Can you help us navigate all the decisions facing us? Mother fell and broke a piece off the second bone in her neck. One surgeon told us she should have surgery to fuse her neck right away. A second surgeon said we could try using a brace and see if the fracture site can be stabilized. Bracing would be less traumatic, but can she get around okay? We don't know what to do.

Posted January 8th, 2009 by Matt

Spine Cervical

It sounds like the injury is a fracture of the odontoid process (sometimes called the dens). The odontoid is a bony knob or upward projection of bone on top of the second cervical vertebra (C2). C2 is also known as the axis. The dens points up and fits through a hole in the first cervical vertebra (called the atlas). The joints of the axis give the neck most of its ability to turn to the left and right.

A fracture in the upper part of the dens is a Type I odontoid fracture. This type of injury is usually stable and will heal nicely. A break right where the odontoid process attaches to the C2 vertebral body is a Type II odontoid fracture. Without this piece of bone in place, the first two vertebral bones (the atlas and the axis) can slide apart. This puts a tremendous compressive or stretching force on the spinal cord as it goes down through the spinal canal. The spinal canal is a round opening or hollow tube formed by the vertebrae stacked on top of each other.

Type III odontoid fractures occur through the vertebral body. This type of fracture is also usually stable and heals well without surgery. It's the Type II odontoid fractures that require the most thought in planning the best treatment.

There are pros and cons with both types of treatments (surgical versus nonsurgical) for a type II odontoid fracture. Nonoperative treatment to allow the bone to knit back together can be successful. If the atlas and axis have not been displaced (moved), then immobilizing the neck for a period of time is an option. The two most common forms of immobilizers used include a rigid cervical collar or a halothoracic brace.

The halo brace is a titanium ring (the halo) that goes around the head. This portion of the brace is secured to the skull by metal screws (pins). Four metal bars attach the halo ring to a vest worn on the chest. This vest offers the weight to anchor the ring and immobilize the neck. Sometimes the halo brace is referred to as a halo vest.

Complications can occur with either conservative or surgical care. The loss of movement and immobility is often a risk factor for all kinds of problems in older adults. There's the risk of pneumonia or other respiratory problems. With bracing, pressure ulcers (skin sores) can develop. Infection at the pin sites used with the halo vest is another potential problem. Most of these can be prevented with proper follow-up home care.

Bracing may be preferred because of known complications that occur when surgery is done for this problem in older adults. If conservative care fails, then surgery to fuse the spine can still be done. Surgery is indicated in cases of nonunion instability such as recurrent dislocation or when there is serious neurologic involvement (e.g., paralysis).

You may want to seek a third opinion and then weigh all the factors when making the final decision. Your decision will be based on the exact type of fracture your mother has, whether or not it is stable, her overall health, and the kind of postoperative care that is available.

Florentius Koech, MB, ChB, MMed (GSurgery), et al. Nonoperative Management of Type II Odontoid Fractures in the Elderly. In Spine. December 15, 2008. Vol. 33. No. 26. Pp. 2881-2886.

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