Treffer: Comparative Effectiveness of Conservative Management Versus Surgical Fixation in Acute Type II Odontoid Fractures.
Title:
Comparative Effectiveness of Conservative Management Versus Surgical Fixation in Acute Type II Odontoid Fractures.
Authors:
Yazdanian F; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Enriquez-Marulanda A; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Ramirez-Velandia F; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Alwakaa O; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Sconzo D; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA., Terry F; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Pandya P; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Papavassiliou E; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Stippler M; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA., Moses ZB; Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA.; Harvard Medical School, Boston , Massachusetts , USA.
Source:
Neurosurgery [Neurosurgery] 2026 Jan 01; Vol. 98 (1), pp. 61-72. Date of Electronic Publication: 2025 May 19.
Publication Type:
Journal Article; Comparative Study
Language:
English
Journal Info:
Publisher: Lippincott Williams & Wilkins, Inc Country of Publication: United States NLM ID: 7802914 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1524-4040 (Electronic) Linking ISSN: 0148396X NLM ISO Abbreviation: Neurosurgery Subsets: MEDLINE
Imprint Name(s):
Publication: 2022- : [Philadelphia] : Lippincott Williams & Wilkins, Inc.
Original Publication: Baltimore, Williams & Wilkins.
Original Publication: Baltimore, Williams & Wilkins.
MeSH Terms:
Conservative Treatment*/methods , Odontoid Process*/injuries , Odontoid Process*/surgery , Odontoid Process*/diagnostic imaging , Spinal Fractures*/therapy , Spinal Fractures*/surgery , Spinal Fractures*/diagnostic imaging , Fracture Fixation, Internal*/methods , Fracture Fixation*/methods, Humans ; Female ; Male ; Aged ; Aged, 80 and over ; Retrospective Studies ; Treatment Outcome
References:
Rizvi SAM, Helseth E, Rønning P, et al. Odontoid fractures: impact of age and comorbidities on surgical decision making. BMC Surg. 2020;20(1):236.
Scheyerer MJ, Zimmermann SM, Simmen HP, Wanner GA, Werner CM. Treatment modality in type II odontoid fractures defines the outcome in elderly patients. BMC Surg. 2013;13:54.
Hamilton P, Lawrence P, Eisenring CV. Treatment of type II odontoid fracture in the elderly. J Surg Case Rep. 2020;2020(8):rjaa235.
Hart R, Saterbak A, Rapp T, Clark C. Nonoperative management of dens fracture nonunion in elderly patients without myelopathy. Spine. 2000;25(11):1339-1343.
Joaquim AF, Patel AA. Surgical treatment of Type II odontoid fractures: anterior odontoid screw fixation or posterior cervical instrumented fusion? Neurosurg Focus. 2015;38(4):e11.
Avila MJ, Farber SH, Rabah NM, et al. Nonoperative versus operative management of type II odontoid fracture in older adults: a systematic review and meta-analysis. J Neurosurg Spine. 2024;40(1):45-53.
Pearson AM, Martin BI, Lindsey M, Mirza SK. C2 vertebral fractures in the medicare population: incidence, outcomes, and costs. J Bone Joint Surg Am. 2016;98(6):449-456.
Moses ZB, Oh SY, Fontes RBV, Deutsch H, O’Toole JE, Fessler RG. The modified frailty index and patient outcomes following transforaminal lumbar interbody fusion surgery for single-level degenerative spine disease. J Neurosurg Spine. 2021;35(2):163-169.
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991;73(6):802-808.
Huybregts JGJ, Polak SB, Jacobs WCH, et al. Low-threshold-for-surgery versus primarily-conservative treatment for odontoid fractures in the elderly: evaluating practice variation in The Netherlands. Glob Spine J. 2025;15(2):490-497.
Lofrese G, Musio A, De Iure F, et al. Type II odontoid fracture in elderly patients treated conservatively: is fracture healing the goal? Eur Spine J. 2019;28(5):1064-1071.
Wilson C, Hoyos M, Huh A, et al. Institutional review of the management of type II odontoid fractures: associations and outcomes with fibrous union. J Neurosurg Spine. 2021;34(4):623-631.
Hong J, Zaman R, Coy S, et al. A cohort study of the natural history of odontoid pseudoarthrosis managed nonoperatively in elderly patients. World Neurosurg. 2018;114:e1007-e1015.
