The optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis

Jeroen G J Huybregts; Karma A Barot; Camila Recio; Joanne Doucette; Rania A Mekary; Carmen L A Vleggeert-Lankamp

doi:10.1007/s00586-023-07779-1

The optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis

Eur Spine J. 2023 Oct;32(10):3434-3449. doi: 10.1007/s00586-023-07779-1. Epub 2023 Jul 13.

Authors

Jeroen G J Huybregts^{1

2}, Karma A Barot^#³, Camila Recio^#⁴, Joanne Doucette⁵, Rania A Mekary^#^{4

5}, Carmen L A Vleggeert-Lankamp^#^{6

7}

Affiliations

¹ Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, PO Box 9600, 2300 RC, Leiden, The Netherlands. j.g.j.huybregts@lumc.nl.
² Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands. j.g.j.huybregts@lumc.nl.
³ Eastern Virginia Medical School, Norfolk, VA, USA.
⁴ Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁵ School of Pharmacy, MCPHS University, Boston, MA, USA.
⁶ Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, PO Box 9600, 2300 RC, Leiden, The Netherlands.
⁷ Department of Neurosurgery, Spaarne Hospital Haarlem/Hoofddorp, Hoofddorp, The Netherlands.

^# Contributed equally.

PMID: 37439865
DOI: 10.1007/s00586-023-07779-1

Abstract

Purpose: Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the outcome of surgical and conservative treatments in elderly (≥ 65 years), by updating a systematic review published by the authors in 2013.

Methods: A comprehensive search was conducted in seven databases. Clinical outcome was the primary outcome. Fracture union- and stability were secondary outcomes. Pooled point estimates and their respective 95% confidence intervals (CIs) were derived using the random-effects model. A random-effects multivariable meta-regression model was used to correct for baseline co-variates when sufficiently reported.

Results: Forty-one studies met the inclusion criteria, of which forty were case series and one a cohort study. No clinical differences in outcomes including the Neck Disability Index (NDI, 700 patients), Visual Analogue Scale pain (VAS, 180 patients), and Smiley-Webster Scale (SWS, 231 patients) scores were identified between surgical and conservative treatments. However, fracture union was higher in surgically treated patients (pooled incidence 72.7%, 95% CI 66.1%, 78.5%, 31 studies, 988 patients) than in conservatively treated patients (40.2%, 95% CI 32.0%, 49.0%, 22 studies, 912 patients). This difference remained after correcting for age and fracture type. Fracture stability (41 studies, 1917 patients), although numerically favoring surgery, did not appear to differ between treatment groups.

Conclusion: While surgically treated patients showed higher union rates than conservatively treated patients, no clinically relevant differences were observed in NDI, VAS pain, and SWS scores and stability rates. These results need to be further confirmed in well-designed comparative studies with proper adjustment for confounding, such as age, fracture characteristics, and osteoporosis degree.

Keywords: Conservative treatment; Elderly; Meta-analysis; Odontoid fractures; Surgical treatment.

Publication types

Systematic Review
Meta-Analysis
Review

MeSH terms

Aged
Cohort Studies
Fractures, Bone*
Humans
Odontoid Process* / injuries
Odontoid Process* / surgery
Pain
Spinal Fractures* / epidemiology
Spinal Fractures* / surgery
Treatment Outcome