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Odontoid fractures in geriatric patients occur frequently and are associated with a high morbidity and mortality. The decision for operative or nonoperative therapy is still controversial. Recent studies confirmed that external stabilization with halo-vest immobilization is associated with high complication rates and mortality. An operation has a high perioperative risk because of comorbidities, but previous data suggest improved outcome in this group.To test this hypothesis, we retrospectively analyzed geriatric patients that underwent operation for isolated unstable type II odontoid fractures (Anderson and D'Alonzo classification) in our institution between March 2003 and March 2005. Twenty-seven patients (17 female, 10 male) with a median age of 85.5 (range, 63–98) years were stabilized by posterior C1/C2 fusion with transarticular screws and an additional modified Gallie fusion with a bone graft. Postoperatively, a rigid cervical collar was applied for 6 to 12 weeks.Six patients died during the observation period (median, 40 days after trauma). Three patients (11%) died perioperatively (cardiac or pulmonary failure, pneumonia), and the other three died as a result of the same after discharge. All 21 surviving patients were reevaluated an average of 3 months after trauma. All but one showed a stable fusion, and all reported no or minor neck pain. No wound infections occurred; one reoperation was necessary for screw misplacement. An initial neurologic deficit improved in two of three cases. Patients were mobilized on day 1 after operation. About two-thirds of patients were discharged directly home.Posterior stabilization of unstable odontoid fractures with transarticular screws and modified Gallie fusion in old patients can be performed safely, with good clinical results and few complications. However, mortality remains high, but is lower than reported after halo-vest immobilization alone. Dorsal C1/C2 Fusion is superior to halo-vest immobilization in terms of nonunion rate and mortality. Thus, it might be the treatment of choice in this high-risk patient population.