Home | About JCVJS | Editorial board | Ahead of print | Current Issue | Archives | Instructions | Subscribe | Advertise | Contact us |   Login 
Journal of Craniovertebral Junction and Spine
Search Articles   
Advanced search   

   Table of Contents  
Year : 2017  |  Volume : 8  |  Issue : 1  |  Page : 64-69  

Patient-reported outcome following nonsurgical management of type II odontoid process fractures in adults

1 Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa, USA
2 Department of Surgery, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
3 Aberdeen Medical School, University of Aberdeen, Aberdeen, Scotland, UK
4 Department of Neurosurgery, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, Scotland, UK

Date of Web Publication9-Feb-2017

Correspondence Address:
Mahmoud H Kamel
Aberdeen Royal Infirmary, Ward 205, Foresterhill Road, Aberdeen AB25 2ZN, Scotland
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-8237.199871

Rights and Permissions

Background: Transverse (type II) odontoid process fracture is among the most commonly encountered cervical spine fractures. Nonsurgical management through external immobilization is occasionally preferred to surgical management but is criticized for its higher rates of failure and lower patient satisfaction. Our aim is to analyze patient-reported outcomes in patients who underwent nonsurgical treatment for type II odontoid fractures.
Methods: We identified patients >18-year-old who underwent external immobilization as a treatment for isolated type II odontoid fracture between 2007 and 2012. We collected demographic parameters, clinical presentation, mode of injury, imaging studies and modality and duration of treatment (soft collar, halo-vest, or both). Patients were contacted by telephone to participate in a 15-min survey addressing their recovery including their subjective rate of return to preinjury level of functioning.
Results: Fifteen patients met the inclusion/exclusion criteria and participated in our survey. Patients were followed up for an average of 19 months after injury. Overall mean age was 61 years. Injury followed a mechanical fall or a road traffic accident in 11 and 4 cases, respectively. External immobilization was achieved by halo vest only in nine patients, soft collar only in two patients (13%), and through a sequential combination in the remaining 4 (27%). This was deployed for a mean of 7.8 months. Radiological studies at the last follow-up showed bony healing (27%), fibrous nonunion (60%), and persistent instability (13%). Patients reported gradual recovery of function throughout the 1st year after injury with levels above 70% of preinjury functioning achieved by 13% of patients at 6 months, 33% at 9 months, and 47% at 12 months. Overall satisfaction with nonsurgical management was 68%.
Conclusion: In selected patients with type II odontoid fractures, external immobilization represents a good option with acceptable course of recovery.

Keywords: Cervical spine; external immobilization; odontoid fracture; patient-reported outcome

How to cite this article:
Fam MD, Zeineddine HA, Nassir RM, Bhatt P, Kamel MH. Patient-reported outcome following nonsurgical management of type II odontoid process fractures in adults. J Craniovert Jun Spine 2017;8:64-9

How to cite this URL:
Fam MD, Zeineddine HA, Nassir RM, Bhatt P, Kamel MH. Patient-reported outcome following nonsurgical management of type II odontoid process fractures in adults. J Craniovert Jun Spine [serial online] 2017 [cited 2023 Feb 4];8:64-9. Available from: https://www.jcvjs.com/text.asp?2017/8/1/64/199871

   Introduction Top

Type II (transverse) fracture of the odontoid process represents a management challenge commonly encountered in neurosurgery spine practices.[1] The fracture is neither uncommon nor exclusive to the elderly population. Odontoid fractures have been reported to account for 9%–15% of all adult cervical fractures with a bi-modal distribution involving early adulthood in addition to the elderly age group.[2],[3],[4] Fractures in the elderly group are more likely to be low-energy falls, unlike those of younger patients that usually sustain it after motor vehicle accidents.[5] In-hospital and early mortality are also significantly high and survivors are at risk of suffering delayed myelopathy even years after injury.[5],[6],[7]

