Anterior screw fixation of type IIB odontoid fractures in octogenarians

The optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis

PURPOSE

Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the outcome of surgical and conservative treatments in elderly (≥ 65 years), by updating a systematic review published by the authors in 2013.

METHODS

A comprehensive search was conducted in seven databases. Clinical outcome was the primary outcome. Fracture union- and stability were secondary outcomes. Pooled point estimates and their respective 95% confidence intervals (CIs) were derived using the random-effects model. A random-effects multivariable meta-regression model was used to correct for baseline co-variates when sufficiently reported.

RESULTS

Forty-one studies met the inclusion criteria, of which forty were case series and one a cohort study. No clinical differences in outcomes including the Neck Disability Index (NDI, 700 patients), Visual Analogue Scale pain (VAS, 180 patients), and Smiley-Webster Scale (SWS, 231 patients) scores were identified between surgical and conservative treatments. However, fracture union was higher in surgically treated patients (pooled incidence 72.7%, 95% CI 66.1%, 78.5%, 31 studies, 988 patients) than in conservatively treated patients (40.2%, 95% CI 32.0%, 49.0%, 22 studies, 912 patients). This difference remained after correcting for age and fracture type. Fracture stability (41 studies, 1917 patients), although numerically favoring surgery, did not appear to differ between treatment groups.

CONCLUSION

While surgically treated patients showed higher union rates than conservatively treated patients, no clinically relevant differences were observed in NDI, VAS pain, and SWS scores and stability rates. These results need to be further confirmed in well-designed comparative studies with proper adjustment for confounding, such as age, fracture characteristics, and osteoporosis degree.

Type II Odontoid Fractures: Is the Anterior Screw a Good Solution for all Patients? A Case Series of 60 Consecutive Patients

OBJECTIVE

Type II odontoid fracture is the most common fracture type, and its treatment remains challenging. The objective of this study was to evaluate the results of anterior screw fixation for type II odontoid fractures in patients aged over and below 60 years.

METHODS

A retrospective analysis of consecutive patients diagnosed with type II odontoid fractures who were surgically treated using the anterior approach by a single surgeon was conducted. Demographic characteristics, including age, sex, type of fracture, time from trauma to surgery, length of stay (LoS), fusion rate, complications, and reoperation, were evaluated. Surgical outcomes were compared between patients over and below 60 years of age.

RESULTS

Sixty consecutive patients underwent odontoid anterior fixation during the analysis period. The mean age of patients was 49.58 ± 23.22 years. Twenty-three (38.3%) patients were aged over 60 years, and the minimum follow-up period was two years. Of the patients, 93.3% developed bone fusion, which was observed in 86.9% of patients over 60 years. Complications related to hardware failure occurred in six (10%) patients. Transient dysphagia was observed in 10% of the cases. Three (5%) patients required reoperation. Patients over 60 years had a significantly increased risk of dysphagia compared with those below 60 years (P = 0.0248). There was no significant difference between the groups regarding nonfusion rate, reoperation rate, or LoS.

CONCLUSIONS

Anterior fixation of the odontoid showed high fusion rates with a low rate of complications. It is a technique to be considered for treating type II odontoid fractures in selected cases.

Too frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy

Type-II odontoid fractures are common and highly morbid injuries, particularly among elderly patients. However, few risk stratification resources exist to predict outcomes and guide management decision making. Frailty indices have been increasingly utilized for these purposes in elective surgery, but have not been assessed for trauma. A single-center prospective trauma registry identified patients aged ≥ 80 years with type-II odontoid fractures. Frailty was the independent variable, using three independent indices: modified-5-item frailty (mFI-5), modified Charlson comorbidity (mCCI), and Davies. 97 patients had complete frailty data and sufficient follow up information, with median mIF-5 of 2 (range 0-4; 34 frail, mFI-5 > 2), median mCCI score of 6 (range 4-14), and median Davies score of 2 (range 0-7). For all indices, increasing score was associated with mortality, mIF-5 (HR = 1.76, 95%CI = 1.06-2.88), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Median post-injury survival among patients with mIF-5 of ≤ 2 was 10-fold longer than patients with mIF-5 of > 2 (70 vs. 710 days, p = 0.0026). After adjusting for initial treatment strategy, frailty status remained an independent predictor of patient mortality; mIF-5 (HR = 1.72, 95%CI = 1.02-2.80), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Among octogenarian patients with type-II odontoid fractures, frailty was associated with increased mortality, independent of treatment strategy.

