Type II Odontoid Fracture in 85-year-old Man
How to Treat? Cervical Collar? Halo Vest? Surgery?
The patient is an 85-year-old male who has neck pain related to an isolated injury from a car accident. He also has significant cardiac history. He lives independently and is sharp and well-educated.
On examination, the patient complains of neck pain.
The patient wore a rigid collar for several weeks with no improvement.
Figure 1: Pre-operative sagittal x-ray
Figure 2: Pre-operative closed-mouth x-ray
Figure 3: Pre-operative sagittal CT scans. Note the spontaneous fusion at C2-C3.
The patient was diagnosed with a type II odontoid fracture.
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The patient had anterior odontoid screw fixation using 1 screw. The odontoid screw was partially threaded.
Figure 4: Intraoperative AP (left) and lateral (right) fluoroscopy images showing the depth gauge
Figure 5: Intraoperative AP (left) and lateral (right) fluoroscopy images showing the placement of the odontoid screw
Figure 6: Lateral x-ray at 6 weeks post-operative showing placement of the odontoid screw
Figure 7: Lateral (left) and extension (right) x-rays at 3 months post-operative
Figure 8: Flexion (left) and extension (right) x-rays at 18 months post-operative
Figure 9: Lateral CT scan at 18 months post-operative
After a year and a half, the fracture non-union is evident on the patient’s x-rays and CT scans. However, the patient has minimal neck pain and is neurologically intact. Follow-up with this patient continues every 6 months.
When dealing with an 85-year-old patient who sustains a type II odontoid fracture, the treatment options include no intervention with observation (benign neglect), collar immobilization, halo vest application, anterior odontoid fixation, and posterior C1-C2 fusion.
My general approach is to treat those patients who are active and can withstand surgery with a posterior cervical C1-C2 fusion. In general, I do not perform odontoid screw fixation in patients older than 70 as the fracture non-union rate is quite high. I typically treat patients who are not good surgical candidates with benign neglect or with soft- or hard-collar immobilization. I follow these patients carefully, and if they develop evidence of instability, I then generally perform a posterior cervical C1-C2 fusion. I warn the patients who are treated non-operatively that they will almost certainly develop a non-union and that there are potentially catastrophic risks involved should they develop instability, fall, etc. Usually, however, these patients seem to do reasonably well and their pain typically resolves.
I try to avoid halo immobilization in geriatric patients given the potential for halo vest-related complications. Odontoid screw fixation is a reasonable alternative in patients who are physiologically younger, although the potential for non-union still exists in these geriatric patients.