NARRATIVE REVIEW
Odontoid Fractures
A Critical Review of Current Management and Future Directions
André D. Carvalho, MD,*† José Figueiredo, MD,* Gregory D. Schroeder, MD,‡
Alexander R. Vaccaro, MD, PhD, MBA,‡ and Ricardo Rodrigues-Pinto, MD, PhD, FEBOT*†
Abstract: 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 im-
portant 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 sur-
gical 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
Received for publication March 24, 2018; accepted April 19, 2019.
From the *Spinal Unit, Department of Orthopaedics, Centro Hospitalar
Universitário do Porto—Hospital de Santo António; †ICBAS—Instituto
de Ciências Biomédicas Abel Salazar, Porto, Portugal; and ‡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 Tech-
nologies, Advanced Spinal Intellectual Properties, Spine Medica,
Computational Biodynamics, Spinology, In Vivo, Flagship Surgical,
Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Loca-
tion-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: ric_pinto@hotmail.com).
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Clin Spine Surg  Volume 32, Number 8, October 2019
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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.
Key Words: odontoid fracture, treatment, halo-vest, cervical
collar, geriatric population, surgical treatment, odontoid fix-
ation, C1–C2 fusion
(Clin Spine Surg 2019;32:313–323)
EPIDEMIOLOGY AND CLINICAL PRESENTATION
With increased life expectancy, and increased road
safety and working conditions, cervical fractures are be-
coming more common in the elderly and less frequent in
younger patients.1 Involvement of the upper cervical spine
has been reported to occur in 69% of all fractures of the
cervical spine in the elderly, in contrast to 36% in young
adults.2–4 Among cervical fractures, odontoid fractures are
the most commonly observed, constituting ∼18% of all
cervical fractures in the overall population and > 50% in
patients over the age of 80.4–6 The incidence of delayed or
missed diagnosis at the cervical spine in critically injured
trauma patients is reported to be relatively high, ranging
from 5% to 20%.7–9
In young patients, odontoid fractures are typically
the result of high-energy trauma such as motor vehicle
accidents or falls from heights. In older patients, they
commonly occur in the setting of low-energy trauma such
as a fall from standing height. Male individuals predom-
inate in the younger population, whereas the sex ratio is
more evenly distributed in the elderly.
The Anderson and D’Alonzo seminal classification
of odontoid fractures is still the most commonly used.
Type I (Fig. 1A) fractures represent just 1% of odontoid
fractures and are characterized by avulsion of the
odontoid tip. Type II (Fig. 1B) fractures are the most
common and occur through the waist of the dens near its
junction with the vertebral body. The higher frequency of
this type of fracture can be explained by the existence of
thinner bone trabeculae compared with the rest of the
odontoid.10,11 A subtype of type II fractures characterized
by greater comminution of fragments leading to greater
instability was proposed by Hadley and colleagues12,13
(type IIA). Type III (Figs. 1C, D) fractures occur through
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Carvalho et al
FIGURE 1. Computed tomographic scan images of different types of odontoid fractures (Anderson and D’Alonzo classification). A,
Coronal view of type I fracture. B, Sagittal view of type II fracture. Coronal (C) and sagittal (D) views of type III fracture.
the anterior proximal aspect and extend into the C2
vertebral body.
CLINICAL EVALUATION AND DIAGNOSIS
Patients with acute dens fractures complain of upper
cervical pain, restriction of neck movement, and tend to
support the head with their hands while moving from an
upright to a supine position. Neurological injuries in these
patients often occur from high-velocity mechanisms such
as traffic accidents. Few patients with an acute axis frac-
ture who sustain a neurological injury survive to be
transported to the hospital,14 and 25%–40% of dens frac-
tures are fatal at the time of accident.15
Although a majority of patients who reach the hos-
pital will have no discernible neurological injury, a de-
tailed neurological evaluation is required, as displaced
fracture fragments may compress the spinal cord, leading
to cervical myelopathy. In a review of 446 type II odon-
toid fractures, Przybylski16 found that 82% of the patients
were neurologically intact, 8% had minimal sensory dis-
turbances over the scalp or limbs, and 10% had significant
neurological deficits. In a retrospective analysis of 16 pa-
tients with neglected odontoid fractures, however,
Crockard et al17 found that all patients had cervical pain
at 1 year, and 69% had clinical signs of myelopathy, in-
cluding upper extremity weakness and gait disturbances.
