K, Kovar F, Vekszler G, MD, Vécsei V, Gaebler C (2007) Nonoperative management of odontoid fractures using a halothoracic brace. Neurosurgery 61(3):522–530

  66. Polin RS, Szabo T, Bogaev CA et al (1996) Nonoperative management of types II and III odontoid fractures: the Philadelphia collar versus the halo vest. Neurosurgery 38:450–456

    Article  CAS  PubMed  Google Scholar 

  67. Ryan MD, Henderson JJ (1992) The epidemiology of fractures and fracture-dislocations of the cervical spine. Injury 23:38–40

    Article  CAS  PubMed  Google Scholar 

  68. Ryan MD, Taylor TFK (1993) Odontoid fractures in the elderly. J Spinal Dis 6:397–401

    Article  CAS  Google Scholar 

  69. Schweigel JF (1987) Management of the fractured odontoid with halo-thoracic bracing. Spine 12:838–839

    Article  CAS  PubMed  Google Scholar 

  70. Seybold EA, Bayley JC (1998) Functional outcome of surgically and conservatively managed dens fractures. Spine 23:1837–1845

    Article  CAS  PubMed  Google Scholar 

  71. Smith HE, Kerr SM, Maltenfort M, Chaudhry S, Norton R, Albert TJ, Harrop J, Hilibrand AS et al (2008) Early complications of surgical versus conservative treatment of isolated type ii odontoid fractures in octogenarians: a retrospective cohort study. J Spinal Disord Tech 21(8):535–539

    Article  PubMed  Google Scholar 

  72. Smith HE, Vaccaro AR, Maltenfort M, Albert TJ, Hilibrand AS et al (2008) Trends in surgical management for type ii odontoid fracture: 20 years of experience at a regional spinal cord injury center. Orthopedics 31(7):650

    PubMed  Google Scholar 

  73. Stoney J, O’Brien J, Wilde P (1998) Treatment of type-two odontoid fractures in halothoracic vests. J Bone Joint Surg Br 80:452–455

    Article  CAS  PubMed  Google Scholar 

  74. Stratford J (1957) Myelopathy caused by atlantoaxial dislocation. J Neurosurg 14:97–104

    Article  CAS  PubMed  Google Scholar 

  75. Stulik J, Vyskocil T, Sebesta P, Kryl J (2007) Atlantoaxial fixation using the polyaxial screw-rod system. Eur Spine J 16:479–484

    Article  PubMed  Google Scholar 

  76. Tan MS et al (2003) Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass. Spine 28:888–895

    Article  PubMed  Google Scholar 

  77. Tashjian RZ, Majercik S, Biffl WL, Palumbo MA, Cioffi WG (2006) Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma 60(1):199–203

    Article  PubMed  Google Scholar 

  78. van Middendorp JJ, Slooff WB, Nellestein WR, Oner FC (2009) Incidence of and risk factors for complications associated with halo-vest immobilization: a prospective, descriptive cohort study of 239 patients. J Bone Joint Surg Am 91(1):71–79

    Google Scholar 

  79. Vieweg U, Schultheiss R (2001) A review of halo vest treatment of upper cervical spine injuries. Arch Orthop Trauma Surg 121:50–55

    Article  CAS  PubMed  Google Scholar 

  80. Weller SJ, Malek AM, Rossitch E (1997) Cervical spine fractures in the elderly. Surg Neurol 47:274–281

    Article  CAS  PubMed  Google Scholar 

  81. Wright NM, Lauryssen C (1998) Vertebral artery injury in C1–2 transarticular screw fixation: results of a surgery of the AANS/CNS section on disorders of the spine and peripheral nerves. American Association of Neurological Surgeons/Congress of Neurological Surgeons. J Neurosurg 88:634–640

    Article  CAS  PubMed  Google Scholar 

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Pal, D., Sell, P. & Grevitt, M. Type II odontoid fractures in the elderly: an evidence-based narrative review of management. Eur Spine J 20, 195–204 (2011). https://doi.org/10.1007/s00586-010-1507-6

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