Odontoid Fracture as Proximal Junctional Failure in Patients With Multilevel Spine Fusions

Bryan M Ladd, Christopher T. Martin, Jonathan N. Sembrano, Kristen E. Jones, David W. Polly, Matthew Hunt

Research output: Contribution to journalArticlepeer-review


Study Design: Retrospective study. Objective: Proximal junctional failure (PJF) commonly occurs as a recognized potential outcome of fusion surgery. Here we describe a unique series of patients with multilevel spine fusion including the cervical spine, who developed PJF as an odontoid fracture. Methods: We performed a single site retrospective review of patients with prior fusion that included a cervical component, who presented with an odontoid fracture between 2012 and 2019. Radiographic measurements included C2-C7 SVA, C2-C7 lordosis, T1 slope, Occiput-C2 angle, proximal junctional kyphosis, and cervical mismatch. Associated fractures, medical comorbidities, and treatments were determined via chart review after IRB approval. Results: Nine patients met inclusion criteria. 5 reported trauma with subsequent onset of pain. All patients sustained a Type II odontoid fracture. 5 with associated C1/Jefferson fractures. In all patients, pre-injury Occiput-C2 angle was outside normative range; C2-C7 SVA was greater than 4 cm in 6 patients; T1-slope minus cervical lordosis was greater than 18.5 degrees in 6 patients. 7 patients were treated operatively with extension of fusion to C1 and 2 patients declined operative treatment. Conclusion: In this series of 9 patients with multilevel fusion with type II odontoid fractures, all patients demonstrated abnormal pre-fracture sagittal alignment parameters and a greater than normal association of C1 fractures was noted. Further study is needed to establish the role of poor sagittal alignment with compensatory occiput-C2 angulation as a predisposing factor for odontoid fracture as a proximal junctional failure mechanism.

Original languageEnglish (US)
Pages (from-to)781-786
Number of pages6
JournalGlobal Spine Journal
Issue number3
StatePublished - May 11 2021

Bibliographical note

Publisher Copyright:
© The Author(s) 2021.


  • T1S-CL
  • cervical lordosis
  • cervical mismatch
  • deformity
  • odontoid fracture


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