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Abstract

Introduction

The retrospective study evaluated the clinical and radiological outcomes of conservative treatment for type II odontoid C2 fractures in octogenerians. The study aimed to assess the clinical outcomes and quality of survival of patients treated using conservative methods. Additionally, the study sought to define radiological outcomes, fracture healing success and the development of complications in correlation with clinical outcomes.

Materials and Methods

Patients aged ≥80 with dens C2 fracture were fixed with a hard cervical collar for 6 weeks, followed by early mobilization. Patients showing delayed fracture healing on computed tomography (CT) scan were subsequently immobilized in a soft neck collar for additional 6 weeks. The follow-up CT scan was then performed with consequential rehabilitation. Patients with nonunion of the C2 on the follow-up CT scan and clinical symptoms were contraindicated for physical rehabilitation for cervical spine till next CT scan after another 12 weeks. Clinical and radiographic evaluations were performed during follow-up visits, with a median follow-up was 109 days, with the range extending from 1 day to 1 year.

Results

In total, 33 patients were included in the study and were followed for 1 year. The 30-day mortality rate was 21.2%, and between 30 days and one year post-treatment, it was 18.2%. Mortality was higher during the study period in displaced fractures (>2 mm; 9 out of 16 patients died) compared to non-displaced fractures (≤2 mm; 4 out of 17 patients died). The Japanese Orthopaedic Association (JOA) score remained unchanged between admission (mean 16.9; SD ± 0.5) and the end of follow-up (mean 16.9; SD ± 0.5; P > 0.05), the Visual Analogue Scale (VAS) score showed improvement from values measured upon admission to the hospital (mean 7.97; SD ± 1.33) to values measured at the end of follow-up (mean 1.58; SD ± 1.62; P < 0.001) and the Neck Disability Index (NDI) showed a statistically significant difference between admission (mean 41.3; SD ± 14.92) and the end of follow-up (mean 14.29; SD ± 4.65; P < 0.001). The standard measurement of Posterior Atlantodental Interval (PADI) had an average value of 18.6 (range 16-22 mm) and primary bony union of odontoid fractures occurred in eleven cases (33.3%), while six patients (18.2%) had fibrous union with minimal clinical difficulties.

Conclusion

This study demonstrates the safety and efficacy of conservative treatment for odontoid fractures in octogenerians and underscores the critical role of conservative management in a polymorbid elderly population.

Keywords

odontoid fracture octogenerians conservative treatment fracture union mortality

Introduction

Fractures of the axis (C2) are the most common isolated fractures of the cervical spine¹ in patients older than 65 years, comprising approximately 5-20% of all cervical spine fractures.^2-5 In patients over 80, C2 fractures represent the majority of all cervical spine fractures, with an incidence of up to 60%,^6,7 often combined with atlas (C1) injuries.^8,9 The most typical fracture of C2 is the type II odontoid fracture according to the Anderson and D'Alonzo classification,^2,10-12 with an increasing incidence due to demographic changes.¹³ Injuries in the geriatric population typically result from low-energy extension mechanisms in the setting of advanced degeneration of the upper cervical spine and low bone quality in the area of the odontoid base.^2,14-18 Delayed diagnosis or failure of conservative therapy can lead to gross dislocation with instability and neurological complications.¹⁹ Prior studies suggest similar mortality rates for both operated and non-operated patients, yet surgical intervention often involves higher morbidity.¹⁹ Treatment options for type II fractures include both conservative and surgical approaches, however, patient age, comorbidities, bone quality, and segmental degeneration contribute to the ongoing debate over optimal management, especially in older patients who may have increased surgical risks. Clear indications for choosing between conservative or surgical treatment are not yet established.²

This retrospective study aimed to evaluate the clinical and radiological outcomes of conservative treatment of type II odontoid fractures according to Anderson and D'Alonzo classification in the geriatric population over 80 years at our institution. The study aimed to accomplish the following: firstly, to evaluate the clinical outcomes including mortality and quality of life of surviving patients (using VAS, JOA and NDI scores) treated by conservative methods, and secondly, to define radiological outcomes, fracture healing success, and the development of complications in relation to clinical outcomes.

