Optimal treatment for odontoid fractures in the elderly

Study Design. Clinically based systematic review. Objective. To define optimal clinical care for elderly patients with Type II and III odontoid fractures using a systematic review with expert opinion. Summary of Background Data. Numerous manuscripts have been written about treatment strategies of odontoid fractures in the elderly. However, these articles are of low quality and optimal treatment algorithms do not exist. Methods. Focused questions on the treatment of elderly patients with Type II and III odontoid fractures were refined by a panel of spine traumologists surgeons, consisting of fellowship trained neurologic and orthopedic surgeons. MeSH keywords were searched through MEDLINE, EMBASE, and the Cochrane Database of Systematic reviews, and pertinent abstracts and manuscripts obtained. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence-based review system, the proposed questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise. Results. The literature searches revealed low and very low quality evidence with no prospective or randomized studies. The MEDLINE search engine returned 1759 articles, which were further limited to "all aged (65 and over)," human subjects and the English language. The subsequent search resulted in a return of 377 manuscripts. These abstracts where then reviewed in detail and 117 manuscripts were selected, which were obtained and supplemented with additional manuscripts to form an evidentiary table. Conclusion. Odontoid fractures have a significant morbidity in the elderly (>65 years) population. Type II fractures in this population are recommended to be treated operatively with a weak recommendation, and if treated nonoperatively using a hard collar immobilization device. Type III odontoid fractures in the elderly optimal treatment with a strong recommendation is immobilization in a hard collar.