Type I and III odontoid fractures are rarely associated
with neurological deficits.16
Radiographic diagnosis maybe difficult, particularly
in the elderly, as in these patients the upper cervical spine
radiographs are often distorted due to degenerative arthritis
and cervical spine deformities.3,4,18 Furthermore, non-
displaced fractures of odontoid are commonly not detected
on plain radiographs. Conventional plain film radiographs
include anteroposterior, lateral, and open-mouth odontoid
process view projection. The establishment of x-ray-based
guidelines is also limited by the presumed low specificity and
sensitivity of distance measurements caused by rotational
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Clin Spine Surg  Volume 32, Number 8, October 2019
distortion.19 Bono and colleagues20,21 described a study in
which 19 patients with a C2 fracture were evaluated by
different surgeons and only moderate reliability for the
evaluation of radiographs was found.
Platzer and colleagues retrospectively evaluated 118
patients with significant cervical spine injuries and found
that radiologic evaluation by a 3-view cervical spine series
had a sensitivity of 90% and that a single cross-table lateral
view was insufficient to clear the cervical spine, as it had a
sensitivity of only 63% in detecting skeletal injuries. Cervical
computed tomography (CT) scan had a sensitivity of 100%
in detecting injuries of the skeletal integrity, being the
most efficient imaging tool with sensitivity of 100%.22 Thin-
cut helical CT is more sensitive and can distinguish acute
fractures from chronic nonunions.23
The role of magnetic resonance imaging (MRI) in
acute fractures of the odontoid remains controversial, as
MRI may demonstrate increased uptake for 2 years fol-
lowing fracture and may demonstrate persistent uptake in
the setting of nonunion. Nonetheless, MRI can be con-
sidered as a supplemental study to assess the integrity of
stabilizing regional ligaments, as plain radiographs and
cervical CT scan fail to detect significant ligamentous in-
juries in 6% of the patients.22 A concomitant transverse
ligament rupture may increase the risk of odontoid non-
union and has been reported to occur in ∼10% of patients.
Transverse ligament injury may also result in persistent
atlantoaxial instability even after successful healing of an
odontoid fracture and may indicate the need for C1–C2
fusion.22,24,25
Imaging of the entire cervical spine is essential due to
a 16% rate of noncontiguous fractures.26
TREATMENT
The evaluation and treatment of patients with a
suspected cervical spine injury, including odontoid frac-
tures, remains a controversial topic. Although for some
fracture types the decision between conservative treatment
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Clin Spine Surg  Volume 32, Number 8, October 2019 Odontoid Fractures: Management & Future Directions

is relatively consensual, others, especially type II fractures, the maintenance of fracture reduction and search for any
maybe challenging. Furthermore, several types of con- complications. This period is associated with complica-
servative and surgical treatments have been proposed with tions associated with the immobilizing device and its re-
varying degrees of success and complications. The next sulting physiological consequences.
sections of this review will analyze in detail the manage- External immobilization of odontoid fractures is one
ment of each fracture type and discuss the controversies in of the oldest treatment modalities in spinal care. Cur-
their appropriate management. rently, the main conservative immobilization options are
the halo-vest or rigid immobilizations such as the hard
NONSURGICAL TREATMENT cervical collar or cervicothoracic orthosis (such as the
Minerva brace or others). Although some clinical studies
In the absence of an associated atlantooccipital dis-
suggest that devices restrict cervical spine movement to a
location, Anderson and D’Alonzo type I fractures can be
similar degree, biomechanical studies in cadavers have
treated conservatively with good clinical and radiologic re-
suggested that the halo is more effective in restricting
sults. All studies from the first review in 1974 to date report
cervical spine motion; therefore, immobilization with a
a union rate of 100% for this fracture type when treated
halo-vest may have a higher rate of fracture healing and a
conservatively.5,27–29 Cervical spine immobilization in a
lower rate of loss of reduction.34–37 However, immobili-
cervical orthosis for 6 to 8 weeks is usually sufficient.30,31
zation with halo-vest entails complications inherent to the
Treatment of type II fractures is much more con-
device itself and the position assumed by the cervical spine
troversial. Type II fractures that maybe amenable to
in relation to the thorax. Halo-vest immobilization has
conservative treatment are those without or with a minor
been shown to impair swallowing, respiratory function,
degree of displacement. Greene et al,29 analyzed 88 pa-
and mobilization because of the significant weight and
tients with a mean age of 41 with type II fractures treated
constriction of the vest and, hence, complications such as
nonoperatively and found that 25 (28.4%) did not develop
aspiration, pneumonia, pin-site infections, and cerebral
a solid fusion, and needed delayed surgical intervention. In
abscesses have all been reported in the elderly.38,39 Randal
a retrospective analysis of 113 type II fractures in patients
et al40 studied 53 patients treated with halo-vest and found
with a mean age of 43 years, Clark and White27 found that
respiratory distress in 4 patients, dysphagia in 6, and pin-
all type II fractures that had not been treated or managed
related complications in 10.
