Management of odontoid fractures in the elderly: A review of the literature and an evidence-based treatment algorithm

Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature.We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly populationmust be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunionwith close follow-up is an acceptable outcome. If operativemanagement is chosen, a posterior approach is should be chosen when fracture- or patient-related factorsmake an anterior approach challenging. The high levels ofmorbidity andmortality associated with odontoid fractures should encourage all providers to pursue medical comanagement and optimization of bone health following diagnosis.