Management of odontoid fractures in the elderly: A review of the literature and an evidence-based treatment algorithm

Sravisht Iyer, R. John Hurlbert, Todd J. Albert

Research output: Contribution to journalReview article

10 Citations (Scopus)

Abstract

Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature.We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly populationmust be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunionwith close follow-up is an acceptable outcome. If operativemanagement is chosen, a posterior approach is should be chosen when fracture- or patient-related factorsmake an anterior approach challenging. The high levels ofmorbidity andmortality associated with odontoid fractures should encourage all providers to pursue medical comanagement and optimization of bone health following diagnosis.

Original languageEnglish (US)
Pages (from-to)419-430
Number of pages12
JournalClinical neurosurgery
Volume82
Issue number4
DOIs
StatePublished - Apr 1 2018

Fingerprint

Frail Elderly
Bone and Bones
Health
Therapeutics
Comorbidity
Spine
Population

Keywords

  • C1-C2 fusion
  • Dens
  • Geriatric
  • Nonunion
  • Odontoid
  • Operative management
  • Type II odontoid fracture

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Management of odontoid fractures in the elderly : A review of the literature and an evidence-based treatment algorithm. / Iyer, Sravisht; Hurlbert, R. John; Albert, Todd J.

In: Clinical neurosurgery, Vol. 82, No. 4, 01.04.2018, p. 419-430.

Research output: Contribution to journalReview article

@article{9dedd1aa6e0149138dc6835f68ec1ddc,
title = "Management of odontoid fractures in the elderly: A review of the literature and an evidence-based treatment algorithm",
abstract = "Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature.We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly populationmust be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunionwith close follow-up is an acceptable outcome. If operativemanagement is chosen, a posterior approach is should be chosen when fracture- or patient-related factorsmake an anterior approach challenging. The high levels ofmorbidity andmortality associated with odontoid fractures should encourage all providers to pursue medical comanagement and optimization of bone health following diagnosis.",
keywords = "C1-C2 fusion, Dens, Geriatric, Nonunion, Odontoid, Operative management, Type II odontoid fracture",
author = "Sravisht Iyer and Hurlbert, {R. John} and Albert, {Todd J.}",
year = "2018",
month = "4",
day = "1",
doi = "10.1093/neuros/nyx546",
language = "English (US)",
volume = "82",
pages = "419--430",
journal = "Neurosurgery",
issn = "0148-396X",
publisher = "Lippincott Williams and Wilkins",
number = "4",

}

TY - JOUR

T1 - Management of odontoid fractures in the elderly

T2 - A review of the literature and an evidence-based treatment algorithm

AU - Iyer, Sravisht

AU - Hurlbert, R. John

AU - Albert, Todd J.

PY - 2018/4/1

Y1 - 2018/4/1

N2 - Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature.We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly populationmust be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunionwith close follow-up is an acceptable outcome. If operativemanagement is chosen, a posterior approach is should be chosen when fracture- or patient-related factorsmake an anterior approach challenging. The high levels ofmorbidity andmortality associated with odontoid fractures should encourage all providers to pursue medical comanagement and optimization of bone health following diagnosis.

AB - Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature.We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly populationmust be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunionwith close follow-up is an acceptable outcome. If operativemanagement is chosen, a posterior approach is should be chosen when fracture- or patient-related factorsmake an anterior approach challenging. The high levels ofmorbidity andmortality associated with odontoid fractures should encourage all providers to pursue medical comanagement and optimization of bone health following diagnosis.

KW - C1-C2 fusion

KW - Dens

KW - Geriatric

KW - Nonunion

KW - Odontoid

KW - Operative management

KW - Type II odontoid fracture

UR - http://www.scopus.com/inward/record.url?scp=85050323405&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85050323405&partnerID=8YFLogxK

U2 - 10.1093/neuros/nyx546

DO - 10.1093/neuros/nyx546

M3 - Review article

C2 - 29165688

AN - SCOPUS:85050323405

VL - 82

SP - 419

EP - 430

JO - Neurosurgery

JF - Neurosurgery

SN - 0148-396X

IS - 4

ER -