in an orthosis developed a nonunion. Conversely, in a
In a recent systematic review of studies comparing
series of 22 patients with type II fractures treated in halo-
halo with hard cervical collar immobilization, Waqar and
vests for 6–8 weeks followed by a hard collar for 4 weeks,
colleagues identified 12 papers including 714 fractures and
Stoney et al32 reported a union rate of 82%.
found that the rate of nonunion was equivalent between
Results from these studies highlight the controversies
the halo and cervical collar. The number of complications,
and variable results found with conservative treatment of type
however, was 34% in patients immobilized with halo and
II odontoid fractures. Age has also been shown to be one of
15% in those with a hard cervical collar. The most fre-
the key determinants of success of conservative treatment, with
quently encountered complications were an infection or
the elderly having a higher rate of nonunion after conservative
pressure-related ulceration from collar or pins, mechanical
than after surgical treatment. In an attempt to address the risks
device failure (eg, pin loosening), and medical complica-
of conservative care in geriatric patients, a systematic review
tions (eg, pneumonia), all of them in a higher rate in the
including 1233 type II fractures in patients over the age of 60
group of patients treated with a halo.30
was performed, and Schroeder et al33 found that the risk of
For this reason, when conservative treatment is ad-
complications was similar with operative and nonoperative
vised, a hard cervical collar or a cervicothoracic orthosis is
treatment, but conservative treatment was associated with
preferable to the use of halo-vest, particularly in elderly
higher short-term and long-term mortality.
patients, as it is associated with similar rates of fusion and
Type III fractures are generally considered stable, and
lower complication rates.
nonoperative treatment has traditionally been recom-
mended. Patients with type III fractures and without neu-
rological impairment, occipitoatlantal dislocation, SURGICAL TREATMENT
atlantoaxial instability, fragmented pattern, or significant
In a seminal paper, Osgood and Lund41 reviewed the
displacement can be treated conservatively. Different studies
literature and identified 56 odontoid fractures, with all but
have reported 85% fusion rates for type III odontoid frac-
3 being treated conservatively. Since then, the approach to
tures treated with cervical spine immobilization.28,29 How-
these fractures has radically changed, with a growing rise
ever, some type III fractures have characteristics that may
in the number of surgeries being performed.
lead to early intervention, and these will be discussed in the
As previously mentioned, type I fractures are in-
following sections of this paper.
herently stable and, in the absence of an associated atlan-
tooccipital dislocation, should be treated conservatively.
COLLAR OR HALO-VEST? Muller et al42 have defined stable type II and III
Nonoperative treatment of odontoid fractures usu- fractures as those with a fracture gap inferior to 2 mm,
ally consists of 6–12 weeks of immobilization. Patients displacement inferior to 5 mm, and angulation inferior to 11
should be regularly assessed during this period to confirm degrees. Using these criteria, they reported a conservative

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Carvalho et al
treatment union rate of 73.7% for type II and 85.7% for type
III fractures.
