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168
Fig. 11.4 Odontoid Type II fracture seen on sagittal classical
tomogram
Fig. 11.5 3D CT showing the odontoid Type II fracture
scanning also confirms or excludes any other associated spinal fractures. MRI evaluation is nonurgent in
neurologically intact patients but is helpful in evaluation of the soft tissues, and especially the integrity of
TAL (Fig. 11.6) [20].
11.5 Treatment Strategy
Holdsworth [46] stated: “any classification has a sense
if it can influence our therapeutic decision.” From this
point of view, the most widely accepted classification
11 Odontoid Process Fractures
Fig. 11.6 MRI depicting the lateral tear of the transverse atlan-
tal ligament (TAL)
of Anderson and D’Alonso has some limitations.
Generally, it is necessary to define which fractures are
unstable and would thus eventually require surgical
intervention. Most of the authors accept that Type I
and III fractures are stable enough to allow conservative treatment with external bracing [2, 6, 7, 42, 62].
However, the “gray zone” exists between Type II and
III fractures. The so called “high, rostral or shallow”
Type III fractures should only include fractures that
extend into the superior C2 articular surface. However,
those that involve rostral C2 body but do not extend
into the articular surfaces should be classified as Type
II, as elegantly addressed by Grauer et al. [34]. Another
classification issue is the caudal extent of the fracture,
i.e., what distinguishes whether a fracture is a Type III
OF or a fracture of the body (Fig. 11.7). Furthermore,
there is also a wide range of different morphologies of
Type II fracture patterns, not involved in the original
classification, which can substantially influence the
treatment decision. Fracture site, comminution, obliquity, and/or dislocation can all be of importance.
Historically, most of the pioneers treated delayed fracture presentation. First procedure done for odontoid fracture is credited to Mixter who performed posterior AA
wire and graft fusion, in fact, for odontoid pseudoarthrosis [61]. Generally, all types of odontoid fractures were
primarily treated conservatively in the past. Following
traction reduction of dislocated fractures, hard external
orthoses (Minerva jackets, SOMI braces, and hard
11.5 Treatment Strategy
Fig. 11.7 Coronal plane CT showing a horizontal fracture of C2
body which should not be considered as odontoid fracture
collars) were used to stabilize the UCS. The halo-vest
was popularized later due to its supposedly higher rigidity
[16, 23, 36]. Predominantly, posterior surgical intervention was mostly reserved for fractures that had failed conservative therapy. Many modifications of the Gallie
technique have been developed to achieve stable posterior AA fusion [12, 17, 22, 29, 37]. The techniques are
described in detail in Chap. 6. All posterior AA fusion
techniques were initially supplemented by halo-vest fixation thus adding further stress to the patient and it was not
clear if healing was achieved due to the fusion, external
immobilization or both. However, with the introduction
of transarticular technique of Magerl, immediate AA stability could be achieved by posterior rigid screw techniques and thus lead to much improved fusion rates and
clinical results [17, 21, 31, 32, 38, 44, 49, 59, 60].
Nonetheless, any atlantoaxial fusion substantially limits
the cervical spine rotation (50%) and therefore, does not
represent an ideal solution to the problem.
The first attempt to approach the fracture directly
was reported by Estridge and Smith [24]. They followed the idea of Fang and Ong [25] who fixed the
odontoid pseudoarthrosis by intra-articular C1-2 grafting performed transorally. They directly refreshed the
fracture site and implanted vertically oriented autologous iliac crest bone graft. Their patient fused in a
Minerva jacket but, unfortunately, successfully committed suicide a year later. Interestingly, a firm bony
fusion was confirmed at autopsy in this case.
The development of direct screw compressive osteosynthesis by Nakanishi and Magerl was the real
169
breakthrough in the philosophy of the odontoid fracture treatment. This technique is suitable for Type II
and shallow Type III fractures and represents the most
physiological approach directly targeting the pathology and theoretically not influencing adjacent segment
mobility [2, 10, 52, 88, 91].
It has been proven that without any treatment, odontoid fracture have close to 100% nonunion rate [16].
However, given the number of surgical options for
odontoid fractures, there is no evidence clearly favoring one particular treatment strategy over the other,
including both conservative and surgical methods [7].
In displaced fractures, traction reduction should always
precede the final immobilization, whatever it may be
[52, 94].
As in the past, patients with the rare Type I OF with
no other associated UCS injury (e.g.: AOD) are treated
conservatively with collar or more rigid external braces
including halo-vest [62, 70, 83].
The majority of the Type III fractures are successfully treated in external braces with expected fusion
rates of approximately 87–100% [15, 16, 28, 52, 94].
