Surgical versus conservative management for an odontoid fracture (a serious neck injury)

The seven bones making up the neck region of the backbone are called the cervical vertebrae. The first vertebra, called the atlas, supports the skull. Underneath this is the axis or second vertebra, which has a upward pointing process called the odontoid process around which the atlas can rotate, enabling the head to be turned. Fracture of the odontoid process is a serious injury and is often fatal. In survivors there is a risk of ongoing damage to the spinal cord and paralysis. People with these fractures are often treated conservatively, which entails stabilisation of the neck in devices such as a 'Halo' (external frame) and/or rigid collar for several months. Another option is surgical stabilisation of the fractured parts. The review aimed to examine the evidence from randomised controlled trials comparing surgical versus conservative treatment for these fractures to find if either approach gave a better outcome. Despite a comprehensive search, the review authors found no evidence from completed randomised controlled trials to inform the choice between surgical and conservative management.

Authors' conclusions: 

There is no evidence available from adequately controlled trials to inform the decision on whether the surgical treatment of odontoid fractures gives a better outcome. A sufficiently powered good quality multicentre randomised controlled trial comparing surgery versus conservative treatment is warranted.

Read the full abstract...

Fractures of the odontoid process of the second cervical vertebra can result in instability, neurological damage and death. Treatment includes conservative management (external immobilisation devices) or surgical treatment (internal fixation by posterior fusion or anterior screw fixation).


To compare surgical with conservative treatment for fractures of the odontoid process.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (1950 to August Week 5 2010), EMBASE (1980 to 2010 Week 35), LILACS (September 2010), reference lists of articles and registries of ongoing trials.

Selection criteria: 

Randomised and quasi-randomised controlled trials comparing surgical versus conservative treatment of odontoid fractures.

Data collection and analysis: 

Two review authors independently examined the search results to identify trials for inclusion.

Main results: 

We identified an interm report of one study which appeared to meet our inclusion criteria but are awaiting further details from the trial authors before making a final judgment. We excluded one registered study comparing surgery and conservative treatment which does not involve randomisation of treatment allocation.