A Nationwide Analysis of Geriatric Odontoid Fracture Incidence, Complications, Mortality, and Cost

Ram Alluri, MD; Gabriel Bouz, MD; Samantha Solaru, BS; Hyunwoo Kang, MD; Jeffrey Wang, MD; Raymond J. Hah, MD


Spine. 2021;46(2):131-137. 

In This Article

Abstract and Introduction


Study Design: Retrospective database analysis.

Objective: To identify nationwide temporal trends in management of geriatric odontoid fractures and to compare comorbidities, inpatient complications, hospital characteristics, and cost between patients receiving operative versus nonoperative management.

Summary of Background Data: The treatment of geriatric odontoid fractures remains controversial with some studies demonstrating decreased mortality and improved functional outcomes associated with operative management and significant morbidity associated with halo devices during nonoperative management.

Methods: Patients between ages 65 to 90 years with odontoid fractures who underwent operative or nonoperative management between the years 2003 and 2017 were identified in the National Inpatient Sample (NIS) database. Year of injury, demographic variables, comorbidities, inpatient complications, mortality, length of stay, inpatient cost, and hospital characteristics were compared between operative and nonoperative treatment groups.

Results: Thirty two thousand four hundred nineteen patients (average age 77 yr, 54% female) were included in the final analysis. Operative treatment occurred in 21,954 (67%) patients and nonoperative treatment occurred in 10,465 (32%). In 2003, operative treatment occurred in 46% of patients and nearly doubled to 86% in 2017, with an average increase of 3.7% per year (P < 0.001). Patients undergoing operative management had a lower prevalence of at least one major medical comorbidity (76% vs. 83%, P < 0.001). Patients undergoing operative treatment demonstrated higher odds of developing most complications, particularly pulmonary, gastrointestinal, and renal (P < 0.01). Inpatient mortality was 3.6% in patients receiving operative treatment and 5.9% in patients receiving nonoperative treatment (P < 0.001). Average cost per episode of care during the study period was $131,855 for operative treatment and $65,374 for nonoperative treatment (P < 0.001).

Conclusion: This study demonstrates a clear national paradigm shift in the management of geriatric odontoid fractures, wherein operative management nearly doubled from 46% in 2003 to 86% in 2017.

Level of Evidence: 3


Odontoid fractures account for 9% to 15% of all cervical spine injuries and comprise the majority of cervical fractures in patients older than 65 years.[1–3] Within North America, the geriatric population represents the fastest growing demographic, and is estimated to double, accounting for 17% of the populace by 2050 based on census data.[4–8] Some studies have demonstrated that the rate of odontoid fractures is increasing disproportionately faster than geriatric population growth.[4] The growth of this population subset is only going to further increase the cost of treatment for odontoid fractures, which, in 2010, was estimated to be $1.5 billion.[5]

The treatment of type II and III odontoid fractures through the base and/or body remains controversial while the treatment of type I fractures is generally nonoperative.[9] With regards to type II and III fractures, management is challenging, particularly in geriatric patients due to diminished bone mineral density, altered biomechanics and an inherently poor blood supply to the odontoid base. The inability to heal a fracture through the odontoid base can lead to atlantoaxial instability, neurologic compression, and potentially irreversible myelopathic changes. The avoidance of these potentially long-term sequalae make the diagnosis and appropriate management of these injuries of utmost importance; however, there is no evidence-based consensus regarding management of odontoid fractures in this patient population.

Numerous studies have demonstrated high mortality and complication rates, regardless of operative or nonoperative management.[7,10–16] Nonoperative management options include a hard cervical collar or a halo-vest orthosis, and operative management commonly involves either anterior osteosynthesis or posterior C1–C2 arthrodesis. Nonoperative management avoids the risk of surgery but is associated with elevated rates of nonunion,[17,18] and prolonged immobilization may be poorly tolerated in an elderly patient population which can result in respiratory complications, pneumonia, aspiration, dehydration, dysphagia, and failure to thrive.[10,17,19–21] In an attempt to avoid the complications of nonoperative management, some surgeons may recommend operative fixation; however, surgery presents its own unique set of risks, particularly perioperative complications in the geriatric population.

Over the last decade, several studies have been conducted to compare operative versus nonoperative management of geriatric odontoid fractures and some have demonstrated lower mortality rates, improved functional outcomes, and greater cost effectiveness in favor of operative treatment.[15,16,22,23] The primary purpose of this study was to identify nationwide temporal trends in management of geriatric odontoid fractures. We hypothesized that there would be a trend towards increased operative management in more recent years. We secondarily sought to compare comorbidities, inpatient complications, hospital characteristics, and cost between patients receiving operative versus nonoperative management.