C2 spinous process, and then gently wedged into place. With proper dimensions the fit should be tight—compressive force is necessary to promote adequate fusion. The graft can be bolstered in place with suture material looped under the lamina and over the graft in a figure-eight pattern (Tips from the Masters 11-5). Alternatively, the graft may be secured with stainless steel wire or titanium cable using a modified Gallie technique.
Tips from the Masters 11-5 • Graft may be bolstered with suture material to minimize risk of dislodgment.
As with all posterior cervical cases, meticulous hemostasis and wound closure technique are imperative. Preferred practice is to use a cervical orthosis (Philadelphia collar) in the postoperative period and to place a drain deep to the fascia. Patient- specific issues should be considered in determining the length of time the cervical orthosis should be worn. The recommendation is to maintain the orthosis for a mini- mum of 6 weeks; at that point the relative merits of continued immobilization should be balanced against patient-specific factors such as ease of feeding and activity level.
For a minimally active patient who is developing occipital irritation and/or having difficulty eating, it may be reasonable to discontinue use of the orthosis.
DISCUSSION OF BEST EVIDENCE
The current evidence regarding the management of type II odontoid fractures comes primarily from Level III studies as well as from some Level II studies. No Level I evidence is available.
Level III Studies
Numerous Level III studies have demonstrated excellent union rates with anterior odontoid screw fixation.8,9,12,39 Level III evidence11,13,22 suggests a higher rate of nonunion and complications in elderly patients, but whether this is due solely to bone quality or age is not clear. Posterior C1-C2 fusion techniques are associated with union rates exceeding 90%.11,16,40,41 Kuntz and co-workers30 found that opera- tive management was associated with fewer early failures than nonoperative man- agement, but equivalent overall morbidity and mortality. Peri-injury mortality rates in the octogenarian population were found by Smith and colleagues3 to be similar for both operative and nonoperative management.
COMMENTARY
The management of type II odontoid fractures is controversial, particularly in the elderly population. There is a lack of Level II follow-up data describing the respective outcomes of surgical and nonsurgical management, and the long-term morbidity of a fibrous nonunion is similarly controversial due in large part to a lack of consensus regarding the relative risk of developing late-onset myelopathy. It is clear that surgical management of these fractures can be safely accomplished in the elderly population via either anterior or posterior approaches. The choice of approach and fixation should be made by the surgeon taking into account fracture geometry, bone quality, and patient- specific considerations. This injury is associated with significant morbidity and mortality in patients undergoing both nonoperative and operative treatment as reported in multi- ple studies. Optimal management of this injury necessitates careful consideration of the given patient’s clinical situation and baseline activity level, so that the patient may make an informed decision regarding operative versus nonoperative management. Long-term follow-up studies of patients treated for this injury are needed to more accurately delin- eate the outcomes of both surgical and nonsurgical management of odontoid fractures.
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