Materials and Methods

This single center retrospective study assessing the effectiveness of conservative treatment of dens fractures in octogenarians, was conducted from January 2016 to June 2021 in University hospital (tertiary center). Patients were identified by reviewing hospital admissions for odontoid fractures in octogenarians within this period. All patients provided written informed consent upon admission, and the data were retrospectively collected from medical records. The study was performed with the approval of the institutional ethics committee of the hospital.

During the study period, a total of 34 patients (21 women, 13 men) aged 80 years and older with a mean age of 86 years (range 80-99 years) were treated for injuries. Of these, 33 conservatively treated patients were included in the study, as 1 patient underwent surgery. Inclusion criteria were defined as follows: age 80 years and older, Anderson and D'Alonzo type II odontoid fracture, normal neurological findings, ASA (The American Society of Anesthesiologists) risk IV, V, dislocation assessed by posterior atlanto-dental interval (PADI) over 15 mm. Conversely, exclusion criteria for the study were defined as: pathological fracture, manifested neurological deficit, ASA risk I, II, III, PADI dislocation less than 15 mm. Patients with ASA risk levels I, II and III, neurological deficit or PADI dislocation less than 15 mm were indicated for surgery. The simultaneous presence of other types of cervical fractures was not an exclusion criterion. In our cohort, we proceeded conservatively even in the presence of primary gross displacement (PADI under 15 mm) without further progression, if the patient was contraindicated for surgical intervention based on ASA classification or absence of neurological deficit.

Patients were admitted to our department through the acute trauma admission of the hospital for the acute phase treatment. All patients underwent standard CT examination to assess the type and size of fracture dislocation, as well as neurological and internal examination with ASA risk determination. Patients were then immobilized with a hard cervical collar, and if there were no contraindications present (hemodynamical instability, fever, anemia requiring blood transfusion therapy, decompensated internal comorbidities), early mobilization was initiated on the second day after admission under the supervision of certified physiotherapist. The early mobilization encompassed verticalization, sitting and respiratory exercises. The cervical spine remained immobilized during physical rehabilitation. Follow-up anteroposterior (AP), lateral and open-mouth X-ray projection examinations were conducted during hospitalization, 2-3 days after verticalization. In case of worsening findings, CT scan was also performed. If the patient developed a neurological deficit, experienced pain significantly limiting verticalization, or gross dislocation with PADI under 15 mm during follow-ups, surgical treatment was chosen. Subsequent follow-up appointments of conservatively treated patients were scheduled at 3, 6 weeks, 3 months, 6 months, and 1 year post-injury. Post-discharge check-ups at 3 weeks included AP, lateral and open-mouth radiographs. At 6 weeks after discharge, all living patients underwent CT examination and dynamic cervical spine X-ray. If patients showed delayed fracture healing on CT at 6 weeks, a follow up CT was indicated after the next 6 weeks (i.e. 3 months after discharge). The subsequent follow-ups at 3, 6 and 12 months respectively consisted either of CT scan if the fracture showed non-union features on the previous CT scan or X-ray if the fracture was healed on previous radiographs. Bony union was diagnosed if trabecular bone spanned the fracture on CT. Otherwise, patients were classified as having nonunion using evaluation through CT and dynamic X-rays, which showed no pathological motion between the fracture fragments, based on these findings, this was considered fibrous union. The stability of the fractures was assessed based on the CT scans as well as dynamic X rays. The hard collar was worn by the patient for at least of 6 weeks (no longer than necessary because of prevention of ulcers development) and if the fracture was assessed as stable on dynamic X rays the hard collar was switched for soft collar with subsequent mobilization including verticalization, physiotherapy of all extremities, however the cervical spine remained immobilized. When patients showed healed fracture on CT the soft collar was removed.

