title: Commentary on the management of type II odontoid process fractures in octogenarians: Article by Graffeoet al. and Editorial by Falavigna (J Neurosurgery Spine August 19, 2016).
abstract: BACKGROUND
  Establishing a clear treatment paradigm for octogenarians with type II odontoid fractures in hampered by a literature replete with level III articles.
  
  
  METHODS
  In the study by Graffeoet al., the authors evaluated 111 patients over the age of 79 (average age: 87) with type II odontoid fractures undergoing nonoperative (94 patients) vs. operative intervention (17 total; 15 posterior and 2 anterior). They studied multiple variables and utilized several scales [abbreviated injury scale (AIS), injury severity score (ISS), and the Glasgow coma scale (GCS)] to determine the outcomes of nonoperative vs. operative management.
  
  
  RESULTS
  Graffeoet al. concluded that there were no significant differences between nonoperative and operative management for type II odontoid fractures in octogenarians. They found similar frequencies of additional cervical fractures, mechanisms of injury, GCS of 8 or under, AIS/ISS scores, and disposition to "nonhome" facilities. Furthermore, both appeared to have increased mortality rates at 1-year post injury; 13% during hospitalization, 26% within the first post-injury month, and 41% at 1 year.
  
  
  CONCLUSIONS
  In the editorial by Falavigna, his major criticism of Graffeo's article was the marked disparity in the number of patients in the operative (17 patients) vs. the nonoperative group (94 patients), making it difficult to accept any conclusions as "significant". He further noted that few prior studies provided level I evidence, and that most, like this one, were level III analyses that did not "significantly" advance our knowledge as to whether to treat octogenarians with type II odontoid fractures operatively vs. nonoperatively.
authors.affiliation: Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA.
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Epstein
keywords: Cons; conservative management; octogenarians; odontoid fractures; pros; surery; type II