Typ-II-Densfrakturen des alten Menschen und therapiebedingte Mortalität

[Conservative treatment of trauma-associated fractures of the cervical spine with orthoses-A review]

BACKGROUND

Traumatic injuries of the cervical spine are common and can significantly differ in the prognosis and treatment depending on the structure affected. We present the current evidence for conservative treatment of these fractures with orthoses in this review.

METHODOLOGY

The literature search followed the PRISMA protocol. The risk of bias was assessed using ROBINS‑I and evidence levels were determined according to AHCPR.

RESULTS

A total of 22 studies were identified. The level of evidence according to AHCPR is limited (IIb, III and IV) and every study had a serious risk of bias in at least one subdivision. Of the authors 11 presented conservative treatment concepts for C2 dens fractures, 7 studies focussed on vertebral arch fractures and 9 on vertebral body fractures. Radiological parameters (kyphosis angle, bone consolidation) and the neurological status were frequently reported as endpoints.

CONCLUSION

Stable C2 dens fractures without relevant clinical restrictions allow conservative treatment in a rigid cervical orthosis under radiological monitoring every 1-4 weeks. Type II fractures require special attention due to the risk of instability. Hangman's fractures can be safely treated in rigid cervical orthoses. The current state of knowledge does not allow any recommendation for conservative treatment of Hangman's fractures with orthoses. Stable vertebral body fractures without involvement of the spinal canal can also be treated conservatively with orthotic devices. Randomized controlled studies are required to develop a secure state of evidence and are currently not available.

Geriatric Odontoid Fractures: Treatment Algorithms of the German Society for Orthopaedics and Trauma Based on Expert Consensus and a Systematic Review

STUDY DESIGN

Systematic review/expert consensus.

OBJECTIVES

Fractures of the axis represent the most frequent injury of the spine in elderly patients. Both, operative and non-operative treatment are associated with a high rate of complications and mortality. The aim of this article was to summarize the current literature on the management of odontoid fractures in geriatric patients and to weigh it based on an expert consensus process.

METHODS

In a joint consensus process, members of the Spine Section of the German Orthopaedic and Trauma Society (DGOU) aimed to formulate recommendations for the diagnostic workup and treatment of odontoid fractures in geriatric patients. Based on the previously published recommendations, this article is an updated version with incorporating a systematic review of the recent literature.

RESULTS

Based on the new data available, the recommendations established in the initial consensus process were adapted.

CONCLUSIONS

Computed tomography represents the diagnostic standard for patients with suspected injuries of the upper cervical spine. Anderson/D'Alonzo odontoid fractures type 1, non-displaced type 2, and type 3 can be treated conservatively. Even non-unions do not necessarily result in poor clinical outcome. In Anderson/D'Alonzo type 2 fractures, surgical therapy offers the advantage of relatively safe osseous healing with no increased complication rate even in elderly patients and can thus be recommended. In very high aged patients, however, a case-by-case decision should be made. When surgical stabilization of osteoporotic odontoid fractures is indicated, posterior techniques are biomechanically advantageous and can be considered the standard.

Early mortality and morbidity of odontoid fractures after 70 years of age

INTRODUCTION

Odontoid fractures are very common in older adults and are associated with a high mortality rate. The aim of this study was to evaluate the outcomes after conservative treatment of non-displaced odontoid fractures and surgical treatment of displaced fractures in patients older than 70 years. It was hypothesized that early mortality of displaced fractures is higher than in non-displaced fractures.

MATERIAL AND METHODS

This was a single-center retrospective observational study of odontoid fractures (type II in the Anderson and Alonzo classification) in patients older than 70 years that occurred between 2014 and 2017. Conservative treatment with immobilization for 3 months was proposed when the fracture was displaced less than 2 mm (non-displaced fracture group). Surgical treatment in the form of anterior screw fixation was proposed when the fracture displacement was more than 2 mm (displaced fracture group). The primary endpoint was the mortality rate at 3 months.

RESULTS

The study included 79 patients (46 women) who had a mean age of 85 years (70-105). The 3-month mortality in the entire cohort was 27% and the 1-year mortality was 30%. Conservative treatment was provided to the 36 patients with non-displaced fractures. The 3-month mortality rate in this group was 11%. A displaced fracture occurred in 43 patients: 17 were treated surgically by anterior screw fixation; 20 could not be operated on because of anesthesia contraindications and 6 died within 24hours of the fracture event. The 3-month mortality rate in this group was 40%; 3 of the 17 operated patients died from postoperative respiratory complications; 8 of the 20 patients with contraindications died, in addition to the 6 that died soon after the fracture occurred.

DISCUSSION

This study confirms that mortality and morbidity are high following odontoid fractures. The mortality rate was significantly higher in patients with displaced fractures, confirming our hypothesis. The mortality rate was especially high when patients with displaced fractures could not undergo surgery because of anesthesia contraindications. Also, there was a high rate of respiratory complications after anterior screw fixation of displaced fractures.

CONCLUSION

Given our findings, conservative treatment should be compared to surgical treatment for displaced fractures and the anterior approach should be compared to the posterior one for surgical cases.

LEVEL OF EVIDENCE

IV.

Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients

BACKGROUND

Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature.

METHODS

In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients.

RESULTS

For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.

Mortality, complication, and fusion rates of patients with odontoid fracture: the impact of age and comorbidities in 204 cases

PURPOSE

The French Society of Spine Surgery (SFCR) conducted a prospective epidemiologic multicenter study. The purpose was to investigate mortality, complication, and fusion rates in patients with odontoid fracture, depending on age, comorbidities, fracture type, and treatment.