The underpinning pathophysiology and biomechanics are not well understood to explain the relatively higher rates of nonunion.[8],[9] In addition, there remains no global consensus on the best management paradigm for this fracture pattern.[10],[11],[12],[13] Multiple surgical approaches and techniques were advocated over time, but none has proven conclusive benefit.[14],[15] Conservative (nonsurgical) management, on the other side, has also been practiced but still as well with no definite evidence.[9],[16],[17] Nonsurgical management is achieved through external immobilization, either through a halo vest or soft collar. Although deemed as the least invasive treatment option, external immobilization has been criticized for the longer duration, low success rate, inconvenience, and associated morbidity in the fragile elderly population.[11] With the new calls for practicing patient-centered care (PCC), it was necessary to assess the impact of nonsurgical management from the patient's point of view.[18] The aim of this study is to gather patient-reported outcomes (PROs) and patients' satisfaction in those undergoing nonsurgical treatment of type II odontoid process fracture.

   Methods Top

Patient enrollment and clinical parameters

This is a retrospective survey analysis of PROs in nonsurgically treated type II (transverse) odontoid process fracture. The study took place at Aberdeen Royal Infirmary Teaching Hospital. On exemption of the local Institutional Review Board, medical records were searched for patients aged 16–80 years of age who were diagnosed for the first time with cervical spine fractures of all causes in the 5-year period May 2007–April 2012. Medical records search utilized the inclusive International Classification of Diseases 10 code S12 for fracture of cervical vertebra and other parts of neck. For all patients, we collected demographic parameters (age, gender), medical history of malignancy or arthritis (osteoarthritis, rheumatoid arthritis, or other), clinical presentation, mode of injury, mechanism of injury, follow-up imaging studies, and concomitant radiology reports (cervical spine magnetic resonance imaging, computed tomography [CT], or X-ray). We also collected timing and modality of treatment rendered (soft collar, Halo-vest, or surgical fixation) through the 1st year after diagnosis. We then excluded patients with follow-up <12 months from diagnosis and cases of pathological fractures. We also excluded patients who received surgical intervention (primary or salvage) within the 1st year after injury.

Imaging, fracture classification, and follow-up

For all patients, radiology reports were then reviewed to exclude patients with cervical spine fractures other than type II odontoid process fracture. Patients with multiple cervical spine fractures including a type II odontoid fracture were also excluded. Diagnostic CT imaging for patients with radiologically reported type II fractures was adjudicated by the senior authors (MHK and PB) to confirm the diagnosis and absence of other concomitant cervical spine injuries. Type II odontoid process fracture was defined as per Anderson and D'Alonzo classification as that involving the base of the odontoid process below the level of the transverse band of cruciform ligament. As per local institutional guidelines, all patients with odontoid process fractures are routinely followed up with both plain neck CT and dynamic flexion/extension X-ray of the cervical spine to assess radiological healing. Radiological recovery was determined based on imaging studies at the last follow-up and classified as bony healing, fibrous nonunion, or persistent instability. Persistent instability was diagnosed by the end of the follow-up when movement of the odontoid process stump is seen on dynamic (flexion/extension) lateral cervical spine X-rays. In the absence of instability, the patient was deemed to have achieved bony healing if bone trabeculations are visualized bridging the fracture site on high-resolution CT imaging. Fibrous nonunion was diagnosed when there is no mechanical instability but without evidence of bony healing at the fracture site.


