Traumatic Odontoid Fracture in an Elderly Female
The patient is a 66-year-old female who was a restrained driver in a motor vehicle accident (MVA). Her major complaint was mild left upper extremity weakness. She did not lose consciousness as a result of the MVA, and had no nausea, vomiting, numbness, or bowel/bladder complaints.
- Left upper extremity 4+ deltoid; otherwise, 5/5
- No sensory deficits
- Reflexes are 2 throughout
- No Hoffman's sign, clonus, or Babinski's sign
- No tenderness at the spinous processes
Figure 1. Cervical CT without contrast
Figure 2. Coronal reconstruction of the cervical spine; CT without contrast
Figure 3. Sagittal view of the cervical spine; MRI STIR
Cervical MRI studies did not reveal any foraminal or canal stenosis, or nerve avulsion.
Type II odontoid fracture
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- Since the odontoid was aligned to the C2 body, and only had minimal displacement, the patient was treated conservatively with a rigid cervical collar.
- She was neurologically intact at her 6 month follow-up.
- The 6 month follow-up CT scan (Fig. 4) revealed callus formation through the fracture line demonstrating a healthy bony fusion.
Post-treatment Image and Outcome
Six months after wearing a rigid cervical collar, the patient's fracture is fused and she is doing well. The patient's left upper extremity weakness resolved prior to bony fusion.
Figure 4. CT scan at 6 months; bony fusion
Drs. Murray and Uribe present a classic case of an elderly patient with a Type II odontoid fracture. Various classification schemes exist to describe these, but in essence, the imaging here shows a non-displaced, non-angulated, well-aligned fracture at the base of the dens. The coronal image shows that the fracture on the right side may be extending slightly into the body. The authors choose to treat this with a rigid collar, and at 6 months, there was evidence of healing and a good clinical outcome.
This seemingly "simple case" often presents real decision-making challenges for the clinician. A plethora of literature is devoted to this topic, yet there remains no precise standard for treatment of Type II dens fractures in the elderly. One must balance the risks and benefits of surgical versus non-surgical treatments carefully. In some instances, prolonged bracing may actually carry a higher risk than operative fixation (due to non-compliance, skin breakdown, longer periods of activity restrictions, for example). In other cases, advanced age or significant comorbidities may preclude the surgical options. The use of halo-vest immobilization in the elderly is not generally recommended.
I often approach trauma cases like this one with a simple but practical viewpoint: What's the safest treatment option for the patient that yields the most effective and predictable outcome? One has to consider this in the context of their own practice and institution.