Fractures were classified using the Anderson and D'Alonzo,¹⁰ Roy-Camille,²⁰ and White and Panjabi²¹ schemes. Clinical outcome assessment used the JOA (Modified Japanese Orthopaedic Association) score²² and VAS (Visual Analog Scale for Pain) interval measured upon admission to the hospital and at the time of fracture healing, defined by radiograph, with some patients’ scores assessed at the final clinical follow-up. The pain severity VAS used in this study was measured on a 10-cm scale ranging from “no pain” (0 cm) to “worst pain” (10 cm), no patient had cognitive deficit impairing their judgment. The ASA score was determined by an internist to assess the risk of surgical treatment for the patient. Functional ability assessment of the patient was evaluated using the NDI (Neck Disability Index) questionnaire completed by patient upon admission and at the time of fracture healing.²³ Fracture healing was monitored using X-ray and CT scans²⁴ at intervals during hospitalization, of 3, 6 weeks, 3 months, 6 months and 1 year. Nominal values are expressed as mean and standard deviation. Two-tailed paired t test was used for statistical evaluation of clinical outcomes of JOA, VAS and NDI with significance level P value <0.05. For NDI, only data collected from surviving patients were included for the statistical analysis.

Results

During the observed period, a total of 33 patients over 80 years old were conservatively treated for C2 odontoid fractures, with an average hospitalization duration of 6.5 days (range 1-14 days). The most common cause of injury was low-energy trauma from ground-level falls in 28 patients (84.8%), while five patients (15.2%) fell from stairs. Initially, 21 cases met the criteria for dens fracture surgical approaches (posterior fixation/direct anterior screw fixation) according to PADI (<15 mm), displacement size (>2 mm), and atlantoaxial instability, but surgery was contraindicated in 20 patients due to internal comorbidities assessed as ASA risk IV in 15 patients (45.5%) and ASA risk V in five patients (15.2%). Among the recorded comorbidities, arterial hypertension, type 2 diabetes mellitus, and coronary heart disease were most prevalent (Table 1). We categorized the combination of parameters for surgical indication: in three cases, it was an isolated indication for C1-C2 subluxation, in 1 case, it was an isolated indication based on PADI dimensions, in 13 cases, it was isolated displacement >2 mm, in 1 case, it was a combination of displacement + PADI, and in another three cases, it was a combination of displacement with subluxation.

Table 1.

Comorbidities Prevalence Among Patients. Data are Expressed as Absolute Values.

Number of octogenarians	33
Age (years)	86 ± 5.7
Males (%)	12 (36.4%)
Patients with comorbidities	32 (97%)
Hypertension	23 (69.7%)
Coronary heart disease	10 (30.3%)
Diabetes mellitus	8 (24.2%)
Arrhythmia	7 (21.2%)
Malignancy	4 (12.1%)
Chronic obstructive pulmonary disease	3 (9.1%)
Dementia	3 (9.1%)

One patient in this study was chosen for posterior fixation by the Goel-Harms, thus this patient was not included among the 33 conservatively treated patients. The patient was indicated for surgery due to unstable fracture of C2, Anderson D’Alonzo II, Roy-Camille type II, displacement size 4 mm, two side C1-C2 subluxation, PADI 17 mm, ASA III, without neurological deficit.

The average follow-up time was 109 days (range 1 day to 1 year; SD ± 106.65 days), in which eight patients had a follow-up duration of approximately three months. During the study period, 13 patients died. Within 30 days since trauma admission, seven patients died (including four during hospitalization, three due to cardiac arrest and 1 due to respiratory failure), representing a mortality rate of 21.2%. Between 30 days and 1 year, six patients died, corresponding to 18.2% mortality rate. (Figure 1). All deceased patients succumbed to internal medical conditions. In patients with displaced fractures greater than 2 mm, 9 out of 16 patients died during the study period. In patients with non-displaced fractures under 2 mm, 4 out of 17 patients died during the study period.

Figure 1.

Mortality during follow-up expressed in absolute counts and percentages in two intervals: during the first month and from 30 days to 1 year.

