Operative versus nonoperative management of type II odontoid fractures in the elderly: A systematic review and meta-analysis of comparative studies

Abstract

Background

Type II odontoid fractures (OFs) are common cervical spine injuries in elderly patients. Management strategies remain controversial, as both operative and nonoperative approaches carry distinct risks and benefits.

Methods

A systematic search of PubMed, Scopus, Cochrane Library, and Google Scholar was conducted through August 2025. Studies comparing patients aged ≥ 65 years with Type II OFs treated either operatively or nonoperatively were included. Outcomes were analyzed based on follow-up periods and included clinical measures (length of hospital stay (LOS), residual pain), radiological outcomes (nonunion and instability), and complication and survival rates, graded using the adapted Clavien–Dindo classification for trauma.

Results

Twenty comparative studies were included, encompassing 8296 patients (3754 operative and 4542 nonoperative). Surgical treatment was associated with significantly lower nonunion rates at 1-year follow-up (p = 0.03) and showed a non-significant trend toward reduced post-treatment instability, also at 1 year (p = 0.12). The nonoperative group demonstrated a significantly shorter LOS (p < 0.001) and fewer grade III–IV complications, observed both early postoperatively and at 2–3 years, including cardiopulmonary, neurological, and digestive events (p < 0.001). Mortality or grade V complication showed a lower risk at 3 years in the nonoperative group (p = 0.04). Residual pain outcomes, reported at 9 months, was comparable between groups (p = 0.40).

Conclusions

Operative management improves union and stability, while nonoperative treatment offering fewer complications. These findings support the importance of individualized treatment decisions based on patient comorbidities, fracture characteristics and stability, and surgical risks.