Fibrous non-union of odontoid fracture: Is it safe to accept non-operative management? A systematic review

Document Type


Publication Date



Neurology, Surgery, Trauma & Acute Care Surgery

Journal Title

World neurosurgery


OBJECTIVE: Non-operative management of odontoid fractures can result in solid fusion, unstable non-union and fibrous non-union. Those with fibrous non-union do not demonstrate dynamic instability on imaging but the safety of accepting this as an outcome is debatable. The authors provide the first systematic review of the existing literature, exploring the safety of accepting fibrous non-union as an outcome of odontoid fracture. METHODS: The Pubmed and Embase databases were searched in January 2022. Outcomes were extracted and categorized according to mortality, neurologic sequelae, pain, neck disability index and satisfaction. RESULTS: Of a total 700 abstracts screened, 79 full texts were assessed of which 13 studies were included. A total 141 patients had a fibrous non-union, all described in observational studies. Follow-up ranged between studies ranged from 0.6 to 5.8 years. None of the 141 patients had a neurologic event. One patient had a trauma-related mortality, however causality was not exposed. The majority of studies reported good to excellent pain scores. The majority of neck disabilities reported were in the range of mild to moderate apart from one study with five patients reporting severe disability. All patients reported good or excellent satisfaction. CONCLUSIONS: The evidence supports it is safe to forgo surgery in carefully selected patients with non-united odontoid fractures when there is near-anatomic alignment, lack of dynamic instability on imaging, normal neurologic exam and low risk for neck injury. Further study is needed to define the full natural history of fibrous non-union of odontoid fracture.