Surgery vs conservative treatment for type II and III odontoid fractures in a geriatric population: A meta-analysis

BACKGROUND

It is unclear whether surgery or conservative treatment is more suitable for elderly patients with type II and type III odontoid fractures. We performed this meta-analysis to compare the efficacy of surgical and conservative treatments for type II and type III odontoid fractures.

METHODS

A literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library in January 2017. Only articles comparing surgery with conservative treatment in elderly patients with type II and type III odontoid fractures were selected. After 2 authors independently assessed the retrieved studies, 18 articles were included in this meta-analysis, and the primary endpoints were the nonunion rate and mortality rate. The secondary outcomes were patient satisfaction, complications, and the length of the hospital stay. The quality of the included studies was evaluated using the modified Newcastle-Ottawa scale. Sensitivity analyses were performed for high-quality studies, and the publication bias was evaluated using a funnel plot.

RESULTS

Lower nonunion (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.18-0.40, P < .05) and mortality rates (OR: 0.52, 95% CI: 0.34-0.79, P < .05) confirmed the superiority of surgery in treating type II and type III fractures. The secondary outcomes differed. Patients in the surgery group felt more satisfied with the outcome (OR: 3.44, 95% CI: 1.19-9.95, P < .05), and the complications were similar in the 2 groups (OR: 1.14, 95% CI: 0.78-1.68, P = .5), whereas patients in conservative groups spent less time in the hospital (OR: 5.10, 95% CI: 2.73-7.47, P < .05). The results of the subgroup analyses and sensitivity analysis were similar to the original outcomes, and no obvious publication bias was observed in the funnel plot.

CONCLUSION

Most elderly (younger than 70 years) patients with type II or type III odontoid fractures should be considered candidates for surgical treatment, due to the higher union rate and lower mortality rate, while statistically significant differences were not observed in the population with an advanced age (older than 70 years). Therefore, the selection of the therapeutic approach for elderly patients with odontoid fractures requires further exploration. Simultaneously, based on our meta-analysis, a posterior arthrodesis treatment was significantly superior to the anterior odontoid screw treatment.

Functional Outcome After Odontoid Fractures in the Elderly

While several papers on mortality and the fusion rate in elderly patients treated surgically or non-surgically for odontoid fractures exist, little information is available on quality of life after treatment. The aim of treatment in these patients should not be fracture healing alone but also quality of life improvement.A literature search using PubMed identified seven papers including information on functional evaluation of 402 patients.Patients treated with anterior screw fixation had a good functional outcome in 92.6% of cases. This percentage seemed to decrease in octogenarians. Less information was available for patients treated with posterior approaches; it would seem that up to a half of such patients experienced pain and limitations in activities of daily living after surgery. Patients treated with a halo device had a functional outcome that was worse (or at least no better) than that of patients treated with surgery, with absence of limitations in activities of daily living in 77.3% of patients. Patients treated with a collar had a good functional outcome in the majority of cases, with absence of limitations in activities of daily living in 89% of patients.More studies are needed for evaluation of functional outcome, especially in patients treated with a collar, a halo device or a posterior approach.

Functional Outcome of Elderly Patients Treated for Odontoid Fracture: A Multicenter Study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

Analysis of impact of conservative and surgical treatments on functional outcome of geriatric odontoid fractures.

SUMMARY OF BACKGROUND DATA

Treatment of odontoid fractures in aged population is still debatable.

METHODS

One hundred fourty-seven consecutive odontoid fractures in elderly patients were classified according to Anderson-D'Alonzo and Roy-Camille classifications. Philadelphia type collar was always positioned and kept as a treatment whenever acceptable. Halo-vest, anterior screw fixation, C1-C2 posterior arthrodesis, and occipito-cervical fixation were the other treatments adopted. Conservative or surgical treatment strategy was more significantly influenced by antero-posterior displacement (< or >5 mm) and by surgeon decision. On admission ASA, modified Rankin scale (mRS-pre) and Charlson Comorbidity Index (CCI) were assessed. Modified Rankin scale (mRS-post), Neck Disability Index (NDI), and Smiley Webster Pain Scale (SWPS) were administered 12 to 15 months after treatment to estimate functional outcome in terms of general disability, neck-related disability, and ability to return to work/former activity. Risk of treatment crossover was calculated considering factors affecting outcome. Fracture healing process in terms of fusion-stability, no fusion-stability, no fusion-no stability was evaluated at 12 months through a cervical computed tomography (CT) scan. Dynamic cervical spine x-rays were obtained whether necessary. No fusion-stability was considered an adequate treatment goal in our geriatric population. Chi square/Fisher exact test and logistic regression were performed for statistical anal.