Alluri R, Bouz G, Solaru S, Kang H, Wang J, Hah RJ. A nationwide analysis of geriatric odontoid fracture incidence, complications, mortality, and cost. Spine. 2021;46(2):131-137.
Iyer S, Hurlbert RJ, Albert TJ. Management of odontoid fractures in the elderly: a review of the literature and an evidence-based treatment algorithm. Neurosurgery. 2018;82(4):419-430.
Govender S, Maharaj JF, Haffajee MR. Fractures of the odontoid process. J Bone Joint Surg Br. 2000;82(8):1143-1147.
Koivikko MP, Kiuru MJ, Koskinen SK, Myllynen P, Santavirta S, Kivisaari L. Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br. 2004;86(8):1146-1151.
Karamian BA, Liu N, Ajiboye RM, Cheng I, Hu SS, Wood KB. Reliability of radiological measurements of type 2 odontoid fracture. Spine J. 2019;19(8):1324-1330.
Rizk E, Kelleher JP, Zalatimo O, et al. Nonoperative management of odontoid fractures: a review of 59 cases. Clin Neurol Neurosurg. 2013;115(9):1653-1656.
Yamaguchi S, Park BJ, Takeda M, et al. Healing process of Type II odontoid fractures after C1-C2 posterior screw fixation: predictive factors for pseudoarthrosis. Surg Neurol Int. 2022;13:116.
Pongmanee S, Kaensuk S, Sarasombath P, Rojdumrongrattana B, Kritworakarn N, Liawrungrueang W. Anterior screw fixation for type II odontoid process fractures: a single-center experience with the double Herbert screw fixation technique (Retrospective cohort study). Ann Med Surg. 2022;74:103337.
Pearson RG, Clement RGE, Edwards KL, Scammell BE. Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis. BMJ Open. 2016;6(11):e010303.
van Trikt CH, Donders JCE, Klinger CE, Wellman DS, Helfet DL, Kloen P. Operative treatment of nonunions in the elderly: clinical and radiographic outcomes in patients at minimum 75 years of age. BMC Geriatr. 2022;22(1):985.
Schlundt C, Bucher CH, Tsitsilonis S, Schell H, Duda GN, Schmidt-Bleek K. Clinical and research approaches to treat non-union fracture. Curr Osteoporos Rep. 2018;16(2):155-168.
Cloney M, Thirunavu V, Roumeliotis A, et al. Odontoid fracture type and angulation affect nonunion risk, but comminution and displacement do not: a propensity score matched analysis of fracture morphology. Clin Neurol Neurosurg. 2023;231:107855.
Harris L, Arif S, Elliot M, et al. Fusion rates for conservative and surgical management of type II odontoid fractures and its impact. Br J Neurosurg. 2021;35(5):607-610.
Lennarson PJ, Mostafavi H, Traynelis VC, Walters BC. Management of type II dens fractures: a case-control study. Spine. 2000;25(10):1234-1237.
Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative management of Types II and III odontoid fractures: the Philadelphia collar versus the halo vest. Neurosurgery. 1996;38(3):450-457; discussion 456-457.
Dunn ME, Seljeskog EL. Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306-310.
DePasse JM, Palumbo MA, Ahmed AK, Adams CA, Daniels AH. Halo-Vest immobilization in elderly odontoid fracture patients: evolution in treatment modality and in-hospital outcomes. Clin Spine Surg. 2017;30(9):e1206-e1210.
De Nardi M, French E, Jones JB, McCauley J. Medical spending of the US elderly. Fisc Stud. 2016;37(3-4):717-747.
Crockard HA, Heilman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features. J Neurosurg. 1993;78(4):579-586.
Kirankumar MV, Behari S, Salunke P, Banerji D, Chhabra DK, Jain VK. Surgical management of remote, isolated type II odontoid fractures with atlantoaxial dislocation causing cervical compressive myelopathy. Neurosurgery. 2005;56(5):1004-1012; discussion 1004-1012.
Butler JS, Dolan RT, Burbridge M, et al. The long-term functional outcome of type II odontoid fractures managed non-operatively. Eur Spine J. 2010;19(10):1635-1642.
Texakalidis P, Matsoukas S, Karras CL, et al. Outcomes following anterior odontoid screw versus posterior arthrodesis for odontoid fractures: a systematic review and meta-analysis. J Neurosurg Spine. 2023;39(2):196-205.
Scheyerer MJ, Zimmermann SM, Simmen HP, Wanner GA, Werner CM. Treatment modality in type II odontoid fractures defines the outcome in elderly patients. BMC Surg. 2013;13:54.