METHODS

Out of 204 patients, 60 were ≤ 70 years and 144 were > 70 years. Demographic data, comorbidities, treatment types and complications (general medical, infectious, neurologic, and mechanical), and death were registered within the first year. Fractures were classified according to Anderson-D'Alonzo and Roy-Camille on the initial CT. A 1-year follow-up CT was available in 144 patients to evaluate fracture consolidation.

RESULTS

Type II and oblique-posterior fractures were the most frequent patterns. The treatment was conservative in 52.5% and surgical in 47.5%. The mortality rate in patients ≤ 70 was 3.3% and 16.7% in patients > 70 years (p = 0.0002). Fracture pattern and treatment type did not influence mortality. General medical complications were significantly more frequent > 70 years (p = 0.021) and after surgical treatment (p = 0.028). Neurologic complications occurred in 0.5%, postoperative infections in 2.0%, and implant-related mechanical complications in 10.3% (associated with pseudarthrosis). Fracture fusion was observed in 93.5% of patients ≤ 70 years and in 62.5% >70 years (p < 0.0001). Pseudarthrosis was present in 31.5% of oblique-posterior fractures and in 24.3% after conservative treatment.

CONCLUSIONS

Age and comorbidities influenced mortality and medical complication rates most regardless of fracture type and treatment choice. Pseudarthrosis represented the main complication, which increased with age. Pseudarthrosis was most frequent in type II and oblique-posterior fractures after conservative treatment.

Predictors of 30-Day Outcomes in Octogenarians with Traumatic C2 Fractures Undergoing Surgery

BACKGROUND

Predictors of surgical outcomes following traumatic axis (C2) fractures in octogenarians remain undercharacterized.

METHODS

Patients age ≥80 years undergoing cervical spine surgery following traumatic C2 fractures were extracted from the National Sample Program of the National Trauma Data Bank (2003-2012). Outcomes include overall inpatient complications, individual complications with an incidence >1%, hospital length of stay (HLOS), discharge disposition, and mortality. Demographics, comorbidities, and injury predictors were analyzed using multivariable regression. Odds ratios (OR), mean differences, and 95% confidence intervals (CIs) were calculated. Statistical significance was assessed at P < 0.05.

RESULTS

The cohort of 442 patients was 48.6% male and had a mean age of 84.3 ± 2.7 years. The distribution of admissions was 42.3% to the hospital floor, 40.3% to the intensive care unit (ICU), 7.7% to telemetry, 2.0% to the operating room, and 7.7% to other/unknown. Mortality was 9.7%, mean HLOS was 13.1 ± 9.2 days, the rate of complications was 38.5%, and 81.5% of survivors were discharged to a nonhome facility. Injury severity was predictive of mortality and overall complications. History of bleeding disorder/coagulopathy predicted mortality (OR, 4.02; 95% CI, 1.07-15.05), overall complications (OR, 3.01; 95% CI, 1.09-8.32), cardiac arrest (OR, 8.19; 95% CI, 1.06-63.54), and renal complications (OR, 10.36; 95% CI, 2.13-50.38). History of congestive heart failure predicted mortality (OR, 3.10; 95% CI, 1.10-8.69). ICU admission (vs. floor) predicted overall complications (OR, 2.01; 95% CI, 1.23-3.27) and pneumonia (OR, 4.65; 95% CI, 1.91-11.30). Telemetry admission (vs. floor) predicted unplanned intubation (OR, 7.76; 95% CI, 1.24-48.49).

CONCLUSIONS

In this cohort of octogenarians undergoing surgery for traumatic C2 fracture, injury severity and a history of bleeding disorder/coagulopathy were identified as risk factors for inpatient complications and mortality. Heightened surveillance should be considered for ICU and/or telemetry admissions for the development of complications. These findings warrant consideration by the clinician, patient, and family to inform clinical decisions and goals of care.

[Management and outcome of type II fractures of the odontoid process]

BACKGROUND

The most effective treatment of type II dens fractures according to Anderson and D'Alonzo remains controversial as there is no guidance on the choice of conservative or surgical therapy and if the anterior or the posterior approach is more advantageous. In 1993 Eysel and Roosen showed that the consolidation rate of type II odontoid fractures mostly depends on the morphology of the fracture and established a classification with corresponding treatment recommendations.

OBJECTIVE

The investigation aimed at clarifying the outcome of type II dens fractures treated according to the recommendations of Eysel and Roosen.

MATERIAL AND METHODS

Data of dens fractures from 72 patients were analyzed and categorized according to the Eysel and Roosen classification. Furthermore, the treatment was analyzed and the outcome was evaluated retrospectively using radiographs acquired during follow-up.

RESULTS

The mean age of the 72 patients was 70.7 years. Of the patients 19.4% suffered from type A, 75% from type B and 5.6% from type C fractures according to Eysel and Roosen. Out of the 72 patients 45 were assessed by computed tomography (CT) scan during follow-up. According to the recommendations of the authors 34 of the 41 patients with type A or type B fractures underwent anterior screw fixation of the dens and 3 out of the 4 patients with a type C fracture underwent a dorsal C1 and C2 fusion. After a mean follow-up of 7 months non-union was observed in 15.6% of the patients whereby 6 of the these patients were treated by surgery and 1 patient was managed conservatively. All of the patients who developed a non-union had a type B fracture.

CONCLUSION

The simple clinical applicability together with the low rate of non-union development shows that the Eysel and Roosen classification appears to be a suitable guide for clinical use when deciding on the appropriate treatment regimen.