Surgical treatment of odontoid fractures: Posterior approach

The objective of this article is to review and discuss surgical management of odontoid fractures via posterior approach. Odontoid fractures represent 11% cervical fractures, and optimal management of type II fractures in the elderly has been controversial. Recent literature suggests lower mortality rates with operative intervention. Anterior osteosynthesis ideally affords motion preservation but has many contraindications and often is suboptimal in elderly, often osteoporotic, patients. Modern C1–C2 polyaxial screw–rod instrumentation allows immediate stability and allows avoidance of postoperative external immobilization. This article discusses and reviews the following with respect to posterior atlantoaxial fusion: (1) indications with preoperative considerations, (2) author׳s preferred surgical technique, (3) complications, and (4) literature review (particularly regarding optimal treatment of odontoid fractures in the elderly) with (5) final recommendations. Modern posterior surgical stabilization has successfully evolved from posterior wiring and clamps to transarticular screw and subsequent polyaxial C1–C2 independent screw–rod custom constructs. This has allowed high fusion, low complication, and low revision rates with excellent predictable outcomes in patients with unstable odontoid fractures or nonunion. Careful preoperative planning and meticulous technique must be utilized for successful outcomes.