RESULTS

Overall 67 patients were treated conservatively whereas 80 underwent surgery. Collar was adopted in 45 patients, while anterior odontoid fixation and C1-C2 posterior arthrodesis were preferred for 30 patients each. 79.8% of patients showed good outcomes according to NDI. No significant differences were observed between patients of 65 to 79 years and more than or equal to 80 years (P = 0.81). CCI greatly correlated with mRS-post, with higher indexes in 68.8% of cases characterized by good outcomes (P = 0.05). mRS-pre correlated with NDI (P < 0.000001) and mRS-post (P = 0.04). CCI, mRS-pre, and surgery were associated with worse NDI, while both C1-C2 posterior arthrodesis and occipito-cervical stabilization were associated with worse mRS-post, respectively in 40% and 30% of cases. Younger patients had a higher risk of treatment crossover.

CONCLUSION

mRS-pre and CCI provided two independent predictive values respectively for functional outcome and post-treatment disability. Compared with conservative immobilizations, surgery revealed no advantages in the elderly in terms of functional outcome.

LEVEL OF EVIDENCE

3.

Biomechanical comparison of cemented versus non-cemented anterior screw fixation in type II odontoid fractures in the elderly: a cadaveric study

BACKGROUND CONTEXT

Odontoid process fractures are the most common injuries of the cervical spine in the elderly. Anterior screw stabilization of type II odontoid process fractures improves survival and function in these patients but may be complicated by failure of fixation.

PURPOSE

The present study aimed to determine whether cement augmentation of a standard anterior screw provides biomechanically superior fixation of type II odontoid fractures in comparison with a non-cemented standard screw.

STUDY DESIGN

Twenty human cadaveric C2 vertebrae from elderly donors (mean age 83 years) were obtained.

METHODS

Anderson and D'Alonzo type IIa odontoid fracture was created by transverse osteotomy, and fluoroscopy-guided anterior screw fixation was performed. The specimens were divided into two matched groups. The cemented group (n=10) had radiopaque high viscosity polymethylmethacrylate cement injected via Jamshidi needle into the base of the odontoid process. The other group was not augmented. A V-shaped punch was used for loading the odontoid in an anteroposterior direction until failure. The failure state was defined as screw cutout or 5% force decrease. Mean failure load and bending stiffness were calculated.

RESULTS

The mean failure load for the cemented group was 352±12 N compared with 168±23 N for the non-cemented group (p<.001). The mean initial stiffness of the non-cemented group was 153±19 N/mm compared with 195±29 N/mm for the cemented group (p<.001) CONCLUSIONS: Cement augmentation of an anterior standard screw fixation of type II odontoid process fractures in elderly patients significantly increased load to failure under anteroposterior load in comparison with non-augmented fixation. This may be a valuable technique to reduce failure of fixation.

Treatment of type II odontoid fracture with a novel technique: Titanium cable-dragged reduction and cantilever-beam internal fixation

Surgical methods for type II odontoid fracture can be classified into 2 main groups: anterior or posterior approach. A more effective way to achieve bone fusion with the lowest possible surgical risk is needed. Therefore, the aim of our study was to describe and evaluate a novel technique, cable-dragged reduction/cantilever beam internal fixation for the treatment of type II odontoid fracture.This was a retrospective study enrolled 34 patients underwent posterior cable-dragged reduction/cantilever-beam internal fixation surgery. Medical records, rates of reduction, the location of the instrumentation and fracture healing during follow-up were analyzed. Once fracture healing was obtained, instrumentation was removed. Neck pain (scored using a visual analog scale [VAS]), neck stiffness, patient satisfaction, and neck disability index (NDI) were recorded before and after removing the instrumentation during follow-up.The mean duration of follow up was 22.8 ± 5.3 months. There was no iatrogenic damage to nerves or blood vessels. Radiographic evaluation showed complete reduction in the 20 patients with fracture displacement and satisfactory fracture healing in all 34 cases. Titanium cable breakage was observed in 4 patients after fracture healing. After removal of instrumentation, significant improvements were seen in neck-pain VAS score, neck stiffness, patient satisfaction, and NDI (all P < .01).Posterior cable-dragged reduction/cantilever-beam internal fixation was an optimal salvage maneuver to conventional surgical methods such as anterior screw fixation and C1-C2 screw-rod system. The operative difficulty and incidence of nerve and vascular injury were reduced. Its major disadvantage is the exposure and screw-setting at C3, which is left intact in traditional surgery, and it is suitable only for patients with intact C1 posterior arches.