For this purpose, more surgeons recommend halo-vest
immobilization [7, 36] although reports of successful
hard collar treatment of Type III fracture were published [55, 63, 70].
Halo-vest fixation was recently criticized because it
offers no advantage of a more solid immobilization
than a rigid cervical collar and increases the rate
of complications, especially in the older population
[55, 82]. Frequent complications (26–66%) related to
wearing a halo-vest are not benign and can include
pressure sores, pin infection, pin loosening, fracture
correction loss and, in the worst case scenario, breathing problems and pneumonia [27, 47, 76]. Fatal cardiopulmonary complications resulting in cardiac arrest
have been reported in the elderly [92]. In some series
of patients treated for odontoid fractures, the halo-vest
related mortality was much higher than that for
Philadelphia collar and/or surgical treatment [27, 87,
92]. Strohm et al. [87] also noted that 58% of his
patients judged the halo to be intolerable.
The most commonly discussed topic in odontoid
fractures nowadays is the treatment of Type II and
“shallow” Type III fractures. These injuries are highly
unstable and external immobilization fails to create
bony union, on an average, in 30–50% of patients [36,
54, 57, 84]. Even further, if patients older than 60 years
are included in the series, the failure rate dramatically
increases up to 77–86% [36, 75].
170
11 Odontoid Process Fractures
Nonetheless, halo-vest or even hard collar immobilization is still accepted in certain nondisplaced and
stable Type II fracture scenarios [36, 63, 69, 70],
although the majority of modern surgeons [1, 2, 8, 18,
66, 88, 91, 95] prefer early surgical stabilization in
acute forms.
The reasons surrounding the high frequency of nonunion following conservative treatment of Type II fractures are also the subject of considerable debate. Some
authors propose that there is a weak vascular watershed
zone with poor blood supply in the odontoid neck whereas
others believe that the odontoid neck is a place of enormous load transmission in the location of structurally
poor bone [4, 5, 81]. The following factors have been
shown to negatively influence healing of Type II fractures: fracture dislocation greater than 6 mm, angulation
greater than 10°, fracture site comminution, osteoporosis,
age over 60 years, delayed treatment, and loss of fracture
alignment during the follow-up [9, 42, 58, 71, 80].
Despite its obvious logical advantage, the direct
anterior screw osteosynthesis does have its opponents
who prefer posterior AA fusion, especially in the
elderly [14, 64]. The reported fusion rate of Type II
fracture treated with anterior screw is 80–96% and for
shallow Type III even higher being near 100% in most
cases [7, 8, 52, 88, 89, 91].
Different techniques were developed to achieve
anterior compressive osteosynthesis, as described in
Chap. 6. Initially, fully threaded 3.5 mm steel screws
were used [10] with the necessity of proximal canal
overdrilling to achieve fracture compression. Later,
partially threaded titanium alloy cannulated screws
were introduced along the guiding Kirschner wire [2].
Apfelbaum advocated the use of 4 mm noncannulated
screws as a stronger option [8]. Knöringer proposed a
double-threaded screw (similar to Herbert screw) with
self-compressive property [53]. Different types of
approach instruments were subsequently developed to
minimize morbidity of the surgical approach [45, 85].
Special plates introduced via a high anterolateral
approach to fix comminuted, oblique, and delayed
fractures were suggested with the aim to spare atlantoaxial movement [68, 86].
Currently, there is still ongoing discussion if one or
two anterior screws should be used for fracture stabilization. Originally, it was proposed to introduce the first
screw as compressive and the second one to stabilize
against the rotational forces [2, 10]. However, biomechanical studies confirmed similar strength for one
or two screw construct [35, 78]. This finding was supported by excellent clinical results documenting up to
95% fusion rate using only one screw for fixation [26,
48, 50, 79, 89].
Although far less physiological, the posterior atlantoaxial fixation does indeed have its place in the treatment of odontoid fractures, especially when anterior
osteosynthesis is not possible or when pseudoarthrosis
already exists [8]. Short neck, barrel chest, hyperkyphotic cervical spine, comminuted fracture site, nonreducible dislocation, certain combined C1-2 injuries,
and TAL deficiency can represent relative contraindications to the anterior procedure.
11.6 Our Preference
Similar to other CVJ traumatic injuries, all our patients
with suspected odontoid process injury undergo mandatory spiral CT with 3D reconstructions. We are also
convinced that MRI should be done in the first 24 h
even in patients without neurological deficit. In those
with neurological compromise, MRI evaluation should
be undertaken on an emergent basis. MRI is valuable
in evaluation of the spinal cord status and the integrity
of transverse ligament. It can also exclude other soft tissue injuries – for example, a disk prolapse. (Fig. 11.8).
