Surgery vs conservative treatment for type II and III odontoid fractures in a geriatric population

Abstract

Background: It is unclear whether surgery or conservative treatment is more suitable for elderly patients with type II and type III odontoid fractures. We performed this meta-analysis to compare the efficacy of surgical and conservative treatments for type II and type III odontoid fractures.Methods: A literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library in January 2017. Only articles comparing surgery with conservative treatment in elderly patients with type II and type III odontoid fractures were selected. After 2 authors independently assessed the retrieved studies, 18 articles were included in this meta-analysis, and the primary endpoints were the nonunion rate and mortality rate. The secondary outcomes were patient satisfaction, complications, and the length of the hospital stay. The quality of the included studies was evaluated using the modified Newcastle-Ottawa scale. Sensitivity analyses were performed for high-quality studies, and the publication bias was evaluated using a funnel plot.Results: Lower nonunion (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.18-0.40, P < .05) and mortality rates (OR: 0.52, 95% CI: 0.34-0.79, P < .05) confirmed the superiority of surgery in treating type II and type III fractures. The secondary outcomes differed. Patients in the surgery group felt more satisfied with the outcome (OR: 3.44, 95% CI: 1.19-9.95, P < .05), and the complications were similar in the 2 groups (OR: 1.14, 95% CI: 0.78-1.68, P = .5), whereas patients in conservative groups spent less time in the hospital (OR: 5.10, 95% CI: 2.73-7.47, P < .05). The results of the subgroup analyses and sensitivity analysis were similar to the original outcomes, and no obvious publication bias was observed in the funnel plot. Conclusion:Most elderly (younger than 70 years) patients with type II or type III odontoid fractures should be considered candidates for surgical treatment, due to the higher union rate and lower mortality rate, while statistically significant differences were not observed in the population with an advanced age (older than 70 years). Therefore, the selection of the therapeutic approach for elderly patients with odontoid fractures requires further exploration. Simultaneously, based on our meta-analysis, a posterior arthrodesis treatment was significantly superior to the anterior odontoid screw treatment.

Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study

“…A consensus on the preferred treatment for Anderson type II odontoid fractures remains missing. 3,[6][7][8]11,13,14,16,18,19 An external orthosis is usually prescribed for conservative management; however, patient discomfort, reduced quality of life, risk for sarcopenia, residual neck pain, and restriction of the cervical range of motion should be carefully considered. [20][21][22] Surgery provides primary stability, which increases the chances for secondary bone fusion, although this treatment is associated with specific risks.…”

“…[20][21][22] Surgery provides primary stability, which increases the chances for secondary bone fusion, although this treatment is associated with specific risks. [6][7][8]11 When compared with posterior approaches, anterior odontoid screw placement for Anderson type II fractures reported better surgical outcomes in terms of intraoperative blood loss and surgical duration, as well as lower risks for posterior approach-related complications such as CSF leak, vertebral artery injuries, and prone position-related risks, especially in elderly patients. 3,10,11,23 This represents a minimally invasive approach through the cervical fascial planes, which requires a mild soft-tissue retraction and preserves the C1-2 range of motion.…”

“…4,5 Both conservative and surgical management have been proposed for odontoid type II fractures. [6][7][8] The anterior cervical approach for dens screw placement was first reported by Böhler in 1982; it has been increasingly preferred to posterior and anterior C1-2 fusion techniques due to its surgical advantages and to the possibility of preserving segmental range of motion. [9][10][11] Achieving no residual instability has been proposed as the treatment goal after Anderson type II fractures.…”

Temporary spanning internal fixation for management of complex upper cervical spine fractures

“…[ 3 ] The rationale behind that global trend is the high complication rates and the questionable efficacy of halo-vest treatment. [ 4 5 6 ] Furthermore, the surgeon is occasionally faced with a complex fracture of the Atlas or Axis that neither fusion nor halo-vest immobilization is a good option. The ideal solution would provide better stabilization and less complications-than a halo-vest and would not eliminate motion from the adjacent segments.…”

Non-Operative Treatment of Odontoid Peg Fractures

“…It is also more cost-effective than conservative treatment in this patient group. However, the advantage of surgery over nonsurgical management is lost as the patients age further, with studies placing the turn between 75 years and 84 years [15] [16]. Treatment with halo vest immobilisation is associated with higher mortality in elderly than younger patients [17].…”