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Fifty-seven patients with dens fractures were identified from 1986 to 1996 at the authors' institution. Forty-six were available for reevaluation by two independent observers with a mean follow-up period of 26 months.To determine by age and fracture type which treatment regimen provided the best functional outcome in patients with dens fractures.There were no Type I fractures, but there were 37 Type II and 20 Type III fractures. Twenty-nine patients were under 60 years of age, and 28 were 60 years and older. Six patients had been treated by immediate C1-C2 posterior fusion, and five received treatment with a Philadelphia collar only. Forty-six patients were placed in a halo thoracic immobilizer with a symptomatic nonunion rate of 19.5%. These patients ultimately required posterior cervical fusion.Final functional outcome, level of pain, and cervical range of motion were all statistically evaluated using multivariate analysis (Wilcoxon's two-sample test). The influence of age, fracture type, and treatment method were determined.There were no cases of short- or long-term neurologic deterioration in any of the patients in the study group. There was a significantly higher rate of complications associated with halo use in the older population. Pain scores were higher in Type II fractures and in patients treated conservatively with halo immobilization, especially those patients over 60 years of age. No statistically significant difference in these paramefers were found. Older patients treated surgically did not have a better functional outcome score than those treated nonoperatively (P < 0.8). Persons over 60 years of age treated in a halo had a significantly (P < 0.05) decreased range of motion when compared with younger patients treated similarly.Patients over 60 years of age with a dens fracture had a higher complication rate and lower cervical range of motion when treated conservatively with a halo. Final functional outcome and overall pain levels, however, did not differ significantly by age group or treatment modality.