Several publications recommend primary surgical fixation for type II and III OFx with major translation of the odontoid fragment, regardless of the patient’s age, and for all type II OFx in patients aged ≥50 years. A consensus for the management of OFx is currently lacking, and the choice of treatment has mainly been guided by the fracture type (II or III), magnitude and direction of displacement of the OFx fragment, patient age and the knowledge of variations in bony fusion rates after the use of different treatment options. The aims of treatment are to preserve neurological function, provide pain relief and establish bony fusion. When left untreated, these patients are at risk of fracture dislocation with secondary spinal cord injury (SCI) or persistent and severe neck pain due to chronic instability/pseudarthrosis. However, the majority of patients present with an OFx after trauma with various degrees of neck pain. Type I fractures are very rare and do not require stabilization, while type II and III fractures are common and considered unstable.Ī minor proportion of patients with OFx die immediately at the scene of the accident due to severe fracture dislocation with subsequent injury to the upper spinal cord, causing tetraplegia and respiratory arrest. OFx are subdivided into types I, II and III according to the classification proposed by Anderson and D’Alonzo. The incidence of this injury increases with age, making OFx the most common CS-fx in the elderly population. Twenty percent of these fractures are odontoid fractures (OFx) of cervical vertebra 2 (C2). The incidence of traumatic cervical spine fractures (CS-fx) in the Norwegian population is 15/100,000/year. Hence, comorbidities and age should be considered for inclusion in the decision tree for the choice of treatment for OFx in future guidelines. Major comorbidities and an older age appear to be significant factors contributing to physicians’ decision to refrain from the surgical fixation of OFx. The most common reasons listed for choosing primary external immobilization instead of primary surgical fixation were an older age and comorbidities. The main deviation was the underuse of primary surgical fixation for type II OFx. The level of compliance with the treatment recommendations for OFx was low. Significant differences the in conversion rate were not observed between patients with type II and III fractures. Conversion from external immobilization alone to subsequent open surgical fixation was performed in 10% of patients. In the multivariate analysis, the following parameters were significantly associated with surgery as the primary treatment: independent living, less serious comorbidities prior to the injury, type II OFx and major sagittal translation of the odontoid fragment. The primary fracture treatment was rigid collar alone in 79% of patients and open surgical fixation in 21%. According to the Anderson and D’Alonzo classification, the OFx were type II in 199 patients (59%) and type III in 137 patients (41%). The median age of the patients was 80 years, and 45% were females. Three hundred thirty-six patients with an OFx were diagnosed, resulting in an overall incidence of 2.8/100000 persons/year. We present a prospective observational cohort study of all patients in the southeastern Norwegian population (3.0 million) diagnosed with a traumatic OFx in the period from 2015 to 2018. We suspect that this discrepancy might be due to the older age and comorbidities among patients with OFx. The level of compliance with this recommendation is unknown, and our hypothesis is that open surgical fixation is less frequently performed than recommended. Surgical fixation is recommended for type II and III odontoid fractures (OFx) with major translation of the odontoid fragment, regardless of the patient’s age, and for all type II OFx in patients aged ≥50 years.
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