Epidemiology of C2 Fractures in the 21st Century: A National Registry Cohort Study of 6,370 Patients from 1997 to 2014

OBJECTIVE

C2 fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. This study aims to investigate the incidence and treatment trend of C2 fractures in Sweden.

METHODS

Patients with the principal and secondary diagnosis of fracture of the second vertebrae (ICD-10: S12.1) between 1997 and 2014 were identified in the Swedish National Patient Registry (NPR).

RESULTS

Between 1997 and 2014, 6,370 patients with a C2 fracture (51% male; age: 72 ± 18) were identified in the NPR. The incidence of C2 fractures increased from 3 to 6 per 100,000 (r = 0.94; p < 0.01), mainly due to an increase of incidence in the geriatric subgroup (≥70 years). The percentage of surgically treated patients decreased from 1997 to 2014 (r = -0.80; p < 0.01). Younger age, male gender, spinal cord injury, and earlier year of admission were associated with surgical treatment assignment.

DISCUSSION

This study documents a rising incidence of C2 fractures in the elderly during the last two decades in Sweden. Greater awareness of fractures, improved diagnostics, coding, and a higher activity level of the patients are plausible causes. The declining trend of surgical treatment warrants further study.

Deadly falls: operative versus nonoperative management of Type II odontoid process fracture in octogenarians

OBJECTIVE

Type II odontoid fracture is a common injury among elderly patients, particularly given their predisposition toward low-energy falls. Previous studies have demonstrated a survival advantage following early surgery among patients older than 65 years, yet octogenarians represent a medically distinct and rapidly growing population. The authors compared operative and nonoperative management in patients older than 79 years.

METHODS

A single-center prospectively maintained trauma database was reviewed using ICD-9 codes to identify octogenarians with C-2 cervical fractures between 1998 and 2014. Cervical CT images were independently reviewed by blinded neurosurgeons to confirm a Type II fracture pattern. Prospectively recorded outcomes included Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), additional cervical fracture, and cord injury. Primary end points were mortality at 30 days and at 1 year. Statistical tests included the Student t-test, chi-square test, Fisher's exact test, Kaplan-Meier test, and Cox proportional hazard.

RESULTS

A total of 111 patients met inclusion criteria (94 nonoperative and 17 operative [15 posterior and 2 anterior]). Mortality data were available for 100% of patients. The mean age was 87 years (range 80–104 years). Additional cervical fracture, spinal cord injury, GCS score, AIS score, and ISS were not associated with either management strategy at the time of presentation. The mean time to death or last follow-up was 22 months (range 0–129 months) and was nonsignificant between operative and nonoperative groups (p = 0.3). Overall mortality was 13% in-hospital, 26% at 30 days, and 41% at 1 year. Nonoperative and operative mortality rates were not significant at any time point (12% vs 18%, p = 0.5 [in-hospital]; 27% vs 24%, p = 0.8 [30-day]; and 41% vs 41%, p = 1.0 [1-year]). Kaplan-Meier analysis did not demonstrate a survival advantage for either management strategy. Spinal cord injury, GCS score, AIS score, and ISS were significantly associated with 30-day and 1-year mortality; however, Cox modeling was not significant for any variable. Additional cervical fracture was not associated with increased mortality. The rate of nonhome disposition was not significant between the groups.

CONCLUSIONS

Type II odontoid fracture is associated with high morbidity among octogenarians, with 41% 1-year mortality independent of intervention—a dramatic decrease from actuarial survival rates for all 80-, 90-, and 100-year-old Americans. Poor outcome is associated with spinal cord injury, GCS score, AIS score, and ISS.

Commentary on the management of type II odontoid process fractures in octogenarians: Article by Graffeo et al. and Editorial by Falavigna (J Neurosurgery Spine August 19, 2016)

Background:

Establishing a clear treatment paradigm for octogenarians with type II odontoid fractures in hampered by a literature replete with level III articles.

