I heard recently of a 97-year-old member of “The Greatest Generation” falling rather gently from his chair, sustaining abrasions without much neck pain and without any neurological symptoms. The ER visit next day revealed a type II Odontoid Dens fracture and he was placed in a rigid occipito-cervical orthosis.
His case raises many questions about the appropriate management of this very common fracture in the advanced elderly with limited activity and mobility, and since they can occur following very minor trauma, many can go undiagnosed.
*Would this fracture have been diagnosed if the minor pain subsided and no x-ray was taken. The advanced elderly unfortunately have frequent falls and episodes of minor trauma, any of which could result in an undiagnosed Dens fracture.
*Does the absence of any neurological symptoms or signs indicate a state of relative stability from a fibrous union and that only a soft collar for comfort is required – a collar that provides precious little stability to the upper cervical spine.
The patient has been checked clinically and radiologically and the fracture remains un-united and unstable and remains pain free and neurologically intact. So now the dilemma on what to recommend: –
*Wear the soft collar indefinitely?
* Go collar free?
*Consider anterior screw dens fixation?
*Consider posterior C1/2 fusion?
Fortunately, common sense prevailed and his surgeon recommended going collar free.
The patient remains symptom free.
-Anthony Dwyer, M.D.
(The opinions stated in this blog are those of the author Dr. Anthony Dwyer and not necessarily those of the American College of Spine Surgery).