The clinical status of patients assessed using the JOA score remained unchanged for all 33 patients (mean 16.9; SD ± 0.5) from admission and at the end of follow-up (mean 16.9; SD ± 0.5; P > 0.05) (Figure 2). Pain assessment using the VAS score showed improvement in 33 patients from admission (mean 7.97; SD ± 1.33) to the end of follow-up (mean 1.58; SD ± 1.62; P < 0.001 (Figure 3). NDI was initially evaluated in 33 conservatively treated patients. Upon admission, three patients had severe scores (25-34 points), and 30 patients had complete scores (over 34 points). The final NDI value was assessed at the time of fracture healing in 17 patients. At the end of follow-up, nine patients scored in the mild range (5-14 points), and eight in the moderate range (15-24 points). There was a statistically significant difference between admission (mean 41.3; SD ± 14.92) and at the end of follow-up NDI values (mean 14.29; SD ± 4.65; P < 0.001) (Figure 4). The statistical significance was assessed only in the 17 patients for whom both the initial and final values were known.

Figure 2.

Clinical assessment before and after treatment using Japanese Orthopaedic Association score (JOA). Data are expressed as mean ± SD. We did not observe a statistically significant difference before (dark blue) and after (light blue) treatment in terms of clinical status.

Figure 3.

Visual analog scale (VAS) for pain quantification before (dark blue) and after (light blue) follow up. Data are expressed as mean + − SD. Statistical significance is indicated as follows: ***P < 0.001.

Figure 4.

Clinical assessment evaluation using neck disability index (NDI) before (dark blue) and after treatment (light blue). Data are expressed as mean + − SD. Statistical significance as follows: ***P < 0.001.

Radiological evaluation of CT findings, including fracture types and characteristics, is presented in Tables 2 and 3. Standard measurement of PADI dimensions for dorsal dislocations were completed, with an average value of 18.6 (min. 16, max. 22). Overall, primary bony union of odontoid fractures occurred in eleven cases (33.3%), and six patients (18.2%) had fibrous union with minimal clinical difficulties. Patients with fibrous union occasionally experienced stiffness in the cervical spine and sensitivity in the cervical area during weather changes, while walking, bending forward, and during normal activities, however, these were not permanent issues but rather intermittent and episodic. For the remaining patients (16 patients), the outcome of fracture healing is unknown due to death or failure to attend follow-up appointments. Two patients from the healed fracture subgroup died from internal comorbidities during further follow-up. Atlas fractures were diagnosed in 14 patients. The classification of atlas fractures according to the Gehweiler scheme²⁵ showed type I in fracture C1 in 1 case (1.3%), type II in 9 cases (9.3%), type III in 3 cases (3.9%), and type IV in 1 case (1.3%). These were always non-displaced fractures. All C1 (atlas fractures) fully healed. All six stable nonunion odontoid fractures were classified as Anderson D'Alonso type II, with four being Roy-Camille type II and two type III.

Table 2.

Fracture Type Assessment is Conducted Using Anderson D´Alonzo, Roy-Camille, White – Panjabi Classifications. Data are Expressed as Absolute Numbers.

Anderson d´Alonzo	Roy-Camille (Type)	White - Panjabi	Number of Patients
II	I	Anterior	4
		Posterior	0
		Non dislocation	1
	II	Anterior	0
		Posterior	13
		Non dislocation	6
	III	Anterior	4
		Posterior	2
		Non dislocation	3

Table 3.

Characterization of Fracture Dislocation Using Anderson D´Alonzo and White-Panjabi Classifications. Fractures With Dislocation Equal to or Greater Than 2 mm Were Considered Dislocated. Data are Expressed as Absolute Counts as Well as Mean ± SD.

Anderson d´Alonzo	White - Panjabi	Dislocation (Number of Patients)		Dislocation (Average mm ± SD)
Anderson d´Alonzo	White - Panjabi	≤2 mm	>2 mm	≤2 mm	>2 mm
II	Anterior	5	3	1.4 ± 0.55	4.67 ± 2.89
II	Posterior	2	13	1.5 ± 0.7	3.85 ± 1.47

Discussion

Odontoid C2 fractures represent a significant medical problem, especially in the frail elderly population over 80 years old. The incidence of odontoid fractures is increasing with demographic changes. Treatment decisions for fractures in the geriatric population are highly individualized due to numerous severe comorbidities, reduced patient cooperation, decreased bone quality, and other local anatomical complications.^11,26,27 In our study, we retrospectively evaluated the effect of conservative therapy in octogenarians. The average age of patients in our sample was 86 years, with a predominance of women.

