Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly

This study is a retrospective analysis of patients older than 65 years with odontoid fractures. The series consisted of 29 consecutive patients with odontoid fractures (18 women, mean age 78, range 66-99 years). Twenty-six patients were neurologically intact, Frankel E, whereas three had neurological symptoms: two Frankel D and one Frankel C. Eleven patients were treated with anterior screw fixation according to Böhler, seven with a posterior C1-C2 fusion. Ten patients with either minimally displaced fractures or with complicating medical conditions were treated conservatively. At follow-up, 7/7 patients with posterior fusion had healed without any problems, whereas 8/11 patients treated with anterior screw fixation, and 7/10 conservatively treated patients were either failures or had healed, but after a complicated course of events. We conclude that anterior screw fixation according to Böhler is associated with an unacceptably high rate of problems in the elderly. Probable causes may be osteoporosis with comminution at the fracture site, or stiffness of the cervical spine preventing ideal positioning of the screws. As non-operative treatment also often fails, the method of choice seems to be posterior C1-C2 fusion.