Objective: Odontoid fractures are the most common cervical spine fractures in elderly patients. The optimal treatment in this age group remains controversial. The goal of this study was to compare outcomes of surgical and conservative treatments. Methods: A retrospective cohort study was conducted in three tertiary referral centers in the Netherlands. Patient records were reviewed for patients who met the selection criteria (i.a. age ≥55 years, type II/III odontoid fractures). Fracture healing (union/stability) and clinical outcomes (Likert scale) were assessed. The influence of age, applied treatment, and treatment strategy (‘fracture based approach’ or ‘primarily conservative’) was studied. Results: A total of 105 patients were included (18 treated surgically, 87 treated conservatively; 52 treated with ‘fracture based approach’, 53 treated ‘primarily conservative’). No difference was found in fracture union (68% overall) and fracture stability (88% overall). Data on clinical outcome were scarce, but did not differ between treatment groups. Patients ≥80 years had worse outcomes in both applied treatment- and treatment strategy arms. Conclusion: No radiological differences in outcome between surgical or conservative treatment (strategies) were observed. The majority of patients achieved fracture healing. The exact correlation between the quality of fracture healing (union or stability) and clinical outcome remains unclear. Advanced age (>80 years) negatively influenced outcome.