Patients were then contacted through telephone to explain the purpose of the study, confirm information drawn from medical records, and run the survey (or arrange a later convenient appointment). A maximum of three attempts, 10 days apart, were made to contact the patient. A 15-min telephone-based survey was conducted with patients to collect patients' subjective assessment of the healing process. Patients were asked to confirm data extracted from clinical records and report any symptom persisting after the last follow-up. Patients were also asked to express any nuisance or complication encountered due to external immobilization. In addition, we asked patients to quantify their subjective rate of return to preinjury level of functioning/activity throughout the 1st year of treatment. Patients were also asked to rate their satisfaction among five graded strata (very dissatisfied, moderately dissatisfied, neutral, moderately satisfied, and very satisfied) and again on a scale from 1 to 10, with ten being the most satisfied. Finally, participants were asked if they would have preferred surgical fixation after the procedure was explained to them [Figure 1].
Figure 1: Telephone-based survey sheet. Contacted subjects were asked to participate in a 15-min survey over the phone to confirm data on the injury, treatment received, and also to report their subjective rate of recovery

Click here to view

   Results Top

Patient characteristics

A total of 19 patients with isolated traumatic type II odontoid process fractures met our inclusion and exclusion criteria. Two patients passed within the 1st year of injury and another two patients could not be reached after three attempts. All contacted patients agreed to participate and answered all items in the telephone-based survey. Participating patients were followed up for a mean of 19 months, ranging 16–27 months. Six (40%) of the patients were males and nine (60%) females, with an overall mean age at time of diagnosis of 61 years (32–80). Past medical history was significant for osteoarthritis in four patients (27%), but none of the patients had history of rheumatoid arthritis or malignancy. In 11 (73%) patients, the injury followed a mechanical fall and the other four (27%) had suffered a road traffic accident. Of those who had a mechanical fall, the mechanism of injury was hyperflexion in seven patients (64%), hyperextension (fall onto forehead) in two patients (18%), and two (18%) patients could not accurately specify/recall the incident. External immobilization was achieved only by halo vest in nine patients (60%), only by soft collar in two patients (13%), and through a sequential combination in the remaining four patients (27%). External immobilization was deployed for a mean duration of 7.8 months (ranging 6–11) [Table 1].
Table 1: Baseline characteristics and treatment rendered in the surveyed patients

Click here to view

Clinical and radiological assessment at the last follow-up visit

Radiological assessment of imaging studies at the last follow-up visit involved formal radiology reports adjudicated by the senior authors (MHK and PB). Patients were classified into three categories based on the presence or absence of bony trabeculations bridging the fracture site on CT scans and visualization of movement/angulation of the distal stump on flexion/extension films [Figure 2]. Six (40%) out of the fifteen patients were completely asymptomatic at the last follow-up assessment. In the remaining patients, persistent clinical symptoms reported at the last follow-up visit were pain (40%), restriction of neck movement (20%), tingling/discomfort sensation (20%), and grittiness/clicking (7%). Complications of external immobilization were seen in seven cases (47%) and were in the form of mild pressure-related skin changes in four patients and pin-site superficial infection in three patients at the end of follow-up.
Figure 2: Patient-reported outcome. Fifteen patient surveyed in our analysis quantified the rate of return to preinjury level of activity at 3, 6, 9, and 12 months after starting treatment. Lines are < 15 due to overlap in numbers

Click here to view

Patient reported outcomes

Patients reported gradual recovery of function throughout the 1st year after injury with levels above 70% of preinjury functioning achieved by 2 (13%) patients at 6 months, 5 (33%) patients at 9 months, and 8 (54%) patients at 12 months [Figure 3]. Overall satisfaction with nonsurgical management was 68% ranging 4–10 out of 10. None of the patients reported being very dissatisfied with treatment. Reported grades were moderately dissatisfied in 13% (n = 2), neutral in 33% (n = 5), moderately satisfied 26% (n = 4), and very satisfied 26% (n = 4). When asked about surgical fixation, only two patients (13%) expressed preference to surgical fixation, had it been an option.
Figure 3: Computed tomography scan of odontoid fractures showing nonunion (left), fibrous nonunion (middle), and bony healing (right)