In selected and cooperating patients, flexion – extension films performed under physician guidance can
reveal potential instability in Type III fractures and/or
other level of concomitant injury, not immediately
detectable on static images (Fig. 11.9).
Despite 15 years of experience with UCS injuries
and surgical treatment of more than 90 patients with
odontoid fracture, we have never encountered a Type I
odontoid fracture. Nonetheless, even Type I injury
could be unstable in the presence of bilateral apical
ligament disruption or combined injury with occipital
condyle fractures. In those situations, when initial
attempt of conservative treatment with standard hard
cervical collar is undertaken, it is essential to confirm
CVJ stability radiographically at the end of follow-up
as one can discover a potentially dangerous, initially
reduced AOD.
Transverse ligament damage is, in our experience,
rarer than presumed in the literature [20]. In the era of
lower quality MRI, most of our patients with Type II
fractures were treated with anterior screws without the
11.6 Our Preference
Fig. 11.8 Odontoid Type II
fracture accompanied by a
disk prolapse at the C3/4
level. (a) Sagittal MRI in T2
sequence. (b) Postoperative
lateral radiograph showing
single screw odontoid
fixation performed simultaneously with graft and plate
C3/4 fusion
171
Fig. 11.9 (a) Patient with
instability revealed during
physician-guided flexion and
extension films a. lateral film
obtained at admission.
(b) Flexion revealed odontoid
and C2 ring fracture.
(c) Sagittal CT reconstruction
showing combination of
hangman’s type and odontoid
Type III fracture. (d) Double
screw fixation of odontoid
with concomitant graft and
plate C2/3 fusion
172
11 Odontoid Process Fractures
exact knowledge of TAL status. No single case of AA
instability was identified on dynamic films performed
routinely at 6 weeks after procedure (Fig. 11.10).
We do not typically operate on nondisplaced Type
III OFs and even more so, we believe that if conservative treatment is selected, a hard cervical collar (e.g.,
Philadelphia) is sufficient to allow successful healing
of this type of fracture if isolated. We use a halo-vest
fixation only exceptionally in certain combined UCS
injuries and in situations where surgical fixation does
not necessarily guarantee sufficient stability. Due to
our repeated experience of highly morbid halo vests,
we never select this option as a first choice treatment in
Type II or shallow Type III fractures (Fig. 11.11).
We select a direct anterior compressive osteosynthesis for almost all Type II and “shallow” Type III
fractures (especially if the AA joint is affected
(Fig. 11.12). Also, Type III injuries that are dislocated
and/or unstable on dynamic films can be treated with
anterior screws if there is enough bone available at the
base of the C2 body. In our opinion, as long as the previously described condition of sufficient bone “stock”
Fig. 11.10 Dynamic films
6 weeks after double-screw
fixation of Type II odontoid
fracture confirming AA
stability. (a) Lateral film in
flexion and (b) extension
Fig. 11.11 Halo-vest fixation
was unable to maintain
odontoid Type II fracture
alignment. (a) Reduced
fracture before patient’s
discharge. (b) Posterior
dislocation registered at
1 month check up
11.6 Our Preference
Fig. 11.12 CT reconstruction of “shallow” Type III fracture with left AA joint involvement. (a) Reconstruction in coronal plane.
(b) Sagittal reconstruction showing the anteriorly oblique pattern. (c) Anterior view of 3D reconstruction
173
Fig. 11.13 The same patient as Fig. 11.12, treated with a double
anterior screw fixation with K-wire safeguarding against anterior
redislocation. (a) First, the K-wire introduced through reduced
is respected, even anteriorly oblique fractures do not
represent a contraindication to the anterior screw fixation. The described unintentional anterior dislocation
can be simply prevented with parallelly-introduced
K-wires (Fig. 11.13). However, if the anterior procedure is not possible (barrel chest, fracture site comminution etc.) or failed, we perform a salvage posterior
fixation. The posterior approach of choice for us is the
solid screw fixation according to Magerl or Goel-Harms
technique of atlantoaxial fixation.
Prior to scheduled anterior procedure, all dislocated
fractures are reduced with halo-ring traction with its
continued application during the operation if necessary
(Fig. 11.14). We prefer the use of four-point fixation
ring instead of Crutschfield, Barton or Gardner-Wells
tongs because it is easy to attach, safe, and forces
can be applied in any direction. Different weights can
be used to achieve reduction, starting with 2 kg,
odontoid fracture on fluoroscopical view. (b) Lateral fluoroscopical view documenting the K-wire protective function during first
odontoid screw tightening. (c) Final result shown on transoral film
but frequently reaching much higher values during
reduction maneuvers in experienced hands (20 kg on
one occasion).