In the nongeriatric population, surgical treatment of
type II fractures is indicated when displacement is > 4–6
mm, angulation is > 10 degrees, and patient age is above
40–50 years, and also in type IIA variants, in cases
wherein it is not possible to achieve or maintain fracture
alignment with external immobilization, and in associated
neurologic injury or a pathologic fracture (eg, malignancy,
infection, metabolic disease).43
In type III fractures, there is a substantial area of
contact of cancellous bone along the fracture area, which
favors the formation of osseous callus and consolidation
of the fracture. The rate of healing with nonoperative
treatment is 85%–100%.14,28,29,44 Type III fractures must
be treated surgically if there is a displacement > 5 mm, a
shallow type III variant, as described by Aebi et al,45 and,
when there is an inability to achieve or maintain fracture
alignment with external immobilization, the fracture is
neurologic injury associated, or when there is a pathologic
fracture (eg, malignancy, infection, metabolic disease).27,31,45
It should be mentioned that displacement maybe difficult to
assess, as it can change with patient and neck posture and
even with respiration.
Several types of surgical techniques have been pro-
posed, ranging from an anterior approach for odontoid
fracture fixation to C1–C2 fusion using a posterior ap-
proach. In Figure 2, the most frequently used treatments
are summarized.
Anterior Odontoid Fracture Fixation
Nakanishi was the first to describe a technique of
anterior screw fixation of odontoid fractures using a lag
screw.46 This nonfusion technique provides immediate
stability, promotes healing, and may preserve most of the
remaining C1–C2 motion; in this technique, adequate
Anterior approach
Surgical Treatment
Posterior approach
FIGURE 2. Surgical treatment options.
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Clin Spine Surg  Volume 32, Number 8, October 2019
stability for fracture union depends on anatomic reduction
and interfragmentary compression with a lag screw effect.
However, internal fixation of type II odontoid fractures
with screws does not restore the original C1–C2 stability,
and 50% of the patients may need postoperative cervical
immobilization.47
This technique maybe limited in nonreducible frac-
tures due to fragment geometry (eg. fracture comminu-
tion, unfavorable fracture plane angulation, rupture of the
transverse atlantal ligament, or inability to obtain ana-
tomic fracture reduction), body habitus (eg. barrel-shaped
chest), short neck, osteoporotic bone, or when cervical
kyphosis precludes this type of approach.
Although clinical results are consistently good in
several series of patients, there is controversy as to the im-
pact of this technique on the motion of the cervical spine: a
CT-based study suggested that only 39% of patients dem-
onstrated normal C1–C2 rotation following surgery,48
whereas another reported that 71% of patients retained full
functional neck rotation following surgery.48,49
Apfelbaum et al50 reported a fracture healing rate of
88% in patients with recent (< 6 mo) fractures but of 25%
in patients with remote ( > 18 mo) fractures. These results
clearly demonstrate that this technique should not be used
for nonunions. In addition, they investigated factors as-
sociated with the risk of failure and found that fracture
pattern, but not age, sex, displacement, and a number of
screws, was associated with failure. Grauer et al51 pro-
posed a classification of type II odontoid fractures based
on the pattern with a significant impact on the outcome
(Fig. 3). The patterns most often associated with the risk
of failure are comminuted or anterosuperior to
posterosuperior orientations (type II C proposed by
Grauer), when compared with patients with displaced
transverse or anterior superior to posterior inferior
orientations (type IIA and IIB proposed by Grauer).
One screw
Two screws
Brooks technique
C1-2 sublaminar wire fixation
and bone grafting
Gallie technique
Posterior C1-2 transarticular Magerl and Seemann
screw fixation technique
Posterior C1-C2 fusion with
poliaxial screw and rod Harms technique
fixation
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Clin Spine Surg  Volume 32, Number 8, October 2019
FIGURE 3. Proposed subclassification of type II odontoid
fractures, originally in Grauer et al,51 with copyright permis-
sion. Copyright Clinical Spine Surgery, Elsevier. All permission
requests for this image should be made to the copyright
holder.
Fountas et al52 analyzed 31 patients with type II and
III fractures utilizing both plain radiographs and CT at an
average of 58 months after anterior fixation and found that
87.1% had bony union, 9.6% stable nonunions, and 3.2%
unstable nonunions, suggesting that high stability and low
mechanical failure rates can be achieved with this technique.
One of the main controversies with this technique is
whether the fixation should be performed with 1 or 2
screws. In a postmortem biomechanical study, Sasso
et al47 found that the load to failure was equivalent when
FIGURE 4. A and B, Anteroposterior and lateral radiographs of a patient who underwent Gallie technique.