Methods:

In the study by Graffeo et al., the authors evaluated 111 patients over the age of 79 (average age: 87) with type II odontoid fractures undergoing nonoperative (94 patients) vs. operative intervention (17 total; 15 posterior and 2 anterior). They studied multiple variables and utilized several scales [abbreviated injury scale (AIS), injury severity score (ISS), and the Glasgow coma scale (GCS)] to determine the outcomes of nonoperative vs. operative management.

Results:

Graffeo et al. concluded that there were no significant differences between nonoperative and operative management for type II odontoid fractures in octogenarians. They found similar frequencies of additional cervical fractures, mechanisms of injury, GCS of 8 or under, AIS/ISS scores, and disposition to “nonhome” facilities. Furthermore, both appeared to have increased mortality rates at 1-year post injury; 13% during hospitalization, 26% within the first post-injury month, and 41% at 1 year.

Conclusions:

In the editorial by Falavigna, his major criticism of Graffeo's article was the marked disparity in the number of patients in the operative (17 patients) vs. the nonoperative group (94 patients), making it difficult to accept any conclusions as “significant”. He further noted that few prior studies provided level I evidence, and that most, like this one, were level III analyses that did not “significantly” advance our knowledge as to whether to treat octogenarians with type II odontoid fractures operatively vs. nonoperatively.

A Systematic Review of the Treatment of Geriatric Type II Odontoid Fractures

BACKGROUND

Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is controversial.

OBJECTIVE

To compare the short-term (<3 months) mortality, long-term (≥12 months) mortality, and complication rates of patients >60 years of age with a type II odontoid fracture managed either operatively or nonoperatively.

METHODS

We performed a systematic review of literature published between January 1, 2000, and February 1, 2015, related to the treatment of type II odontoid fractures in patients >60 years of age. An analysis of short-term mortality, long-term mortality, and the occurrence of complications was performed.

RESULTS

A total of 452 articles were identified, of which 21 articles with 1233 patients met the inclusion criteria. Short-term mortality (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) and long-term mortality (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) were lower in patients who underwent surgical treatment than in those who had nonsurgical treatment, and there were no significant differences in the rate of complications (odds ratio, 1.01; 95% confidence interval, 0.63-1.63). Surgical approach (posterior vs anterior) showed no significant difference in mortality or complication rate. Similarly, no difference in mortality or complication rate was identified with hard collar or a halo orthosis immobilization.

CONCLUSION

The current literature suggests that well-selected patients >60 years of age undergoing surgical treatment for a type II odontoid fracture have a decreased risk of short-term and long-term mortality without an increase in the risk of complications.

Cement augmented anterior odontoid screw fixation is biomechanically advantageous in osteoporotic patients with Anderson Type II fractures

STUDY DESIGN

A biomechanical human cadaveric study.

OBJECTIVE

The authors tested a cannulated and perforated lag screw and compared in situ polymethylmethacrylate (PMMA) augmentation against nonaugmentation for fixation of osteoporotic type II odontoid fractures.

SUMMARY OF BACKGROUND DATA

Osteoporosis has been identified as a strong predictor for pseudarthrosis after screw fixation of type II odontoid fractures with cut-out through the anterior wall of C2 as the most frequent mode of implant failure. The concept of PMMA augmentation of the proximal screw shank could serve as a useful supplement in this context.

METHODS

A total of 18 fresh-frozen human cadaveric C2 vertebrae were harvested (median 86.5 y; range, 69-98 y). Reduced bone quality was verified by quantitative computed tomography. Type II odontoid fractures were created and repaired with a cannulated lag screw, which has perforations in the proximal screw shank. Additional PMMA augmentation was carried out for 9 specimens. The position of the screw and cement distribution were evaluated by computed tomography. Values for maximum force to failure, energy to failure, and stiffness were statistically compared between cement augmented and nonaugmented screws.

RESULTS

Cement distribution in the C2 vertebral body was circumferential around the screw shank without leakage into the spinal canal or into the fracture gap in all 9 specimens. The cement augmented screws showed a 2.4 times higher maximum force to failure (363±94 N, P<0.001), a 2.7 times higher energy to failure (1300±698 mJ, P<0.001), and a 1.76 times higher stiffness (90±35 N/mm, P=0.031) in comparison with the nonaugmented screws.

