Treatment of Odontoid Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Abstract

Study Design:Narrative review.Objective:To establish recommendations for the treatment of odontoid fractures based on current literature and the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).Methods:Narrative review of the literature. Analyzing treatment algorithms of German trauma and spine centers as members of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).Results:There are many influencing factors leading to appropriate treatment of odontoid fractures such as age, bone quality, arthrosis, classification, and type of the fracture. Conservative nonoperative treatment is appropriate for stable undislocated displaced odontoid fractures. Anterior osteosynthesis with 1 or 2 screws leads to good results in the classical unstable type II odontoid fracture in patients with good bone quality. However, modifiers have been identified by the working group leading to higher complication and failure rates. For these cases, more stable constructs and/or posterior approaches are indicated.Conclusions:Operation seems to be standard treatment for odontoid fractures. However, in the aged population, conservative treatment should be considered as morbidity and mortality rise significantly in the group of >75 years. Conservative treatment may also be started within stable nondislocated fractures, but then regular controls have to be performed. If operation is indicated, many influencing factors have to be considered for appropriate approach and technique. The classification of Anderson and D’Alonzo is still standard. To create an adequate treatment algorithm, dislocation displacement and instability have to be identified. Stable odontoid fractures are treated conservatively non-operatively, but if so regular controls have to be performed. Unstable and/or dislocated displaced odontoid fractures are treated by anterior osteosynthesis with 1 or 2 screws. The technique is demanding and leads to elevated complication and failure rates if modifiers are apparent. In these cases, posterior instrumentation or fusion of C1 and C2 is favorable. In the aged population (>80 years), operative therapy is critical as postoperative morbidity complication and mortality rates rise significantly. As there is still some bias in the treatment algorithms, the working group recommends establishment of a prospective study to result in more objective statements.

Does isolated atlantoaxial fusion result in better clinical outcome compared to occipitocervical fusion?

“…Management of cervical spine injury in the elderly remains controversial because of many influencing factors such as the quality of the bone, osteoarthritis, classification, and type of the fracture [6,7,10,19,20]. Treatment might be complicated by numerous comorbidities and reduced bone quality.…”

Odontoid Process and Femur: A Novel Bond in Anatomy

“…Anterior odontoid osteosynthesis or posterior cervical fusion with or without screw fixation are surgical techniques requiring detailed determination of the dens length, which is not always possible when it is deformed and/or displaced. Our equation may assist with the calculation of the odontoid process height and therefore the screw's size, through the measurement of the length of the right femoral bone [20][21][22].…”

Klippel–Feil Syndrome with Multiple Cervical Anomalies Discovered Following Trauma

“…Management of the upper cervical spine pathology is a challenge due to its complex anatomical characteristics and for the variety of existing surgical classifications and criteria such as those of AO Spine, German Society for Orthopedics and Trauma (DGOU), among others. [5][6][7] Despite these criteria, there is no definitive consensus on the type of surgery, approach, level of fixation or fusion in patients with cervical injury; even less in patients with KFS. 8,9 KFS is a genetic disease characterized by fusion of the cervical vertebrae, which generates decreased movement; in the long-term, it produces hypermobility and cervical instability, with a natural history that is not very clear.…”