What are the treatment options for odontoid fracture type II (dens fracture)?

From the Guidelines

Treatment for odontoid fracture type II should prioritize surgical options, such as anterior odontoid screw fixation or posterior C1-C2 fusion techniques, for displaced fractures or those with high risk of non-union, as they offer better outcomes in terms of morbidity, mortality, and quality of life. When considering treatment options for Type II odontoid fractures, it's essential to weigh the benefits and risks of conservative versus surgical approaches. Conservative management, involving external immobilization with a rigid cervical collar or halo vest for 8-12 weeks, is typically reserved for stable fractures with minimal displacement and in patients who are poor surgical candidates 1. However, the most recent and highest quality study 1 emphasizes the importance of minimizing cervical spine movement during pre-oxygenation and facemask ventilation, and suggests the use of jaw thrust rather than head tilt plus chin lift when a simple manoeuvre is required to maintain an airway. Key considerations in choosing between treatments include:

• Fracture characteristics, such as displacement and angulation
• Patient age and comorbidities
• Bone quality
• Surgeon experience
• The potential for non-union, which is higher in older patients (>50 years) with conservative treatment 1. Given the potential risks and benefits, surgical options are generally preferred for displaced fractures (>5mm), fractures with angulation >10 degrees, or when there's a high risk of non-union, as they offer better stability and outcomes in terms of morbidity, mortality, and quality of life. Post-treatment follow-up with serial radiographs is essential to monitor healing progress regardless of the chosen approach.

From the Research

Treatment Options for Odontoid Fracture Type II

The treatment options for odontoid fracture type II can be categorized into nonoperative and operative management.

• Nonoperative management includes:
  • External immobilization using a halo vest or a rigid cervical orthosis 2, 3, 4
  • This approach is often recommended for patients with stable fractures, minimal displacement, and no neurological deficits
• Operative management includes:
  • Anterior odontoid screw fixation, which is considered the treatment of choice for unstable odontoid fractures with a horizontal, down and back, or comminuted fracture line 5
  • Posterior stabilization using transarticular screws and modified Gallie fusion, which is often recommended for patients with unstable fractures, significant displacement, or neurological deficits 5, 6
  • Placement of screws in the dens and in the joints through a single approach, which may be necessary in cases with associated Jefferson fracture or dislocation greater than 7 mm 5

Factors Influencing Treatment Choice

The choice of treatment for odontoid fracture type II depends on several factors, including:

• Fracture stability and displacement 5, 6
• Presence of neurological deficits 5, 6
• Patient age and comorbidities 6, 3, 4
• Patient preference and quality of life considerations 3, 4

Outcomes and Complications

The outcomes and complications of treatment for odontoid fracture type II can vary depending on the approach used.

• Nonoperative management may result in a higher risk of nonunion or pseudarthrosis, but can also provide excellent functional outcomes in many cases 2, 3, 4
• Operative management can provide stable fixation and promote bony union, but may also be associated with perioperative risks and complications 5, 6