Click here to view

   Discussion Top

PCC has been gaining considerable momentum owing to the highly positive outcomes associated with such practice.[19] Among the various components of PCC, PRO reflects one of the more important aspects.[20] Fortunately, PRO has been applied to the field of spine surgery, and various studies conducted started to pinpoint the parameters influencing patient satisfaction.[21],[22],[23],[24],[25],[26],[27] For instance, in a number of studies, patient satisfaction correlated with whether or not patient expectations were met.[28],[29] In turn, another study has found that patient expectations are highly affected by demographics, functional statues, and prior treatments.[30] However, many of the assessments present at hand to determine outcome measures are patient-independent and not reflective of what the patient deems important to his or her satisfaction. Such outcome measures in odontoid fractures are reflective in measuring bone fusion, morbidity, mortality, degree of disability, and hospitalization.[12] Yet, in this era of PCC and PRO, it is integral to assess patient satisfaction of their quality of life through self-reported measures.[23]

Odontoid fractures represent a significant portion of spine fractures that is known to be more prevalent among the elderly population with a considerable risk of morbidity and mortality.[9],[11],[31] D'Alonzo and Anderson classified odontoid fractures into three categories.[1] Type I is a relatively stable fracture that is oblique through the upper portion. Type II involves the base of the peg at the junction with the C2 body, while type III extends into the body of C2. Among the three types, type II is considered to be the most unstable, and unfortunately, the most common among the three with studies showing an increasing in its incidence.[9] The management of type II fractures remains controversial, with not enough evidence to justify an intervention over conservative treatment or vice versa.[32],[33] While many of the studies utilized objective parameters to evaluate both strategies (i.e., rate of radiological bony fusion, rates of neurological injury from spinal instability, complications, pain, functions and activity of daily living, and death), this study aimed to directly assess patient satisfaction after conservative treatment in addition to the more commonly utilized measure of outcomes.[33]

External immobilization for type II odontoid fractures is perhaps one of the oldest treatment modalities is spinal surgery.[34],[35] Its continued use in modern neurosurgery in spite of the perceivably protracted duration and higher failure rates denotes a substantial therapeutic value.[36] This study aimed primarily to describe patients' reported experience and satisfaction. While our findings could serve to guide decision making for patients and practitioners, generalizability of these findings is however limited due to the small sample size and the retrospective nature. The study design is also inherently limited by the lack of comparative surgical cohort and lack of randomization whereby included patients were selected for external immobilization and/or were not suitable candidates for surgical treatment. Another limitation of our analysis was the exclusion of patients undergoing delayed or salvage surgical fixation after external immobilization within the 1st year from injury. Those patients were excluded as the indication of surgery could not be accurately elucidated in all cases, and hence, the reported failure rate could be underestimated.

Radiological bony fusion, which is usually quoted as a marker of success, was 25% in our sample. This was relatively lower than the previously reported numbers in other studies.[37] However, the majority of patients were satisfied with their outcome. This highlights the importance of PRO and assessing patient-reported satisfaction in addition to the currently acceptable markers of therapy. Conservative management of type II odontoid fracture, when feasible, has the potential for significant patient satisfaction independent of radiological or clinical findings. As patient satisfaction is a main end-point in PCC, future studies should integrate this as a main end-point for future studies in type II fractures.

