Optimizing treatment for odontoid fractures in the elderly: a balancing act with the patient at center stage

Abstract

This thesis investigates the treatment of odontoid fractures in elderly patients, a common injury of the second cervical vertebra (C2). These fractures mainly result from minor trauma in elderly patients, and the best treatment approach—surgical or conservative—remains debated. A systematic literature review in Chapter 2 of 41 studies found higher fracture union rates after surgery (73% vs. 40%) but no difference in stability or clinical outcomes. However, poor data quality and bias severely limited firm conclusions. Chapter 3 retrospectively examined Dutch practice variation, comparing surgical and conservative strategies; outcomes for union, stability, and mortality were largely similar. Chapter 4 described an international prospective study across 15 European centers showing no difference in clinical outcome, fracture union, and fracture stability between surgical and conservative treatment. Union was not clearly associated with clinical outcomes, suggesting treatment should emphasize favorable clinical over radiological outcomes. Chapter 5 evaluated Hounsfield unit (HU) measurements as predictors of fracture union but found no association; all patients exhibited low bone density, highlighting the need for osteoporosis screening. The thesis concludes that initial conservative management is justified, with surgery reserved as secondary treatment for relatively rare cases of persistent symptomatic non-union.