CONCLUSIONS

Cement augmentation for fixation of osteoporotic type II odontoid fractures showed biomechanical advantages. It was also shown that cement augmentation of the newly developed screw is technically easy and safe under in vitro conditions. The technique might be useful with regard to the surgical treatment of elderly patients with osteoporotic odontoid fractures.

A novel technique of two-hole guide tube for percutaneous anterior odontoid screw fixation

BACKGROUND CONTEXT

Surgical stabilization is recommended for odontoid fractures with mechanical instability. Compared with C1-C2 fusion, percutaneous anterior odontoid screw fixation has the advantages of preserving C1/C2 motion and being a minimally invasive procedure. However, determining the optimal screw trajectory is often difficult. When an initial suboptimal K-wire hole is drilled, it is especially difficult to drill a second optimal K-wire trajectory because the initial hole will be entered inadvertently.

PURPOSE

To design a novel device, two-hole guide tube, to make drilling a second optimal K-wire trajectory easier, and thus, avoid unnecessary additional surgical time and reduce the likelihood of needing to change the procedure to traditional open surgery.

STUDY DESIGN

A technical report.

METHODS

Fifty-three patients with odontoid fractures were treated by percutaneous anterior odontoid screw fixation in our hospital, and the initial K-wire trajectories of 16 cases (12 men and 4 women) among the 53 patients were imperfect. The two-hole guide tube was applied for drilling the second trajectory in each of these 16 cases.

RESULTS

No complications associated with this technique occurred. Satisfactory results and good screw placement was achieved in all patients. Radiographic fusion was confirmed for 15 of 16 patients. None of the patients experienced clinical symptoms or screw loosening or breakage in this study.

CONCLUSIONS

Our novel device, two-hole guide tube, can be used to reduce the difficulty associated with redrilling an optimal K-wire trajectory if the initial trajectory is imperfect during percutaneous anterior odontoid screw fixation. Moreover, by referring to the initial misplaced K-wire, a more accurate trajectory for the second K-wire can be achieved.

Odontoid balloon kyphoplasty associated with screw fixation for Type II fracture in 2 elderly patients

Anterior screw fixation is a well-recognized technique that is used to stabilize Type IIB fractures of the odontoid process in the elderly. However, advanced age and osteoporosis are 2 risk factors for pseudarthrosis. Kyphoplasty has been described in the treatment of lytic lesions in C-2. The authors decided to combine these 2 techniques in the treatment of unstable fractures of the odontoid. Two approximately 90-year-old patients were treated for this type of fracture. Instability was demonstrated on dynamic radiography in one patient, and the fracture was seen on static radiography in the other. Clinical parameters, pain, range of motion, 36-Item Short Form Health Survey (SF-36) score (for the first patient), and radiological examinations (CT scans and dynamic radiographs) were studied both before and after surgery. After inflating the balloon both above and below the fracture line, the authors applied a high-viscosity polymethylmethacrylate cement. Some minor leakage of cement was noted in both cases but proved to be harmless. The screws were correctly positioned. The clinical result was excellent, both in terms of pain relief and in the fact that there was no reduction in the SF-36 score. The range of motion remained the same. A follow-up CT scan obtained 1 year later in one of the patients showed no evidence of change in the materials used, and the dynamic radiographs showed no instability. This combination of kyphoplasty and anterior screw fixation of the odontoid seems to be an interesting technique in osteoporotic Type IIB fractures of the odontoid process in the elderly, with good results both clinically and radiologically.

Pooled analysis of non-union, re-operation, infection, and approach related complications after anterior odontoid screw fixation

Background

Anterior odontoid screw fixation (AOSF) has been one of the most popular treatments for odontoid fractures. However, the true efficacy of AOSF remains unclear. In this study, we aimed to provide the pooled rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid fractures.

Methods

We searched studies that discussed complications after AOSF for type II or type III odontoid fractures. A proportion meta-analysis was done and potential sources of heterogeneity were explored by meta-regression analysis.