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Odontoid Fractures: Management & Future Directions
using 1 or 2 screws. This is supported by a clinical study of
42 patients with an average age of 54 years (20 with a
single screw and 22 with 2 screws) in which no significant
differences in union rates were found with either
technique.53 In another study including 26 patients with
type II fractures and an average age of 35 years, Subach
et al54 reported a 96% fusion rate using only 1 screw.
The favorable biomechanics of using only 1 screw
seems to be lost, however, in older patients. In a retro-
spective analysis of 57 patients above the age of 70, Dailey
et al55 reported stability rates (bony or fibrous union) of 96%
when using 2 screws, but only of 56% when using 1 screw.
Furthermore, anterior surgery in this patient population was
associated with considerable rates of dysphagia (35%), need
for enteric feeding (20%), and death (5.3%).55 These com-
plications, together with the difficulty associated with plac-
ing 2 screws in such a frail bone led the authors to advise
against anterior surgery in elderly patients.
Posterior C1–C2 Fusion
When anterior fixation of the odontoid is not pos-
sible or the risk of complications, such as dysphagia in the
elderly population is too high, a C1–C2 fusion can be
performed to stabilize odontoid fractures. Historically,
this was carried out using sublaminar wiring but is now
commonly performed using screw-rod constructs (SCRs).
C1–C2 Fusion With Sublaminar Wire Fixation
The most commonly performed C1–C2 sublaminar
wiring technique is that described by Gallie in 1939 and
modified by Brooks in 1978. In Gallie’s technique, a mono-
block graft is placed between the arch of C1 and the spinous
process of C2 and fixed with a wire passing underneath the
spinous process of C2 and around the arch of C156 (Fig. 4).
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Carvalho et al
FIGURE 5. A and B, Anteroposterior and lateral radiographs of a patient who underwent Magerl technique.
Brooks reported a variation of this technique in which
2 doubled wires were passed underneath the arch and each
lamina and 2 grafts were fit between the lateral part of the
arch of the atlas and the lamina of the axis,57 and bio-
mechanical studies suggest this method to be relatively more
stable.58–60 A 5%–7% rate of intraoperative spinal cord in-
jury has been associated with wire passage.61 Either tech-
nique, however, does not provide sufficient immediate
stabilization and requires a period of supplemental post-
operative external cervical spine immobilization.
In addition to the need for external immobilization,
fusion rates with sublaminar wiring techniques are generally
lower than with SCR. Yuan et al62 retrospectively reviewed
49 patients (25 with sublaminar wiring and 24 with SRC),
and, although all patients had good clinical results, the rate of
bone fusion at 3 months was 88.0% in the sublaminar wiring
group and 100% in the SRC group. Conversely, patients in
the Gallie group had lower blood loss, operation time, ra-
diographic exposure times, and hospital costs. The authors
concluded that, for patients with atlantoaxial instability in
which (a) the atlantodental interval (ADI) was > 5 mm on
lateral flexion-extension x-ray, or Anderson-D’Alonzo type II
odontoid fracture, (b) without asymmetry between the
odontoid process and lateral mass on open-mouth anterior-
posterior x-ray, and with no displacement of lateral mass
joint on the CT three-dimensional reconstruction, the Gallie
technique could be chosen as a safe and effective method.
However, for patients with irreducible atlantoaxial dis-
location, SRC techniques should be preferred.62
C1–C2 Fusion With SCRs: Transarticular Screw
Fixation
C1–C2 transarticular screw fixation was introduced
by Magerl and Seemann in 1979 and provides superior
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Clin Spine Surg  Volume 32, Number 8, October 2019
initial stabilization compared with posterior wiring
techniques.63 Although initially utilized in conjunction
with posterior wiring, transarticular screw fixation is now
more commonly performed without associated wiring,
with excellent reported results (Fig. 5).
