Traumatic odontoid fracture - Proposal of a treatment algorithm

Abstract

Background: Current management guidelines for odontoid fractures (OFx) lack emphasis on age, comorbidity, and frailty, leading to variability in clinical practice and highlighting the need for guideline reevaluation. We began implementing a new treatment algorithm for OFx management at Oslo University Hospital (OUH) in 2022 with the aim of making it part of standard care for OFx. The main objective of this study was to determine our department's compliance with the new treatment algorithm for OFx.

Methods: In this population-based cohort study, we examine all traumatic OFx diagnosed in Southeast Norway from 2022-2023 and assess the rate of compliance with a new treatment algorithm implemented at OUH. Patient demographics, injury characteristics, treatment decisions, and outcomes, including union rates, rate of conversion from external immobilization to surgery, and long-term disability rates, were collected. Follow-up evaluations included imaging examinations and clinical and functional assessments.

Results: One hundred eighty-one patients with acute odontoid fractures (OFx) were registered from 2022 to 2023, and the median age of the patients was 78 years. Most fractures were caused by falls (92.3 %), and 70 % of the patients had some form of vulnerability (ASA ≥ 3 and/or CFS ≥ 4 and/or dependent living). Type II fractures were the most common (55.3 %), and 9.4 % of all OFx patients underwent surgical fixation. The treatment compliance rate was 97.2 %. At follow-up, 77.9 % of patients were alive, and 80.6 % of patients exhibited union, either bony or fibrous. Most patients (79.9 %) reported little neck pain (VAS score ≤3), and 87.8 % reported mild or no neck stiffness. The survival rate was 87 % at 30 days and 78 % at 6 months. There were no significant differences in the rates of disability, pain, bony union or fibrous union between the treatment groups. The new treatment algorithm resulted in favorable clinical outcomes.

Conclusions: In this observational cohort study involving 181 consecutive patients with traumatic OFx, 97 % were treated in accordance with the department's recommended algorithm for OFx management. Of the patients who were 75 years or older with OFx type II, 7/79 (8.9 %) underwent surgical treatment. The patient outcomes and findings presented in this study align with those presented in previous international studies investigating optimal treatment strategies for OFx. We therefore recommend this algorithm as an appropriate treatment approach for OFx.

Keywords: Elderly; Odontoid fracture; Outcome; Survival; Trauma; Treatment algorithm.