Nonoperative management of dens fracture nonunion in elderly patients without myelopathy

Design. A retrospective review of elderly patients treated without surgery for chronic mobile nonunions of the odontoid process. Patients were observe d on an annual basis with clinical examinations and flexion/extensions plai n film radiographs. Objectives, To evaluate the clinical and radiographic results of elderly pa tients without myelopathy treated without surgery for dens fracture nonunio n. Summary of Background Data. Because of the risk of progressive myelopathy o r sudden neurologic injury, many surgeons recommend operative stabilization for patients with mobile dens nonunions who are able to withstand an opera tion. There is, however, a lack of in formation about the radiographic and neurologic progression of dens nonunions. Although a less aggressive surgic al approach has been recommended by some authors for elderly or medically c ompromised patients with acute fractures, long-term follow-up evaluation of patients with resulting nonunions has not been reported. Methods. A series of elderly patients with chronic, unstable, dens nonunion s without myelopathy were treated with a nonoperative treatment protocol. P atients were informed of the nature of their lesion, including the risk of acute or chronic spinal cord injury and the options for operative treatment . Patients were evaluated yearly for clinical and radiographic progression. No intervention to slow progression of atlantoaxial instability was undert aken. Results. None of the patients developed myelopathic symptoms during the fol low-up period, and no patient experienced more than a 1 mm radiographic inc rease in aylantoaxial excursion. None of the reported patients had less tha n 14 mm available for the spinal cord in either flexion or extension at the start of clinical monitoring. Conclusions. Although further follow-up evaluation is needed, the authors b elieve on the basis of this review that this treatment protocol may be cons idered for patients who are poor candidates for surgical fusion.