Odontoid fracture type II

It is a unstable odontoid fracture at the base of the odontoid, with a high risk of non-union.

There is difficulty in precise differentiation between a low type II and a high type III fractures.

There is the lack of distinction between fractures in terms of fracture line obliquity, displacement and comminution which has an impact on subsequent management.

To address this limitations, Hadley et al. 1) introduced a type IIA fracture subclass to the classification, defined as a type II fracture complicated by an additional chip-fracture fragment at the anterior or posterior aspect of the base of the odontoid.

82% of patients with Type II fractures in a review of 7 reports in the literature were neurologically intact, 8% had minor deficits of scalp or limb sensation, and 10% had significant deficit (ranging from monoparesis to quadriplegia) 2).

Type II odontoid fractures have been associated with limited healing potential, and both nonoperative and operative management are associated with high mortality rates. Historically, there has been some debate in the literature with regards to optimal management strategies to maximize outcomes in geriatric patients. Recent, high-quality evidence has indicated that surgical treatment of type II odontoid fractures in elderly patients is associated with improvements in both short- and long-term mortality. Additionally, surgical intervention has been shown to improve functional outcomes when compared with nonsurgical treatment. Factors to consider before surgery for geriatric type II odontoid fractures include associated comorbidities and the safety of general anesthesia administration. With appropriate measures of patient selection, surgery can provide an efficacious option for geriatric patients with type II odontoid fractures. We recommend surgical intervention via a posterior C1-C2 arthrodesis for geriatric type II odontoid fractures, provided that the surgery itself does not represent an unreasonable risk for mortality 3).

A systematic review of literature published between January 1, 2000, and February 1, 2015, related to the treatment of type II odontoid fractures in patients >60 years of age. An analysis of short-term mortality, long-term mortality, and the occurrence of complications was performed.

A total of 452 articles were identified, of which 21 articles with 1233 patients met the inclusion criteria. Short-term mortality (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) and long-term mortality (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) were lower in patients who underwent surgical treatment than in those who had nonsurgical treatment, and there were no significant differences in the rate of complications (odds ratio, 1.01; 95% confidence interval, 0.63-1.63). Surgical approach (posterior vs anterior) showed no significant difference in mortality or complication rate. Similarly, no difference in mortality or complication rate was identified with hard collar or a halo orthosis immobilization.

The current literature suggests that well-selected patients >60 years of age undergoing surgical treatment for a type II odontoid fracture have a decreased risk of short-term and long-term mortality without an increase in the risk of complications 4).

Hadley MN, Browner CM, Liu SS, et al. New subtype of acute odontoid fractures (type IIA) Neurosurgery. 1988;22:67–71.
Przybylski GJ. Management of Odontoid Fractures. Contemp Neurosurg. 1998; 20:1–6
Wagner SC, Schroeder GD, Kepler CK, Schupper AJ, Kandziora F, Vialle EN, Oner C, Fehlings MG, Vaccaro AR. Controversies in the Management of Geriatric Odontoid Fractures. J Orthop Trauma. 2017 Sep;31 Suppl 4:S44-S48. doi: 10.1097/BOT.0000000000000948. PubMed PMID: 28816875.
Schroeder GD, Kepler CK, Kurd MF, Paul JT, Rubenstein RN, Harrop JS, Brodke DS, Chapman JR, Vaccaro AR. A Systematic Review of the Treatment of Geriatric Type II Odontoid Fractures. Neurosurgery. 2015 Oct;77 Suppl 4:S6-S14. doi: 10.1227/NEU.0000000000000942. PubMed PMID: 26378359.
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