   Conclusion Top

In carefully selected patients, external immobilization represents a good option for treatment of type II odontoid process fracture with acceptable course of recovery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974;56:1663-74.  Back to cited text no. 1
Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am 1979;61:1119-42.  Back to cited text no. 2
Hadley MN, Dickman CA, Browner CM, Sonntag VK. Acute axis fractures: A review of 229 cases. J Neurosurg 1989;71(5 Pt 1):642-7.  Back to cited text no. 3
Hanigan WC, Powell FC, Elwood PW, Henderson JP. Odontoid fractures in elderly patients. J Neurosurg 1993;78:32-5.  Back to cited text no. 4
Pal D, Sell P, Grevitt M. Type II odontoid fractures in the elderly: An evidence-based narrative review of management. Eur Spine J 2011;20:195-204.  Back to cited text no. 5
Crockard HA, Heilman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: Clinical, radiological, and surgical features. J Neurosurg 1993;78:579-86.  Back to cited text no. 6
White AP, Hashimoto R, Norvell DC, Vaccaro AR. Morbidity and mortality related to odontoid fracture surgery in the elderly population. Spine (Phila Pa 1976) 2010;35 9 Suppl:S146-57.  Back to cited text no. 7
Ivancic PC. Odontoid fracture biomechanics. Spine (Phila Pa 1976) 2014;39:E1403-10.  Back to cited text no. 8
Smith JS, Kepler CK, Kopjar B, Harrop JS, Arnold P, Chapman JR, et al. Effect of type II odontoid fracture nonunion on outcome among elderly patients treated without surgery: Based on the AOSpine North America geriatric odontoid fracture study. Spine (Phila Pa 1976) 2013;38:2240-6.  Back to cited text no. 9
Barlow DR, Higgins BT, Ozanne EM, Tosteson AN, Pearson AM. Cost effectiveness of operative versus non-operative treatment of geriatric type-II odontoid fracture. Spine (Phila Pa 1976) 2016;41:610-7.  Back to cited text no. 10
Butler JS, Dolan RT, Burbridge M, Hurson CJ, O'Byrne JM, McCormack D, et al. The long-term functional outcome of type II odontoid fractures managed non-operatively. Eur Spine J 2010;19:1635-42.  Back to cited text no. 11
Julien TD, Frankel B, Traynelis VC, Ryken TC. Evidence-based analysis of odontoid fracture management. Neurosurg Focus 2000;8:e1.  Back to cited text no. 12
Koller H, Acosta F, Forstner R, Zenner J, Resch H, Tauber M, et al. C2-fractures: Part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes. Eur Spine J 2009;18:1135-53.  Back to cited text no. 13
Chapman J, Smith JS, Kopjar B, Vaccaro AR, Arnold P, Shaffrey CI, et al. The AOSpine North America Geriatric Odontoid Fracture Mortality Study: A retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976) 2013;38:1098-104.  Back to cited text no. 14
Steltzlen C, Lazennec JY, Catonné Y, Rousseau MA. Unstable odontoid fracture: Surgical strategy in a 22-case series, and literature review. Orthop Traumatol Surg Res 2013;99:615-23.  Back to cited text no. 15
Bednar DA, Parikh J, Hummel J. Management of type II odontoid process fractures in geriatric patients; a prospective study of sequential cohorts with attention to survivorship. J Spinal Disord 1995;8:166-9.  Back to cited text no. 16
Molinari WJ 3rd, Molinari RW, Khera OA, Gruhn WL. Functional outcomes, morbidity, mortality, and fracture healing in 58 consecutive patients with geriatric odontoid fracture treated with cervical collar or posterior fusion. Global Spine J 2013;3:21-32.  Back to cited text no. 17
Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med 2011;9:100-3.  Back to cited text no. 18
Zeineddine HA, El-Othmani MM, Sayeed Z, Chambers MC, Saleh KJ. Patient centeredness in total joint replacement: Beyond the slogan. Orthop Clin North Am 2016;47:697-706.  Back to cited text no. 19
Deshpande PR, Rajan S, Sudeepthi BL, Abdul Nazir CP. Patient-reported outcomes: A new era in clinical research. Perspect Clin Res 2011;2:137-44.  Back to cited text no. 20
  Medknow Journal  