Hamilton P, Lawrence P, Eisenring CV. Treatment of type II odontoid fracture in the elderly. J Surg Case Rep. 2020;2020(8):rjaa235.
Hart R, Saterbak A, Rapp T, Clark C. Nonoperative management of dens fracture nonunion in elderly patients without myelopathy. Spine. 2000;25(11):1339-1343.
Joaquim AF, Patel AA. Surgical treatment of Type II odontoid fractures: anterior odontoid screw fixation or posterior cervical instrumented fusion? Neurosurg Focus. 2015;38(4):e11.
Avila MJ, Farber SH, Rabah NM, et al. Nonoperative versus operative management of type II odontoid fracture in older adults: a systematic review and meta-analysis. J Neurosurg Spine. 2024;40(1):45-53.
Pearson AM, Martin BI, Lindsey M, Mirza SK. C2 vertebral fractures in the medicare population: incidence, outcomes, and costs. J Bone Joint Surg Am. 2016;98(6):449-456.
Moses ZB, Oh SY, Fontes RBV, Deutsch H, O’Toole JE, Fessler RG. The modified frailty index and patient outcomes following transforaminal lumbar interbody fusion surgery for single-level degenerative spine disease. J Neurosurg Spine. 2021;35(2):163-169.
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991;73(6):802-808.
Huybregts JGJ, Polak SB, Jacobs WCH, et al. Low-threshold-for-surgery versus primarily-conservative treatment for odontoid fractures in the elderly: evaluating practice variation in The Netherlands. Glob Spine J. 2025;15(2):490-497.
Lofrese G, Musio A, De Iure F, et al. Type II odontoid fracture in elderly patients treated conservatively: is fracture healing the goal? Eur Spine J. 2019;28(5):1064-1071.
Wilson C, Hoyos M, Huh A, et al. Institutional review of the management of type II odontoid fractures: associations and outcomes with fibrous union. J Neurosurg Spine. 2021;34(4):623-631.
Hong J, Zaman R, Coy S, et al. A cohort study of the natural history of odontoid pseudoarthrosis managed nonoperatively in elderly patients. World Neurosurg. 2018;114:e1007-e1015.
Alluri R, Bouz G, Solaru S, Kang H, Wang J, Hah RJ. A nationwide analysis of geriatric odontoid fracture incidence, complications, mortality, and cost. Spine. 2021;46(2):131-137.
Iyer S, Hurlbert RJ, Albert TJ. Management of odontoid fractures in the elderly: a review of the literature and an evidence-based treatment algorithm. Neurosurgery. 2018;82(4):419-430.
Govender S, Maharaj JF, Haffajee MR. Fractures of the odontoid process. J Bone Joint Surg Br. 2000;82(8):1143-1147.
Koivikko MP, Kiuru MJ, Koskinen SK, Myllynen P, Santavirta S, Kivisaari L. Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br. 2004;86(8):1146-1151.
Karamian BA, Liu N, Ajiboye RM, Cheng I, Hu SS, Wood KB. Reliability of radiological measurements of type 2 odontoid fracture. Spine J. 2019;19(8):1324-1330.
Rizk E, Kelleher JP, Zalatimo O, et al. Nonoperative management of odontoid fractures: a review of 59 cases. Clin Neurol Neurosurg. 2013;115(9):1653-1656.
Yamaguchi S, Park BJ, Takeda M, et al. Healing process of Type II odontoid fractures after C1-C2 posterior screw fixation: predictive factors for pseudoarthrosis. Surg Neurol Int. 2022;13:116.
Pongmanee S, Kaensuk S, Sarasombath P, Rojdumrongrattana B, Kritworakarn N, Liawrungrueang W. Anterior screw fixation for type II odontoid process fractures: a single-center experience with the double Herbert screw fixation technique (Retrospective cohort study). Ann Med Surg. 2022;74:103337.
Pearson RG, Clement RGE, Edwards KL, Scammell BE. Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis. BMJ Open. 2016;6(11):e010303.
van Trikt CH, Donders JCE, Klinger CE, Wellman DS, Helfet DL, Kloen P. Operative treatment of nonunions in the elderly: clinical and radiographic outcomes in patients at minimum 75 years of age. BMC Geriatr. 2022;22(1):985.
Schlundt C, Bucher CH, Tsitsilonis S, Schell H, Duda GN, Schmidt-Bleek K. Clinical and research approaches to treat non-union fracture. Curr Osteoporos Rep. 2018;16(2):155-168.