The mortality rate showed that 21.2% died within 30 days, which aligns with other authors reporting a 30-day mortality of 14-15%.^14,28 Interestingly, we observed lower mortality between 30 days and 1 year (18.2%), while global sources report a higher mortality (37.5%).¹⁴ This difference was likely due to the size of the sample and the causes of injury, as our sample did not include injuries from high-energy mechanisms.¹⁴ According to meta-analysis⁵ that included twelve studies with a total of 730 patients, eleven studies reported mortality. The overall reported mortalities ranged from 20% to 50%, which well corresponds to the overall mortality in our cohort, where a total of 39.4% individuals died during the 1-year follow-up period. However, these meta-analyses typically include younger patients and those receiving surgical treatments, unlike our study.^5,29

In our cohort, we observed that 17 patients (51.5%) had minimal (<2 mm) or no displacement. Among patients with displacement under 2 mm, seven (21.2%) died. This included two patients (6.1%) with no displacement and five patients (15.2%) with displacement under 2 mm. These data are fully consistent with published literature, where observed mortality was significantly higher in displaced fractures (>2 mm) at 40% compared to patients without displacement (<2 mm) at 11%.²⁹ None of the patients in our cohort died from the primary diagnosis, but rather from comorbidity complications. During hospitalization, four patients died (12.1%). This hospitalization mortality aligns with recently published data,^28,30 which reported hospitalization mortality rates of 15%, i.e, 6.9% in cohorts of similarly aged patients over 80 years old. The difference in mortality may be attributed to the geoethnic specifics of the studied population and the size of the sample. Comparing surgical and conservative treatments, meta-analyses show no significant difference in overall mortality.^5,31 However, these studies include younger age groups, as well as octogenerians only,²⁸ and do not show a significant difference between conservative and surgical solutions. Furthermore, there is no significant difference in 1- and 5-year mortality between patients treated conservatively or surgically.³² According to Honda et al,³⁰ overall hospitalization mortality was similarly low in both conservative treatment and surgical approach (anterior, posterior, and combined) groups, though surgical technique specifics were not provided.

Although treatment selection criteria for C2 dens fractures remain somewhat unclear, surgical intervention is generally indicated in cases of neurological deficit, atlantoaxial instability, unstable dens fractures (PADI <15 mm), and compromised circulatory stability defined by ASA criteria.¹⁴ These criteria were strictly evaluated in relation to each individual patient. Among our patients, a total of 21 cases met at least 1 criterion for dens fracture surgical fixation but were contraindicated for surgery due to internal comorbidities, however none of the 21 patients further progressed in dislocation nor developed neurological symptomatology.

Clinically significant complications of C2 dens fractures include the risks of developing cervical myelopathy, odontoid nonunion, and fracture displacement progression.^1,19,29 Recent studies³³ identified advanced age, conservative therapy, and type II fracture as major risk factors for odontoid nonunion, while direct anterior screw fixation did not lead to a higher incidence of pseudoarthrosis compared to conservative therapy. Overall, dens fractures primarily fully consolidated in eleven cases (33.3%), while nonunion occurred in six patients (18.2%), during the follow-up period. This is likely comparable to other studies, which report union rates from 29% to 37.3%^13,34 and stable nonunion at 37.5%.³⁸ Among these patients, four subjectively did not experience painful symptoms, while two patients reported localized pain.³⁵ All six patients exhibited no neurological deficit manifestation with normal daily activities considering their age and comorbidities, and furthermore, none of our patients experienced secondary fracture displacement. Consistent with literature, a high rate of pseudoarthrosis occurrence is most commonly described in dislocated type II C2 fractures,^33,36 confirming our findings.

