Odontoid fractures comprise as many as 20% of all cervical spine fractures. Fractures at the dens base, classified by the Anderson and D’Alonzo system as Type II injuries, are the most common pattern of all odontoid fractures and are also the most common cervical injuries in patients older than 70 years of age. Surgical treatment is recommended for patients older than 50 years with Type II odontoid fractures, as well as in patients at a high risk for nonunion. Anterior odontoid screw fixation (AOSF) and posterior cervical instrumented fusion (PCIF) are both well-accepted techniques for surgical treatment but with unique indications and contraindications as well as varied reported outcomes. In this paper, the authors review the literature about specific patients and fracture characteristics that may guide treatment toward one technique over the other.
AOSF can preserve atlantoaxial motion, but requires a reduced odontoid, an intact transverse ligament, and a favorable fracture line to achieve adequate fracture compression. Additionally, older patients may have a higher rate of pseudarthrosis using this technique, as well as postoperative dysphagia. PCIF has a higher rate of fusion and is indicated in patients with severe atlantoaxial misalignment and with poor bone quality. PCIF allows direct open reduction of displaced fragments and can reduce any atlantoaxial subluxation. It is also used as a salvage procedure after failed AOSF. However, this technique results in loss of atlantoaxial motion, requires prone positioning, and demands a longer operative duration than AOSF, factors that can be a challenge in patients with severe medical conditions. Although both anterior and posterior approaches are acceptable, many clinical and radiological factors should be taken into account when choosing the best surgical approach. Surgeons must be prepared to perform both procedures to adequately treat these injuries.