Cloney M, Thirunavu V, Roumeliotis A, et al. Odontoid fracture type and angulation affect nonunion risk, but comminution and displacement do not: a propensity score matched analysis of fracture morphology. Clin Neurol Neurosurg. 2023;231:107855.
Harris L, Arif S, Elliot M, et al. Fusion rates for conservative and surgical management of type II odontoid fractures and its impact. Br J Neurosurg. 2021;35(5):607-610.
Lennarson PJ, Mostafavi H, Traynelis VC, Walters BC. Management of type II dens fractures: a case-control study. Spine. 2000;25(10):1234-1237.
Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative management of Types II and III odontoid fractures: the Philadelphia collar versus the halo vest. Neurosurgery. 1996;38(3):450-457; discussion 456-457.
Dunn ME, Seljeskog EL. Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306-310.
DePasse JM, Palumbo MA, Ahmed AK, Adams CA, Daniels AH. Halo-Vest immobilization in elderly odontoid fracture patients: evolution in treatment modality and in-hospital outcomes. Clin Spine Surg. 2017;30(9):e1206-e1210.
De Nardi M, French E, Jones JB, McCauley J. Medical spending of the US elderly. Fisc Stud. 2016;37(3-4):717-747.
Crockard HA, Heilman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features. J Neurosurg. 1993;78(4):579-586.
Kirankumar MV, Behari S, Salunke P, Banerji D, Chhabra DK, Jain VK. Surgical management of remote, isolated type II odontoid fractures with atlantoaxial dislocation causing cervical compressive myelopathy. Neurosurgery. 2005;56(5):1004-1012; discussion 1004-1012.
Butler JS, Dolan RT, Burbridge M, et al. The long-term functional outcome of type II odontoid fractures managed non-operatively. Eur Spine J. 2010;19(10):1635-1642.
Texakalidis P, Matsoukas S, Karras CL, et al. Outcomes following anterior odontoid screw versus posterior arthrodesis for odontoid fractures: a systematic review and meta-analysis. J Neurosurg Spine. 2023;39(2):196-205.
Contributed Indexing:
Keywords: Conservative; Odontoid; Radiological; Surgery; Type II; Union
Entry Date(s):
Date Created: 20250519 Date Completed: 20251215 Latest Revision: 20251215
Update Code:
20251215
DOI:
10.1227/neu.0000000000003533
PMID:
40387334
Database:
MEDLINE
Weitere Informationen
Background and Objectives: Managing acute type II odontoid fractures in the elderly is challenging because of comorbidities and frailty. This study evaluates radiological and functional outcomes of conservative vs surgical treatment.
Methods: A retrospective analysis at a single US institution on elderly patients with acute type II odontoid fractures (January 2015-December 2023) was performed. Bivariate and logistic regression analyses compared outcomes and identified predictors of union.
Results: The study included 273 patients, 20 of which expired during hospital admission, leaving 253 patients available for analysis with outcomes data. The median age was 82 years (IQR: 74-90), and 53% were female. Of 253 patients, 235 (93%) received conservative treatment and 18 (7%) underwent surgical fixation. At a median radiological follow-up of 3.75 months, surgical patients had higher fracture union rates (44% vs 10%, P < .01). Modified Rankin Scale ≤2 rates were similar (75% vs 73%, P = .85), but conservative treatment showed higher excellent pain control (75% vs 47%, P < .01). Logistic regression showed high union prediction accuracy (area under the curve = 0.93). Surgical fixation was the strongest predictor of union (adjusted odds ratio [aOR] = 6.6, 95% CI 1.8-24.5). Age ≥80 years (aOR = 0.1, 95% CI 0.05-0.2), smoking history (aOR = 0.2, 95% CI 0.1-0.6), osteoporosis (aOR = 0.1, 95% CI 0.02-0.6), and mild (aOR = 0.12, 95% CI 0.06-0.3), moderate (aOR = 0.08, 95% CI 0.03-0.2), and severe frailty (aOR = 0.04, 95% CI 0.01-0.1) were negatively associated with union. Angulation ≥11° also reduced union odds (aOR = 0.16, 95% CI 0.07-0.4).
Conclusion: Surgical fixation positively predicts fracture union, whereas advanced age, smoking, osteoporosis, frailty, and angulation (≥11°) reduce union odds. Surgery may enhance union odds, but conservative management remains effective with better pain control, without compromising long-term functional outcomes.
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