What is the treatment for an odontoid fracture?

Treatment for Odontoid Fractures

The treatment of odontoid fractures should be determined based on fracture type, stability, patient age, and presence of neurological symptoms, with surgical intervention recommended for unstable Type II fractures, especially in patients over 50 years of age. 1, 2

Classification and Initial Assessment

• Odontoid fractures represent approximately 20% of all cervical spine fractures, with Type II fractures (at the base of the dens) being the most common pattern 1, 3
• Anderson and D'Alonzo classification is used to categorize odontoid fractures into three types, which guides treatment decisions 2, 3
• Radiographic examination is essential to confirm the fracture type, displacement, and stability 1, 4

Treatment Algorithm Based on Fracture Type

Type I and Type III Fractures

• Generally heal well with non-operative treatment using external immobilization 3
• Some Type III fractures with high and shallow bases may behave like Type II fractures with increased nonunion risk 3

Type II Fractures (Most Common and Controversial)

• Conservative Management:

  • May be appropriate for stable fractures in younger patients 1
  • Hard cervical collar or cervicothoracic orthosis is preferred over halo-vest, especially in elderly patients due to high complication rates with halo devices 1
  • When fracture line is directed down and forward, external immobilization may be sufficient for healing 4

• Surgical Management:

  • Recommended for patients older than 50 years with Type II odontoid fractures 2
  • Also indicated for patients at high risk for nonunion and those with unstable fractures 2, 4

Surgical Options

Anterior Odontoid Screw Fixation (AOSF)

• Preserves atlantoaxial motion 2
• Requirements for successful AOSF:
  • Reducible odontoid fracture 2
  • Intact transverse ligament 2
  • Favorable fracture line for adequate compression 2, 4
  • Displacement less than 7mm 4
• Older patients may have higher pseudarthrosis rates and postoperative dysphagia with this approach 2
• Considered treatment of choice for unstable odontoid fractures with horizontal, down-and-back, or comminuted fracture lines without significant displacement 4

Posterior Cervical Instrumented Fusion (PCIF)

• Higher fusion rates compared to AOSF 2
• Indicated for:
  • Severe atlantoaxial misalignment 2
  • Poor bone quality 2
  • Failed anterior screw fixation 2
  • Fractures associated with Jefferson fractures 4
  • Displacement greater than 7mm 4
• Allows direct open reduction of displaced fragments 2
• Disadvantages include loss of atlantoaxial motion, requirement for prone positioning, and longer operative duration 2

Special Considerations

• For inveterate fractures with severe C1-C2 dislocation, posterior stabilization using the Guo technique offers the best prospects 4
• Patients with delayed presentation and neurological symptoms may require:
  • Assessment of reducibility with extension films 5
  • Cranial traction for up to 14 days to attempt reduction 5
  • Transoral decompression if reduction fails 5
  • C1-C2 fusion in all cases 5

Complications to Monitor

• Nonunion (especially in Type II fractures) 1
• Neurological deterioration due to spinal cord damage 4
• Postoperative dysphagia with anterior approaches 2
• Mortality and morbidity (particularly high in elderly patients) 1