The primary goal of treating dens fractures in the geriatric population is to preserve their independence and quality of life.³⁷ Surgical fixation is associated with a faster fusion rate, but its utility in older patients with comorbidities and poor bone quality is debatable.^34,38 According to Jung et al,³⁹ there is no significant difference in trabecular bone healing between the conservative and surgical groups.

In our octogenarian cohort, conservative treatment led to a significant reduction in pain, as indicated by VAS scores, which showed improvement from admission to the end of the follow-up period after fracture healing. Most patients (n = 27) were either pain-free or experienced only mild pain (VAS less than 3) that did not require analgesic administration upon follow-up. One patient maintained a VAS score of 7 but unfortunately passed away from cardiac causes the day after hospital admission, preventing us from assessing the effectiveness of conservative therapy in this instance. Importantly, there were no new neurological deficits reported, all patients had a median JOA score of 17 at discharge, indicating stable neurological function throughout their treatment. This strongly supports the effectiveness of conservative therapy. On the other hand, in the meta-analysis by Huybregts et al,³¹ no clinically relevant differences were identified between surgically and conservatively treated patients in terms of Neck Disability Index score and VAS pain. All surviving patients showed favorable improvement in activities of daily living as assessed by NDI score, although none of the observed patients were completely without limitations. Our data are consistent with previous reports including a study by Rizvi et al²⁷ In this study, unlike our data, 53% of patients were without disability. Additionally, 19.7% of patients presented with mild disability, and 17.9% exhibited moderate disability. In contrast, our cohort showed mild disability in 27.3% and moderate disability in 24.24% of patients. Furthermore, the median patient age was 72 years, indicating that these patients were younger than those in our cohort, which included individuals with type III fractures.

Our study was limited by its retrospective design, absence of a control group, and was restricted to a single orthopedic center. However, it represents 1 of the largest studies of its kind in our population, primarily demonstrating the safety of a conservative approach in managing type II C2 odontoid fractures in the geriatric population over 80 years old. Still, further multicenter prospective studies are needed to confirm its role in the treatment algorithm for odontoid fractures.

Conclusion

The presented study confirms the seriousness of C2 injuries in octogenarians, associated with high morbidity and mortality in the subsequent period. The results of conservative treatment of odontoid fractures with early mobilization of patients demonstrated the safety and effectiveness of treatment in a group of polymorbid patients with a high risk of complications from surgical therapy. At the same time, it is possible to achieve satisfactory results in patients with significant displacement of odontoid fractures with a PADI of less than 15 mm or with delayed healing and manifested fibrous union (nonunion). The study confirms the severity of injuries to the upper cervical spine in the geriatric population and demonstrates the efficacy of conservative treatment even in borderline indications of significantly displaced fractures.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this study was supported by the Ministry of Health of the Czech Republic, grant no. NU23-10-00413.

Ethical Statement

ORCID iDs

Andrea Speldova

Lucie Sedova

Ondrej Seda

References

McIlroy

Lam

Khan

, et al. Conservative management of type II odontoid fractures in older people: a retrospective observational comparison of osseous union versus nonunion. Neurosurgery. 2020;87(6):E648-E654. doi:10.1093/neuros/nyaa256

Alhashash

Shousha

Gendy

Barakat

Boehm

. Percutaneous posterior transarticular atlantoaxial fixation for the treatment of odontoid fractures in the elderly: a prospective study. Spine. 2018;43(11):761-766. doi:10.1097/BRS.0000000000002417

Tashjian

Majercik

Biffl

Palumbo

Cioffi

. Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma. 2006;60(1):199-203. doi:10.1097/01.ta.0000197426.72261.17

Fredø

Rizvi

Lied

Rønning

Helseth

. The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway. Scand J Trauma Resuscitation Emerg Med. 2012;20:85. doi:10.1186/1757-7241-20-85

Yang

Yuan

. Conservative versus surgical treatment for type II odontoid fractures in the elderly: grading the evidence through a meta-analysis. Orthop Traumatol Surg Res. 2015;101(7):839-844. doi:10.1016/j.otsr.2015.08.011

Greene

Dickman

Marciano

Drabier

Hadley

Sonntag

. Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. Spine. 1997;22(16):1843-1852. doi:10.1097/00007632-199708150-00009

Stulík

Suchomel

Lukás

, et al. Prímá osteosyntéza dentu--multicentrická studie [primary osteosynthesis of the odontoid process: a multicenter study]. Acta Chir Orthop Traumatol Cech. 2002;69(3):141-148.

