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Odontoid Fractures

A Critical Review of Current Management and Future Directions

Carvalho, André D. MD*,†; Figueiredo, José MD*; Schroeder, Gregory D. MD; Vaccaro, Alexander R. MD, PhD, MBA; Rodrigues-Pinto, Ricardo MD, PhD, FEBOT*,†

doi: 10.1097/BSD.0000000000000872

Odontoid fractures represent one of the most common and controversial injury types affecting the cervical spine, being associated with a high incidence of nonunion, morbidity, and mortality. These complications are especially common and important in elderly patients, for which ideal treatment options are still under debate. Stable fractures in young patients maybe treated conservatively, with immobilization. Although halo-vest has been widely used for their conservative management, studies have shown high rates of complications in the elderly, and therefore current evidence suggests that the conservative management of these fractures should be carried out with a hard cervical collar or cervicothoracic orthosis. Elderly patients with stable fractures have been reported to have better clinical results with surgical treatment. For these and for all patients with unstable fractures, several surgical techniques have been proposed. Anterior odontoid fixation can be used in reducible fractures with ideal fracture patterns, with older patients requiring fixation with 2 screws. In other cases, C1–C2 posterior fixation maybe needed with the best surgical option depending on the reducibility of the fracture and vertebral artery anatomy. In this paper, current evidence on the management of odontoid fractures is discussed, and an algorithm for treatment is proposed.

*Spinal Unit, Department of Orthopaedics, Centro Hospitalar Universitário do Porto—Hospital de Santo António

ICBAS—Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal

Rothman Institute, Philadelphia, PA

Dr Schroeder has received funds to travel from AOSpine and Medtronic. Dr Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AOSpine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location-Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. He has also served as deputy editor/editor of Spine. In addition, Dr Vaccaro has also provided expert testimony. The remaining authors declare no conflict of interest.

Reprints: Ricardo Rodrigues-Pinto, MD, PhD, FEBOT, Spinal Unit, Department of Orthopaedics, Centro Hospitalar Universitário do Porto—Hospital de Santo António, Largo Prof. Abel Salazar, Porto 4099-001, Portugal (e-mail:

Received March 24, 2018

Accepted April 19, 2019

© 2019 by Lippincott Williams & Wilkins, Inc.