The long-term functional outcome of type II odontoid fractures managed non-operatively

Abstract

Odontoid fractures currently account for 9-15% of all adult cervical spine fractures, with type II fractures accounting for the majority of these injuries. Despite recent advances in internal fixation techniques, the management of type II fractures still remains controversial with advocates still supporting non-rigid immobilization as the definitive treatment of these injuries. At the NSIU, over an 11-year period between 1 July 1996 and 30 June 2006, 66 patients (n = 66) were treated by external immobilization for type II odontoid fractures. The medical records, radiographs and CT scans of all patients identified were reviewed. Clinical follow-up evaluation was performed using the Cervical Spine Outcomes Questionnaire (CSOQ). The objectives of this study were to evaluate the long-term functional outcome of patients suffering isolated type II odontoid fractures managed non-operatively and to correlate patient age and device type with clinical and functional outcome. Of the 66 patients, there were 42 males and 24 females (M:F = 1.75:1) managed non-operatively for type II odontoid fractures. The mean follow-up time was 66 months. Advancing age was highly correlated with poorer long-term functional outcomes when assessing neck pain (r = 0.19, P = 0.1219), shoulder and arm pain (r = 0.41, P = 0.0007), physical symptoms (r = 0.25, P = 0.472), functional disability (r = 0.24, P = 0.0476) and psychological distress (r = 0.41, P = 0.0007). Patients >65 years displayed a higher rate of pseudoarthrosis (21.43 vs. 1.92%) and established non-union (7.14 vs. 0%) than patients <65 years. The non-operative management of type II odontoid fractures is an effective and satisfactory method of treating type II odontoid fractures, particularly those of a stable nature. However, patients of advancing age have been demonstrated to have significantly poorer functional outcomes in the long term. This may be linked to higher rates of non-union.

Fig. 1

a Pearson correlation representing the association between advancing age and severity of neck pain. Severity of neck pain was positively correlated with advancing age, although the association was found to be outside the range of statistical significance (r = 0.19, 95% CI −0.05 to 0.42, P = 0.1219). b Comparative analysis of neck pain with box plots representing patients aged <65 and ≥65 years. Patients >65 years displayed a greater mean score (33.88 ± 27.08) and poorer outcome than those <65 years (22.20 ± 15.99)

Fig. 2

a Pearson correlation representing the association between advancing age and severity of shoulder and arm pain. The severity of shoulder and arm pain was positively correlated with advancing age (r = 0.41, 95% CI 0.18–0.59, P = 0.0007). b Comparative analysis of shoulder and arm pain with box plots representing patients aged <65 and ≥65 years. Patients >65 years had a poorer outcome and higher mean pain score (35.10 ± 28.20) than patients <65 years (12.86 ± 16.00)

Fig. 3

a Pearson correlation representing the association between advancing age and physical symptoms. The severity of physical symptoms was positively correlated with advancing age, with a statistically significant association (r = 0.25, 95% CI 0.00–0.46, P = 0.0472). b Comparative analysis of physical symptoms with box plots representing patients aged <65 and ≥65 years. Patients >65 years had a poorer outcome with higher mean score (38.57 ± 26.75) than those <65 years (17.23 ± 19.89)

Fig. 4

a Pearson correlation representing the association between advancing age and functional disability. The severity of functional disability was positively correlated with advancing age (r = 0.24, 95% CI 0.00–0.46, P = 0.0476). b Comparative analysis of functional disability with box plots representing patients aged <65 and ≥65 years. Patients >65 years were found to have greater functional disability and higher mean score (33.93 ± 18.04) when compared to patients <65 years (18.11 ± 22.67)

Fig. 5

a Odontoid view b anteroposterior and c lateral cervical spine radiographs of a fracture of the base of the odontoid peg with slight forward subluxation of C1 on C2. This is the case of a 65-year-old lady involved in a road traffic accident sustaining a type II odontoid fracture treated with a halo device