Spiegl

UJA

Keil

Krause

, et al. Combined odontoid (C2) and atlas (C1) fractures in geriatric patients: a systematic review and treatment recommendation. Global Spine J. 2023;13(1_suppl):22S-28S. doi:10.1177/21925682221127951

Hadley

Dickman

Browner

Sonntag

. Acute traumatic atlas fractures: management and long term outcome. Neurosurgery. 1988;23(1):31-35. doi:10.1227/00006123-198807000-00007

10.

Anderson

D'Alonzo

. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663-1674.

11.

Falavigna

Righesso

da Silva

, et al. Management of type II odontoid fractures: experience from Latin American spine centers. World Neurosurg. 2017;98:673-681. doi:10.1016/j.wneu.2016.10.120

12.

Traynelis

Fontes

RBV

Abode-Iyamah

Cox

Greenlee

. Posterior fusion for fragility type 2 odontoid fractures. J Neurosurg Spine. 2021;35:644-650. doi:10.3171/2021.2.SPINE201645.

13.

Arnold

Whiting

. Commentary: conservative management of type II odontoid fractures in older people: a retrospective observational comparison of osseous union versus nonunion. Neurosurgery. 2020;87(6):E655-E656. doi:10.1093/neuros/nyaa296

14.

Alas

Segreto

Chan

, et al. Association between frailty status and odontoid fractures after traumatic falls: investigation of varying injury mechanisms among 70 elderly odontoid fracture patients. J Orthop Trauma. 2019;33(12):e484-e488. doi:10.1097/BOT.0000000000001597

15.

Watanabe

Sakai

Yamamoto

Nagai

Sato

Mochida

. Analysis of predisposing factors in elderly people with type II odontoid fracture. Spine J. 2014;14(6):861-866. doi:10.1016/j.spinee.2013.07.434

16.

Tenny

Munakomi

Varacallo

. Odontoid fractures. In: StatPearls. Treasure Island (FL). StatPearls Publishing; 2023.

17.

Guan

Bisson

. Treatment of odontoid fractures in the aging population. Neurosurg Clin. 2017;28(1):115-123. doi:10.1016/j.nec.2016.07.001

18.

Watanabe

Sakai

Yamamoto

Nagai

Sato

Mochida

. Analysis of predisposing factors in elderly people with type II odontoid fracture. Spine J. 2014;14(6):861-866. doi:10.1016/j.spinee.2013.07.434

19.

Wilson

Hoyos

Huh

, 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. doi:10.3171/2020.8.SPINE20860

20.

Roy-Camille

Bleynie

Saillant

Judet

. Fracture de l'odontoïde associée à une fracture des pédicules de l'axis. A propos de 11 cas [Odontoid process fractures associated with fractures of the pedicles of the axis (author's transl)]. Rev Chir Orthop Reparatrice Appar Mot. 1979;65(7):387-391.

21.

White

Panjabi

. Clinical Bbiomechanics of the Spine. 2nd ed. Philadelphia: Lippincott; 1990.

22.

Hirabayashi

. Scoring system for cervical myelopathy (Japanese Orthopaedic Association). J Jpn Orthop Assoc. 1994;68(5):490-503.

23.

Vernon

Mior

. The Neck Disability Index: a study of reliability and validity. J Manip Physiol Ther. 1991;14(7):409-415. [published correction appears in J Manipulative Physiol Ther 1992 Jan;15(1):followi].

24.