DeVine J, Norvell DC, Ecker E, Fourney DR, Vaccaro A, Wang J, et al. Evaluating the correlation and responsiveness of patient-reported pain with function and quality-of-life outcomes after spine surgery. Spine (Phila Pa 1976) 2011;36 21 Suppl:S69-74.  Back to cited text no. 21
El Miedany Y, El Gaafary M, Youssef S, Palmer D. Towards a multidimensional patient reported outcome measures assessment: Development and validation of a questionnaire for patients with ankylosing spondylitis/spondyloarthritis. Joint Bone Spine 2010;77:575-81.  Back to cited text no. 22
Højmark K, Støttrup C, Carreon L, Andersen MO. Patient-reported outcome measures unbiased by loss of follow-up. Single-center study based on DaneSpine, the Danish spine surgery registry. Eur Spine J 2016;25:282-6.  Back to cited text no. 23
Kienapfel H, Koller M, Hinder D, Georg C, Pfeiffer M, Klose KJ, et al. Integrated outcome assessment after anterior cervical discectomy and fusion: Myelocompression but not adjacent instability affect patient-reported quality of life and cervical spine symptoms. Spine (Phila Pa 1976) 2004;29:2501-9.  Back to cited text no. 24
McCormick JD, Werner BC, Shimer AL. Patient-reported outcome measures in spine surgery. J Am Acad Orthop Surg 2013;21:99-107.  Back to cited text no. 25
Passias PG, Soroceanu A, Smith J, Boniello A, Yang S, Scheer JK, et al. Postoperative cervical deformity in 215 thoracolumbar patients with adult spinal deformity: Prevalence, risk factors, and impact on patient-reported outcome and satisfaction at 2-year follow-up. Spine (Phila Pa 1976) 2015;40:283-91.  Back to cited text no. 26
Patel MS, Newey M, Sell P. A comparison of patient-reported outcome measures after spinal surgery. Bone Joint J 2015;97-B: 366-71.  Back to cited text no. 27
Iversen MD, Daltroy LH, Fossel AH, Katz JN. The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. Patient Educ Couns 1998;34:169-78.  Back to cited text no. 28
Yee A, Adjei N, Do J, Ford M, Finkelstein J. Do patient expectations of spinal surgery relate to functional outcome? Clin Orthop Relat Res 2008;466:1154-61.  Back to cited text no. 29
Lurie JD, Berven SH, Gibson-Chambers J, Tosteson T, Tosteson A, Hu SS, et al. Patient preferences and expectations for care: Determinants in patients with lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 2008;33:2663-8.  Back to cited text no. 30
France JC, Powell EN 2nd, Emery SE, Jones DL. Early morbidity and mortality associated with elderly odontoid fractures. Orthopedics 2012;35:e889-94.  Back to cited text no. 31
Denaro V, Papalia R, Di Martino A, Denaro L, Maffulli N. The best surgical treatment for type II fractures of the dens is still controversial. Clin Orthop Relat Res 2011;469:742-50.  Back to cited text no. 32
Shears E, Armitstead CP. Surgical versus conservative management for odontoid fractures. Cochrane Database Syst Rev 2008:CD005078.  Back to cited text no. 33
Lind B, Sihlbom H, Nordwall A. Halo-vest treatment of unstable traumatic cervical spine injuries. Spine (Phila Pa 1976) 1988;13:425-32.  Back to cited text no. 34
Nickel VL, Perry J, Garrett A, Heppenstall M. The halo. A spinal skeletal traction fixation device. J Bone Joint Surg Am 1968;50:1400-9.  Back to cited text no. 35
Bransford RJ, Stevens DW, Uyeji S, Bellabarba C, Chapman JR. Halo vest treatment of cervical spine injuries: A success and survivorship analysis. Spine (Phila Pa 1976) 2009;34:1561-6.  Back to cited text no. 36
Hsu WK, Anderson PA. Odontoid fractures: Update on management. J Am Acad Orthop Surg 2010;18:383-94.  Back to cited text no. 37


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

This article has been cited by
1 Comparative Propensity-Weighted Mortality After Isolated Acute Traumatic Axis Fractures in Older Adults
Michael P. Catalino, Virginia Pate, Til Stürmer, Deb A. Bhowmick
Geriatric Orthopaedic Surgery & Rehabilitation. 2020; 11: 2151459320
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded75    
    Comments [Add]    
    Cited by others 1    

Recommend this journal