The Neurosurgical Labyrinth: Managing Type II Odontoid Fractures in the Elderly Patient

Cervical spine fractures can lead to truly catastrophic neurological deficits. The management of fractures of the upper cervical spine are particularly vexing secondary to the high degree of range of motion at these segments, and the surrounding neurovascular elements. Of these fractures, odontoid fractures are the most common. There are many classifications of odontoid fractures - the most common categorize them into Types I, II, and III. It has been well established that Type I and Type III odontoid fractures are best treated non-operatively. The management of the Type II odontoid fracture still remains highly controversial, especially within the elderly population. Treatment options range from non-surgical therapies, including various cervical orthosis, to anterior or posterior surgical approaches. For the elderly patient, the surgeon must consider numerous factors when determining in determining the most appropriate approach to recommend. Some of these factors include: the patient’s level of activity and the ability to tolerate surgery, age/displacement of the fracture, stability of the transverse ligament, the relative vascularity of the odonotoid process, the patient’s osteogenic capabilities, and the various comorbidities that many times accompany this patient demographic. Proper consideration of all these factors will allow for the most optimal clinical outcome. Currently, there is no clear consensus as to which treatment should be the standard of care. Herein, the authors will discuss the pathogenesis of the odontoid fracture, the difficulties in the healing process, a review of the literature with the current management options, and our clinical experience and decision making process in managing these complex fractures.