Non-rigid immobilisation of odontoid fractures

Abstract

IntroductionThe appropriate treatment of type II and III odontoid fractures still remains controversial. However in the recent literature there seems to be a tendency to opt for primary internal fixation with interfragmentary screws [1,7,8,19,23,29,36]. The reported rate of non-union varies between 2.4% and 100% for all types of fractures and treatment modalities, with the highest rates for untreated fractures and fractures treated with a cervical collar only. Important factors reported to contribute to non-union of these fracAbstract Despite various reports on the management of odontoid fractures, there is no consensus on the subject, and the appropriate treatment still remains controversial. While untreated fractures or fractures treated only with a cervical orthosis seem to have the highest rate of nonunion, the need for rigid external stabilisation has never been substantiated. In a retrospective analysis we reviewed 26 patients with acute type II and III fractures of the odontoid, treated with a cervical orthosis only. Study inclusion was limited to fractures that had a fracture gap of less than 2 mm, an initial antero-posterior displacement of less than 5 mm and angulation of less than 11°, less than 2 mm displacement on lateral flexion/extension views, and were without neurological deficits. These fractures were defined as stable. There were 19 (73.1%) type II and 7 (26.9%) type III fractures; in 10 (38.5%) of these fractures the odontoid was displaced and/or angulated. The overall complication rate was 11.4% (n=3). One patient suffered from pulmonary embolism, in two patients (7.7%) with initially minimally displaced fractures, secondary internal stabilisation had to be performed because of persistent instability. In 20 (77%) of the remaining fractures healing was uneventful. In 4 nondisplaced fractures (15%) fibrous union was documented. Three of these patients were over 65 years old. The overall fusion rate was 73.7% for type II and 85.7% for type III fractures. At follow-up 39% of the patients were free of symptoms; however, the clinical outcome did not correlate with the radiological findings. According to our findings, stable type II and type III fractures of the odontoid can be successfully treated with non-rigid immobilisation, even if they are displaced. A thorough assessment of the stability of the odontoid with lateral flexion/extension views or dynamic fluoroscopy is recommended to evaluate the appropriate treatment. Nonrigid immobilisation may be an option in selected cases with stable injuries.

The long-term functional outcome of type II odontoid fractures managed non-operatively

“…Additionally, our patient cohort had a stronger male predominance with male:female ratio of 1.75:1, which was higher than the 1:1 ratio usually observed [11].…”

“…Our patient cohort had a mean age of 41.92 years which was slightly younger than the mean age of 59.1 years observed by Müller et al [11], who retrospectively analyzed 26 cases of stable type II and type III odontoid fractures managed with non-rigid immobilization. Additionally, our patient cohort had a stronger male predominance with male:female ratio of 1.75:1, which was higher than the 1:1 ratio usually observed [11].…”

“…According to Müller et al [7], this high complication rate is primarily accounted for by loss of reduction and non-union after non-operative treatment, a complicated post-operative course and complications due to associated injuries [7]. In a second study by Müller et al [11], in spite of demonstrating that elderly patients had a higher rate of pseudoarthrosis, it was concluded that in a stable situation there is no need for internal fixation in the elderly, further supporting our findings.…”

Single institute experience about 108 consecutive cases of type ii odontoid fractures: surgery versus conservative treatment.

“…Appropriate treatment for type II fractures has been the subject of much research but it is still a matter of discussion (26,28,34,45,46). In recent literature, there seems to be a growing trend to surgery as high rates of fusion and return to good function of the cervical spine have been highlighted (1,10, 18,19,32).…”

Type I Odontoid Fracture-Case Report-

“…The findings of 17 previous reviews of odontoid fracture, using the classification of the Anderson and D'Alonzo, are shown in Table 2. 1,2,[5][6][7][8][9][10][11][12][13][14][15]17,[19][20][21] The frequency of type I fracture was 0.82% (11/1328) among all odontoid process fractures.…”