title: Surgical treatment of unstable type II odontoid fractures in skeletally mature individuals.
abstract: METHODS
  Systematic review of literature.
  
  
  OBJECTIVE
  To determine the optimal indications and methods of surgical treatment for unstable type II odontoid fractures in skeletally mature individuals.
  
  
  BACKGROUND
  Odontoid fractures are a frequently encountered injury pattern in the cervical spine. The surgical treatment of type II odontoid fractures varies among spinal surgeons. The optimal surgical indications and treatment for type II odontoid fractures remains unclear.
  
  
  METHODS
  Five primary research questions, based on safety and efficacy, were determined by consensus of a panel of spine trauma surgeons consisting of fellowship trained orthopedic and neurologic surgeons. A comprehensive review of the literature was performed using MeSH search terms in MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Database of Systematic reviews. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence-based review system, the primary questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise.
  
  
  RESULTS
  The initial search resulted in over 1300 results. After initial application of all inclusion and exclusion criteria, 458 abstracts were reviewed from which 22 manuscripts were found to meet all criteria. These were obtained, reviewed, and used to create an evidentiary table. All articles were of either low or very low quality.
  
  
  CONCLUSIONS
  There is no moderate or high quality literature on the surgical management of acute type II odontoid fractures. Optimal indications for either anterior or posterior treatment of fractures are described but with no comparative data. A single anterior odontoid screw is the recommended technique for anterior treatment. Posterior internal fixation (C1-C2 transarticular screw, C1-C2 segmental fixation) is the recommended technique for posterior treatment. In equivocally indicated instances, anterior or posterior treatment can be safely used with good outcome. In this scenario, surgical management decision should be influenced by surgeon and patient preference as well as cost considerations.
authors.affiliation: Department of Orthopaedic Surgery and Neurosurgery, University of Utah, Salt Lake City, UT 84108, USA. alpesh.patel@hsc.utah.edu
authors.forename: Alpesh A
authors.initials: AA
authors.lastname: Patel
authors.forename: Ron
authors.initials: R
authors.lastname: Lindsey
authors.forename: Jason T
authors.initials: JT
authors.lastname: Bessey
authors.forename: Jens
authors.initials: J
authors.lastname: Chapman
authors.forename: Raja
authors.initials: R
authors.lastname: Rampersaud
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001863:Bone Screws; D019317:Evidence-Based Medicine; D005592:Fracture Fixation / Q000009:adverse effects / Q000295:instrumentation; D017102:Fracture Healing; D006801:Humans; D016268:Internal Fixators; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000601:surgery*; D008875:Middle Aged; D009809:Odontoid Process / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D018579:Patient Selection; D011859:Radiography; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult