The optimal treatment of type II and III odontoid fractures in the elderly: a systematic review

Abstract Purpose Odontoid fractures are the most common cervical spine fractures in the elderly. As the population ages, their incidence is expected to increase progressively. The optimal treatment of this condition is still the subject of controversy. The objective of this review is to summarize and compare the outcome of surgical and conservative interventions in the elderly (C65 years). Methods A comprehensive search was conducted in nine databases of medical literature, supplemented by reference and citation tracking. Clinical status was considered the primary outcome. Fracture union and stability rates were considered secondary outcomes. Results A total of nineteen studies met the inclusion criteria. All studies were performed retrospectively and were of limited quality. There was insufficient data, especially from direct comparisons, to determine the difference in clinical outcome between surgical and conservative interventions. Osseous union was achieved in 66-85 % of surgically treated patients and in 28-44 % of conservatively treated patients. Fracture stability was achieved in 82-97 % of surgically patients and in 53-79 % of conservatively treated patients. Conclusions There was insufficient data to determine a potential difference in clinical outcome between different treatment groups. Surgically treated patients showed higher osseous union rates compared to conservatively treated patients, possibly because of different selection mechanisms. The majority of patients appears to achieve fracture stability regardless of the applied treatment. A prospective trial with appropriate sample size is needed to identify the optimal treatment of odontoid fractures in the elderly and predictors for the success of either one of the available treatments

Low-Threshold-For-Surgery Versus Primarily-Conservative Treatment for Odontoid Fractures in the Elderly:Evaluating Practice Variation in The Netherlands

Study Design Retrospective cohort study. Objectives Odontoid fractures are the most common cervical spine fractures in the elderly. The optimal treatment remains controversial. The aim of this study was to compare results of a low-threshold-for-surgery strategy (surgery for dislocated fractures in relatively healthy patients) to a primarily-conservative strategy (for all patients). Methods Patient records from 5 medical centers were reviewed for patients who met the selection criteria (e.g. age & GE;55 years, type II/III odontoid fractures). Demographics, fracture types/characteristics, fracture union/stability, clinical outcome and mortality were compared. The influence of age on outcome was studied (& GE;55-80 vs & GE;80 years). Results A total of 173 patients were included: 120 treated with low-threshold-for-surgery (of which 22 primarily operated, and 23 secondarily) vs 53 treated primarily-conservative. No differences in demographics and fracture characteristics between the groups were identified. Fracture union (53% vs 43%) and fracture stability (90% vs 85%) at last follow-up did not differ between groups. The majority of patients (56%) achieved clinical improvement compared to baseline. Analysis of differences in clinical outcome between groups was infeasible due to data limitations. In both strategies, patients & GE;80 years achieved worse union (64% vs 30%), worse stability (97% vs 77%), and - as to be expected - increased mortality <104 weeks (2% vs 22%). Conclusions Union and stability rates did not differ between the treatment strategies. Advanced age (& GE;80 years) negatively influenced both radiological outcome and mortality. No cases of secondary neurological deficits were identified, suggesting that concerns for the consequences of under-treatment may be unjustified