Koller

Kolb

Zenner

, et al. Study on accuracy and interobserver reliability of the assessment of odontoid fracture union using plain radiographs or CT scans. Eur Spine J. 2009;18(11):1659-1668. doi:10.1007/s00586-009-1134-2

25.

Gehweiler

. The radiology of vertebral trauma. In: John

Gehweiler Raymond

OsborneJr

Becker

, eds. Saunders Monographs in Clinical Radiology, 16. Philadelphia: Saunders; 1980.

26.

Osterhoff

Scholz

Disch

, et al. Geriatric odontoid fractures: treatment algorithms of the German society for orthopaedics and trauma based on expert consensus and a systematic review. Global Spine J. 2023;13(1_suppl):13S-21S. doi:10.1177/21925682231157316

27.

Rizvi

SAM

Helseth

Aarhus

, et al. Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients. Spine J. 2021;21(7):1149-1158. doi:10.1016/j.spinee.2021.02.003

28.

Smith

Kerr

Maltenfort

, et al. Early complications of surgical versus conservative treatment of isolated type II odontoid fractures in octogenarians: a retrospective cohort study. J Spinal Disord Tech. 2008;21(8):535-539. doi:10.1097/BSD.0b013e318163570b

29.

Allia

Darmanté

Barresi

De Peretti

Trojani

Bronsard

. Early mortality and morbidity of odontoid fractures after 70 years of age. Orthop Traumatol Surg Res. 2020;106(7):1399-1403. doi:10.1016/j.otsr.2019.12.017

30.

Honda

Michihata

Iizuka

, et al. Clinical features and early post-operative complications of isolated C2 odontoid fractures: a retrospective analysis using a national inpatient database in Japan. Eur Spine J. 2021;30(12):3631-3638. doi:10.1007/s00586-021-06862-9

31.

Huybregts

JGJ

Barot

Recio

Doucette

Mekary

Vleggeert-Lankamp

CLA

. The optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis. Eur Spine J. 2023;32(10):3434-3449. doi:10.1007/s00586-023-07779-1

32.

Woods

Hohl

Braly

, et al. Mortality in elderly patients following operative and nonoperative management of odontoid fractures. J Spinal Disord Tech. 2014;27(6):321-326. doi:10.1097/BSD.0b013e31825d97c4

33.

Leister

Haider

Vogel

, et al. A Predictive Model to Identify Treatment-related Risk Factors for Odontoid Fracture Nonunion Using Machine Learning. Spine (Phila Pa. 1976). 2023;48(3):164-171. doi: 10.1097/BRS.0000000000004510

34.

Harris

Arif

Elliot

, 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. doi:10.1080/02688697.2021.1926921

35.

Rizvi

SAM

Helseth

Harr

, et al. Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients. Spine J. 2021;21(4):627-637. doi:10.1016/j.spinee.2020.11.012

36.

Raudenbush

Molinari

. Longer-Term Outcomes of Geriatric Odontoid Fracture Nonunion. Geriatr Orthop Surg Rehabil. 2015;6(4):251-257. doi:10.1177/2151458515593774

37.

Rommens

. Paradigm shift in geriatric fracture treatment. Eur J Trauma Emerg Surg. 2019 Apr; 45(2):181-189. doi:10.1007/s00068-019-01080-x

38.

Avila

Farber

Rabah

, et al. Nonoperative versus operative management of type II odontoid fracture in older adults: a systematic review and meta-analysis. J Neurosurg Spine. 2023;40(1):45-53. doi:10.3171/2023.6.SPINE22920

39.

Jung

Hörnig

Raisch

, et al. Odontoid fracture in geriatric patients - analysis of complications and outcome following conservative treatment vs. ventral and dorsal surgery. BMC Geriatr. 2023 Nov; 23(1):748. doi:10.1186/s12877-023-04472-2

Outcome of Conservative Treatment of Odontoid Fractures in Elderly Patients Over 80 Years Old

Abstract

Introduction

Materials and Methods

Results

Conclusion

Keywords

Introduction

Materials and Methods

Results

Discussion

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

Ethical Statement

ORCID iDs

References