A 10-fold increase in rotational stiffness compared
with posterior wiring techniques has been reported.59 In-
creased initial stability eliminates the need for post-
operative halo-vest immobilization, and clinical fusion
rates approaching 100% have been reported in small series
of patients. Survey results suggest the risk of vertebral
artery injury with this technique is ∼4%, with the rate of
clinically apparent stroke being 0.2%.64–67
In a series of 94 patients, Paramore et al68 found a
high-riding transverse foramen on at least 1 side of the C2
vertebra in 17 (18%) patients, which would prohibit the
placement of transarticular screws, indicating that not all
patients maybe suitable candidates for posterior C1–C2
transarticular screw fixation on at least 1 side. To obviate
these problems, it is recommended that patients undergo a
CT angiogram before surgery.
C1–C2 Fusion With SCRs: C1 Lateral Mass and C2
Pedicle Screw Fixation
Although transarticular screw fixation has been
shown to lead to excellent fusion rates, this procedure
cannot be used in the presence of fixed subluxation of C1
on C2 and in cases of an aberrant trajectory of the ver-
tebral artery. To address these limitations, Harms and
colleagues described a technique in which bilateral screws
were inserted in the lateral masses of C1 and in the pars
interarticularis into the pedicle of C2, followed by a flu-
oroscopically controlled reduction maneuver and rod fix-
ation (Fig. 6). There is no need for structural bone graft or
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Clin Spine Surg  Volume 32, Number 8, October 2019
FIGURE 6. A and B, Anteroposterior and lateral radiographs of a patient who underwent Harms technique.
wiring. In a CT scan analysis of 26 patients submitted to
C1–C2 fusion using this technique, Bourdillon et al69
identified no cases of nonunion and mechanical compli-
cations at 6 and 12 months.
Despite its advantages, this technique may also have
complications, especially in the elderly. Bleeding from the
epidural plexus during the preparation of the lateral
masses may cause hemodynamic instability, and the C2
nerve root must be distracted downward, causing post-
operative neuralgia.70,71
Squires et al72 have proposed an intentional sacrifice
of the bilateral C2 nerve root ganglion, which resulted in
less operative time and decreased blood loss in elderly
patients undergoing C1–C2 posterior fusion with the
Harms technique.
C1–C2 Fusion With SCRs: Comparison Between
Transarticular Screw Fixation and C1 Lateral
Mass–C2 Pedicle Screw Fixations
A few studies have compared the outcomes of
transarticular screw fixation with C1 lateral mass–C2
pedicle screw fixation. Lee et al73 compared 28 patients
with C1–C2 transarticular screw fixation with 27 having
C1 lateral mass–C2 pedicle screw fixation and found
equivalent clinical results, but higher fusion rates with the
Harms fixation (96% vs. 82.1%). More recently, Rajinda
et al74 analyzed the results of 45 patients submitted to
transarticular screw fixation and 60 submitted to C1 lat-
eral mass–C2 pedicle screw fixation and found no differ-
ences in fusion rates, but longer surgical time (119.8 vs.
104.3 min) and larger bleeding volume (233.5 vs. 179.3
mL) were found with the Harms technique.
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Odontoid Fractures: Management & Future Directions
Both techniques are safe and effective treatment op-
tions for stabilizing the atlantoaxial joint, providing ex-
cellent clinical and radiologic outcomes. Selection of the
fixation procedure for the treatment of atlantoaxial in-
stability requires a thorough knowledge of the patients’
anatomy, careful preoperative evaluation, and planning for
successful screw positioning, and favorable clinical results.
Posterior Approach: Emerging Techniques
In parallel with other areas of spinal surgery, com-
puter-assisted navigation can also aid in improving the ac-
curacy of C1–C2 fusion techniques; in the case of the upper
cervical spine, in which the visibility provided by conven-
tional fluoroscopic techniques is limited, this maybe even
more important. A case of robotic-assisted posterior fixation
of an atlantoaxial deformity and instability has been de-
scribed in which C1–C2 transarticular screws were in-
troduced under the guidance of a robotic system (TiRobot).
The calculated deviation from the planned position and
actual position was 0.8798 mm. There were no intra-
operative complications, and postoperative CT showed no
perforations and loosening of the screw.75
Recently, it has been proposed that surgical fixation
in these fractures maybe removed over time, to preserve an
axial range of motion.76 This is, however, based in few
cases reports, and further studies are needed to assess the
time needed for stability and whether this can be applied
to all types of surgically treated odontoid fractures.
