Session III - Spine

Fractures of the Odontoid - Operative vs Nonoperative Treatment

Ernst J. Müller, MD; Mark Wick; Otto Russe; Michael P Hahn; Gert Muhr, Trauma Center Bergmannsheil, Bochum, Germany

Purpose of the study: A retrospective analysis of 77 fractures of the odontoid is reported. The results and the complications of operative as well as non-operative management of the injuries are discussed. Based on our results a guideline for the management of the different fracture types is reported.

Significance: Fractures of the odontoid process of the axis have caused confusion and controversy as to the best method of treatment, the prognosis, or the incidence of non-union, which has been reported to be as high as 62.8% and as low as 4.8%. The appropriate treatment for the fractures of the odontoid is still controversial and operative as well as non-operative methods are recommended for the same type of injury.

Methods: Between 1984 and 1995, 77 fractures of the odontoid were treated in our department. There were 29 female and 48 male patients. The average age was 57.7 (range 15-96) yrs. Thirty-three injuries were due to road traffic accidents; in 39 cases the underlying cause was a fall, and in five cases the mechanism of injury could not be evaluated. The fractures were classified according to Anderson and d'Alonzo. There were 62 type-II and 15 type-III injuries; we could not identify a type-I lesion. Twenty-two (28.6%) had primary internal fixation, 20 were type-II and 2 were type-III injuries. Anterior screw fixation of the odontoid was the method of choice in 21 cases; in one patient posterior fusion of the C 1/2 segment was selected as the appropriate treatment. Fifty-two (67.5%) fractures were treated nonoperatively. A halo device was the method of choice in 26 patients; a Philadelphia collar was applied 25 times, and in one patient a Minerva-PoP was chosen for treatment.

Results: The overall complication rate was 39 % (30/77). In the operative group the complication rate was 36.4% (8/22). Failure of stabilization was seen in two cases: one anterior screw fixation of the dens and one posterior fusion C1/2. In one case where an anterior screw fixation was performed, malpositioning of the screws had to be notified. Malunion/non-union occurred in one patient. Two patients suffered from cardiac complications and two patients died in the postoperative period.

In the nonoperative group the complication rate was 40 % (22/55). Loss of reduction and/or non-union occurred in twelve cases; three pins of a halo device had to be changed because of infection. One patient suffered from pulmonary embolism, and six patients of this group died.

In patients older than 70 yrs. (n=23) the overall complication rate was 60.9% (14/23).

Discussion and Conclusion: Operative as well as nonoperative treatment of fractures of the odontoid can lead to significant complications. Judicious selection of the type of injuries requiring operative as opposed to non-operative intervention is mandatory to minimize complications. Non-operative treatment is suitable for stable fractures, evaluated with flexion/extension views and fractures, that can be reduced and kept in position by closed means. For all other fractures internal fixation is the method of choice. In elderly patients early internal stabilization is recommended.