If a fracture dislocation cannot be reduced, either
posterior fixation with an attempted reduction or fixation and fusion in-situ are the options. If cord compression exists on MRI, a transoral decompression may
then be necessary. Theoretically, also, a vice versa
approach is possible.
In general, we prefer to introduce two screws. The
limiting factors for that maneuver are a thin odontoid
process unable to accommodate two 4 mm shortthreaded screws or a technical error made during the
drilling of the first hole, not allowing sufficient space for
a second screw placement. We only consider a singlescrew construct as a bailout option if two are impossible
and only when treating broad-based Type II and III fractures. We have repeatedly seen odontoid peg rotation
174
Fig. 11.14 Type II odontoid posterior dislocation reduced by traction. (a) Lateral film depicting the initial dislocation. (b) Lateral
view of fracture reduced by traction. (c) Double screw fixation
11 Odontoid Process Fractures
during final tightening of a single screw when treating
transverse fractures involving the narrowest part of the
dens. Such situations can be corrected by using a double-screw construct or again with a parallel K-wire
blocking the rotation during tightening. This is a
“conditio sine qua non” in Type IIT fractures where
simple apical cortex drill penetration can be difficult
due to its rotational instability (Fig. 11.15).
The basic prerequisite for a successful endosteal bone
formation is close contact and the best is compression of
Fig. 11.15 Odontoid Type
IIT fracture treated with a
double-screw anterior
fixation. (a) Preoperative
sagittal CT reconstruction.
(b) Preoperative coronal
CT reconstruction.
(c) Postoperative AP film.
(d) Postoperative lateral film
depicting correct length of
screws
11.6 Our Preference
175
the fracture surface accompanied by adequate immobilization [81]. To achieve this goal, the lag screw has to
penetrate the apical odontoid cortex or must be short
enough to adequately fulfill the lag principle.
Postoperatively, if the fracture is deemed sufficiently
stable, hard cervical orthosis (e.g., Philadelphia collar)
is used for the same purpose as stated by Sandler et al.
[77]: “not to move the head too far and too quickly,” for
6 weeks. Certainly, any part of our treatment paradigm
or all of it can be influenced by coexistence of other and
more complex UCS traumatic injuries.
In combination fractures, one has to primarily
address the major instability (usually AA instability)
first. Atlas fractures are the most frequent accompanying injuries. If posterior C1 arch is broken, odontoid
fracture stabilization has the priority. However, if the
anterior arch of C1 is broken or the entire C1 ring is
disconnected, then one has to consider the degree of
AA instability in the treatment paradigm. Most frequently, direct anterior odontoid osteosynthesis followed by longer term use of a Philadelphia collar is
sufficient. However, in cases of marked AA dislocation and/or MRI-proven transverse ligament damage,
anterior triple screw fixation and fusion (odontoid and
two anterior transarticular atlantoaxial screws) can be
chosen. A solid posterior atlantoaxial fixation needs to
be always considered as an option for these injuries.
Not infrequently, one has to treat concomitant
subaxial cervical spine injuries. If this is the case, a
combined surgical approach may be required and is
best performed during a single session (Fig. 11.16).
Given the high complication rate of halo-vest
external fixation and the fact that it does not surpass
Philadelphia collar in UCS immobilization in experimental studies [55, 82], we logically conclude that
halo-vest fixation should be avoided and either surgical intervention or hard cervical collar should be used
in the treatment of odontoid fractures. This is especially true in old, unconscious and/or chronically
ventilated individuals. In this group of patients, we
always prefer surgical stabilization, co-morbidities
permitting. Early mobilization and ease of care can
save their lives.
All patients are followed up regularly at 6 weeks;
and then at 3, 6, and 12 months. Lateral dynamic
films are performed regularly until fracture healing is
confirmed. A healed fracture can nowadays only be
proven by CT documenting bridging bone across the
fracture site. However, in the elderly, a stable fibrous
union can represent a functional and acceptable
result. We believe, however, that in young and active
patients who do not demonstrate fracture union by
one year, a posterior AA fixation and fusion should
be performed.
Fig. 11.16 Odontoid fracture with C3 coronal split. (a)
Preoperative sagittal CT reconstruction. (b) Postoperative lateral
film showing simultaneous odontoid fixation with graft and plate
C2-4 fusion. (c) Sagittal CT reconstruction depicting correct
length of screws
176
11 Odontoid Process Fractures
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