ODONTOID FRACTURES IN THE GERIATRIC
POPULATION
With the progressive population aging, which is ac-
companied by the loss of bone density, osteopenia, and
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Carvalho et al
FIGURE 7. Sagittal view on computed tomographic scan of an
82-year-old man demonstrating the osteopenia of dens.
osteoporosis, the incidence of odontoid fractures has and
will likely continuously increase.77 This is particularly
common in type II fractures, as bone density in the dens is
lost in elderly patients (Fig. 7). Although there is no class I
evidence on which approach is preferable for these patients,
class II evidence suggests that in patients over the age of
50 years, surgical treatment maybe preferable.78 As
aforementioned, in the elderly, bone conditions limit the
choice of the surgical technique and, as such, if the anterior
approach with screw fixation is amenable, 2 screws should
be used instead of 1. Nonetheless, posterior approaches are
more frequently used in this patient population.
In a systematic review of studies including 1233 pa-
tients with type II odontoid fractures over the age of 60,
Schroeder et al33 found a decreased risk of short-term and
long-term mortality, without an increase in the risk of
Odontoid fracture
Type I Type II
Non surgical
Unstable* or
treatment - Hard
elderly patients
Collar
Surgery
FIGURE 8. Algorithm of treatment. *Criteria of instability: displacement > 6 mm, angulation > 10 degrees, type IIA variants,
inability to achieve or maintain fracture alignment with external immobilization, associated neurological injury or a pathologic
fracture.
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Clin Spine Surg  Volume 32, Number 8, October 2019
complication in those treated surgically compared with
those treated conservatively. Conversely, Dhall and
colleagues79,80 analyzed 3847 patients with traumatic C2
fractures over the age of 80 (3449 nonsurgical treatment, 398
surgical treatment) and found equivalent mortality rates,
but a 50% increase in the complication rate (such as pneu-
monia or urinary tract infection) in the surgical group.
AUTHORS’ PREFERRED TREATMENT
Type I fractures should all be treated conservatively
with a hard cervical collar. Care should be taken to
identify associated craniocervical injuries that maybe as-
sociated with these types of fractures. Similarly, stable
type II fracture in young patients and all stable type III
fractures should be treated with a hard cervical collar.
Stable type II fractures in the elderly and unstable type II
and III fractures should be considered for surgical treat-
ment (Fig. 8).
Surgical treatment will depend on whether the fracture
is reducible, on its morphology, and on the age of the pa-
tients. Reducible fractures with a posterior oblique or
transverse fracture line maybe fixed anteriorly. In these
cases, 1 screw is sufficient in young patients but, due to bone
frailty, 2 screws should be used in older patients. For other
fracture patterns or for irreducible fractures, a posterior C1–
C2 fixation should be used. Because of a higher rate of
union, SCR should be preferred to sublaminar wiring
techniques in most cases, with the Magerl and Harms
techniques having similar results in reducible fractures. If the
fracture is irreducible, or in cases of high-riding vertebral
artery trajectory, C1 lateral mass–C2 pedicle screw fixation,
as described by Harms, should be performed (Fig. 9).
CONCLUSIONS
Decision-making in odontoid fractures is challenging
and requires thoughtful consideration of many factors related
to the nature of the fracture and to the patient. Weighing
potential risks and benefits of various treatment options can
be particularly difficult in elderly patients and is complicated
by the fact that the natural history of odontoid nonunions is
largely unknown. A review of the clinical literature provides
insufficient evidence to establish strict guidelines with respect
Type III
Stable and young
Stable Unstable*
patients
Non surgical Non surgical
Surgical
treatment - Hard treatment - Hard
Treatment
Collar Collar
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Clin Spine Surg  Volume 32, Number 8, October 2019
FIGURE 9. Algorithm of surgical treatment.
to the treatment of odontoid fractures. Acceptable options for
initial treatment of all types of odontoid fracture include
external cervical immobilization with a hard cervical collar,
whereas type II and III fractures should be considered for
surgical fixation in the setting of 5 mm displacement, type IIA
comminution, inability to achieve/maintain fracture align-
ment with external immobilization, or in elderly patients.
Selection of the fixation procedure requires a thorough
knowledge of the patient’s anatomy and careful preoperative
evaluation and planning for successful treatment and favor-
able clinical results.
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