Operative versus nonoperative management of acute odontoid Type II fractures: a meta-analysis

The purpose of this study was to evaluate the feasibility of the criteria described in the literature as the indications for surgery for acute Type II odontoid fractures.

The authors searched the PubMed database for studies in which the fusion rate of acute Type II odontoid fractures following external immobilization (halo vest or collar) or surgery (posterior C1-2 fusion or anterior screw fixation) was reported. The only studies included reported the fusion rate for either 1) groups of patients whose age was either more or less than a certain age range (45-55 years); or 2) groups of patients with a fracture displacement of either more or less than a certain odontoid fracture displacement (4-6 mm) or the direction of displacement (see Methods section of text for more details). A meta-analysis in which the random effect model was used was conducted to analyze the data.

There was a statistically significantly higher fusion rate for operative management compared with external immobilization (85 vs 60%, p = 0.01) for the patients > 45-55 years. However, the overall fusion rate was > 80% for the patients whose age was < 45-55 years, regardless of treatment modality, and no significant differences were observed between surgically and nonsurgically treated patients (89 and 81%, respectively; p = 0.29). The result of operation (overall fusion rate 89%) was superior to external immobilization (44%) when the fracture was posteriorly displaced (p < 0.001), but for anteriorly displaced fractures, the results of operative and nonoperative management were identical (p = 0.15). The overall fusion rate of operative management of both anteriorly and posteriorly displaced fractures proved to be > 85%, and no statistically significant difference was observed (p = 0.50). For all degrees of displacement (either > or < 4-6 mm) the operation proved to provide significantly better results than conservative treatment. The fusion rate of conservatively treated fractures with < 4-6 mm displacement was significantly better than in fractures with > 4-6 mm displacement (76 vs 41%, p = 0.002).

Operative treatment (posterior C1-2 fixation or anterior screw fixation) provides a better fusion rate than external immobilization for acute odontoid Type II fractures, although in certain situations, such as anterior displacement of the fracture and for younger (< 45-55 years of age) patients, conservative management (halo vest or collar immobilization) can be as effective as surgery. Operative management is recommended in older patients, in cases of posterior displacement of the fracture, and when there is displacement of > 4-6 mm.