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Identifying factors influencing mortality in patients aged over 65 following an acute type II odontoid process fracture. A retrospective cohort study



Compare short-term mortality rates following operative and nonoperative management of geriatric patients following an acute type II odontoid process fracture.


One hundred forty-one patients with a type II odontoid fracture were identified from a single centre between 2002 and 2018. Patient demographics, details of injury and management, plus mortality data were collected. The incidence of mortality at 3 and 12 months was calculated, and a multivariate model built which included the treatment modality variable and allowed adjustment for six individual confounders.


Of the 141 patients with a type II odontoid process fracture, 39 were managed operatively, while 102 were managed nonoperatively. Relative to the nonoperative group, the operative group was younger (79.0 ± 7.0 vs. 83.7 ± 7.6), more likely to have odontoid angulation > 15° (74.4% vs. 43.1%, p < 0.01), and a greater proportion having fracture displacement > 2 mm (74.4% vs. 31.4%, p < 0.01). Both groups were comparable for gender, comorbidities, and associated injuries. On univariate analysis of treatment modality, the odds ratio of 3-month mortality with nonoperative management was 2.55 (95% CI: 0.82–7.92; p = 0.08), whilst at 12-months it was 3.12 (95% CI: 1.11–8.69; p = 0.02). On multivariate analysis of 12-month mortality, however, treatment modality was not found to be significant. This multivariate analysis suggested that increasing age, male gender, and injury severity were significant predictors of 12-month mortality.


In contrast to the findings of a number of previous studies, operative management may not influence survival at 3- and 12-months.

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The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

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  1. De Bonis P, Iaccarino C, Musio A, Martucci A, De Iure F, Donati R, Cultrera F, Tosatto L, Servadei F, Alesi D, Cavallo MA, Ghadirpour R, Molinari F, Lofrese G (2019) Functional outcome of elderly patients treated for odontoid fracture. Spine 44(13):951–958.

    Article  PubMed  Google Scholar 

  2. Ryan MD, Henderson JJ (1992) The epidemiology of fractures and fracture-dislocations of the cervical spine. Injury 23(1):38–40.

    CAS  Article  PubMed  Google Scholar 

  3. Anderson LD, D’Alonzo RT (1974) Fractures of the odontoid process of the axis. J Bone Joint Surg Am 56(8):1663–1674

    CAS  Article  Google Scholar 

  4. Hsu WK, Anderson PA (2010) Odontoid fractures: update on management. J Am Acad Orthop Surg 18(7):383–394.

    Article  PubMed  Google Scholar 

  5. Julien TD, Frankel B, Traynelis VC, Ryken TC (2000) Evidence-based analysis of odontoid fracture management. Neurosurg Focus 8(6):e1.

    CAS  Article  PubMed  Google Scholar 

  6. Chiba K, Fujimura Y, Toyama Y, Fujii E, Nakanishi T, Hirabayashi K (1996) Treatment protocol for fractures of the odontoid process. J Spinal Disord 9(4):267–276

    CAS  Article  Google Scholar 

  7. Chapman J, Smith JS, Kopjar B, Vaccaro AR, Arnold P, Shaffrey CI, Fehlings MG (2013) The AOSpine North America geriatric odontoid fracture mortality study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976) 38(13):1098–1104.

    Article  Google Scholar 

  8. Fehlings MG, Arun R, Vaccaro AR, Arnold PM, Chapman JR, Kopjar B (2013) Predictors of treatment outcomes in geriatric patients with odontoid fractures: AOSpine North America multi-centre prospective GOF study. Spine (Phila Pa 1976) 38(11):881–886.

    Article  Google Scholar 

  9. Graffeo CS, Perry A, Puffer RC, Carlstrom LP, Chang W, Mallory GW, Clarke MJ (2017) Deadly falls: operative versus nonoperative management of Type II odontoid process fracture in octogenarians. J Neurosurg Spine 26(1):4–9.

    Article  PubMed  Google Scholar 

  10. Perry A, Graffeo CS, Carlstrom LP, Chang W, Mallory GW, Puffer RC, Clarke MJ (2018) Fusion, failure, fatality: long-term outcomes after surgical versus nonoperative management of type ii odontoid fracture in octogenarians. World Neurosurg 110:e484–e489.

    Article  PubMed  Google Scholar 

  11. Robinson Y, Robinson AL, Olerud C (2014) Systematic review on surgical and nonsurgical treatment of type II odontoid fractures in the elderly. Biomed Res Int 2014:231948.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Schoenfeld AJ, Bono CM, Reichmann WM, Warholic N, Wood KB, Losina E, Katz JN, Harris MB (2011) Type II odontoid fractures of the cervical spine: do treatment type and medical comorbidities affect mortality in elderly patients? Spine (Phila Pa 1976) 36(11):879–885.

    Article  Google Scholar 

  13. Smith JS, Kepler CK, Kopjar B, Harrop JS, Arnold P, Chapman JR, Fehlings MG, Vaccaro AR, Shaffrey CI (2013) Effect of type II odontoid fracture nonunion on outcome among elderly patients treated without surgery: based on the AOSpine North America geriatric odontoid fracture study. Spine (Phila Pa 1976) 38(26):2240–2246.

    Article  Google Scholar 

  14. Vaccaro AR, Kepler CK, Kopjar B, Chapman J, Shaffrey C, Arnold P, Gokaslan Z, Brodke D, France J, Dekutoski M, Sasso R, Yoon ST, Bono C, Harrop J, Fehlings MG (2013) Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. J Bone Joint Surg Am 95(8):729–735.

    Article  PubMed  Google Scholar 

  15. Grauer JN, Shafi B, Hilibrand AS, Harrop JS, Kwon BK, Beiner JM, Albert TJ, Fehlings MG, Vaccaro AR (2005) Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J 5(2):123–129.

    Article  PubMed  Google Scholar 

  16. Baker S, O’Neill B, Haddon WJ, Long W (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma Acute Care Surg 14(3):187–196

    CAS  Article  Google Scholar 

  17. Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47(11):1245–1251.

    CAS  Article  PubMed  Google Scholar 

  18. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, Initiative S (2008) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61(4):344–349.

    Article  Google Scholar 

  19. StataCorp, (2019) Stata Statistical Software, 16th edn. StataCorp LLC, College Station

    Google Scholar 

  20. Hanigan WC, Powell FC, Elwood PW, Henderson JP (1993) Odontoid fractures in elderly patients. J Neurosurg 78(1):32–35.

    CAS  Article  PubMed  Google Scholar 

  21. Smith HE, Kerr SM, Maltenfort M, Chaudhry S, Norton R, Albert TJ, Harrop J, Hilibrand AS, Anderson DG, Kopjar B, Brodke DS, Wang JC, Fehlings MG, Chapman JR, Patel A, Arnold PM, Vaccaro AR (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 

  22. Malik SA, Murphy M, Connolly P, O’Byrne J (2008) Evaluation of morbidity, mortality and outcome following cervical spine injuries in elderly patients. Eur Spine J 17(4):585–591.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Lukins, T., Nguyen, L., Hansen, M.A. et al. Identifying factors influencing mortality in patients aged over 65 following an acute type II odontoid process fracture. A retrospective cohort study. Eur Spine J 30, 1551–1555 (2021).

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  • Odontoid process
  • Spinal fracture
  • Aged
  • Mortality