Results

Of 972 references initially identified, 63 were eligible for inclusion. 54 studies provided data regarding non-union. The pooled non-union rate was 10% (95% CI: 7%–3%). 48 citations provided re-operation information with a pooled proportion of 5% (95% CI: 3%–7%). Infection was described in 20 studies with an overall rate of 0.2% (95% CI: 0%–1.2%). The main approach related complication is postoperative dysphagia with a pooled rate of 10% (95% CI: 4%–17%). Proportions for the other approach related complications such as postoperative hoarseness (1.2%, 95% CI: 0%–3.7%), esophageal/retropharyngeal injury (0%, 95% CI: 0%–1.1%), wound hematomas (0.2%, 95% CI: 0%–1.8%), and spinal cord injury (0%, 95% CI: 0%–0.2%) were very low. Significant heterogeneities were detected when we combined the rates of non-union, re-operation, and dysphagia. Multivariate meta-regression analysis showed that old age was significantly predictive of non-union. Subgroup comparisons showed significant higher non-union rates in age ≥70 than that in age ≤40 and in age 40 to <50. Meta-regression analysis did not reveal any examined variables influencing the re-operation rate. Meta-regression analysis showed age had a significant effect on the dysphagia rate.

Conclusions/Significances

This study summarized the rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid factures. Elderly patients were more likely to experience non-union and dysphagia.

Systematic review on surgical and nonsurgical treatment of type II odontoid fractures in the elderly

Odontoid fractures type II according to Anderson and d'Alonzo are not uncommon in the elderly patients. Still, due to the paucity of evidence the published treatment guidelines are far from equivocal. This systematic review focuses on the published results of type II odontoid fracture treatment in the elderly with regard to survival, nonunion, and complications. After a systematic literature research 38 publications were included. A cumulative analysis of 1284 published cases found greater survival if elderly patients with odontoid fractures type II received surgical treatment (RR = 0.64). With regard to nonunion in 669 published cases primary posterior fusion had the best fusion results. The systematic literature review came to the following conclusions. (1) Surgical stabilisation of odontoid fractures type II improves survival in patients between 65 and 85 years of age compared to nonsurgical treatment. (2) Posterior atlantoaxial fusion for odontoid fractures type II in the elderly has the greatest bony union rate. (3) Odontoid nonunion is not associated with worse clinical or functional results in the elderly. (4) The complication rate of nonsurgical treatment is similar to the complication rate of surgical treatment of odontoid fractures type II in the elderly.

Rationale and design of the INNOVATE Trial: an international cooperative study on surgical versus conservative treatment for odontoid fractures in the elderly

Background

Fractures of the odontoid process of the axis are the most common fractures of the geriatric cervical spine. As the population ages, their incidence is expected to increase progressively, as is the number of very old patients (>80 years) with an odontoid fracture. No consensus exists on the optimal treatment (surgical or conservative) and the most relevant outcome parameter (osseous union, fracture stability or clinical outcome). The aim of the INNOVATE (INterNational study on Odontoid frActure Treatment in the Elderly) Trial is to prospectively assess fracture healing and clinical outcome after surgical and conservative treatment for odontoid fractures in the elderly patient, with a specific focus on the very old patient.

Methods/Design

The trial is an observational study in which eleven centres in five European countries are involved. All patients admitted to one of these centres who meet the selection criteria (≥55 years, acute (<two weeks) type II/III odontoid fracture, no rheumatoid arthritis, no ankylosing spondylitis, no previous treatment for odontoid fracture) are asked to participate. The applied treatment is in accordance with usual care and chosen by the treating surgeon and patient. A cohort of 275 patients will be included. Clinical and radiological follow-up moments are scheduled at 6, 12, 26, 52 and 104 weeks, at which both surgeon and patient will complete Case Record Forms (CRFs). The primary outcome will be a combination of fracture healing and clinical outcome at 52 weeks. Osseous union and fracture stability will be assessed with CT-imaging and dynamic X-ray. Clinical outcome will be scored by the Neck Disability Index (NDI) and correlated to the imaging data. Additionally, predefined subgroup analysis will be carried out (i.e. for patient age and osteoporosis) and prognostic factors will be identified.

Discussion

Evidence for the optimal treatment for odontoid fractures is lacking. Focusing on both fracture healing and clinical outcome, the results of this study will yield valuable information enabling more rational decision making in the treatment for odontoid fractures in the elderly.

Trial registration

Netherlands Trial Register NTR3630

Anterior screw fixation for an odontoid fracture using an Acutrak 4/5 screw: a case report

The direct anterior screw fixation of odontoid fractures by a single cancellous screw, especially for osteoporotic vertebrae, has a potential risk of leading to insufficient stability and implant failures. We experienced good results following surgery using a single Acutrak 4/5 screw to obtain sufficient stability for an odontoid fracture in a patient with osteopenia. The screw is a cannulated self-tapping headless screw and has a tapered profile and full threads with variable pitches, and it can yield sufficient compression force as the screw is inserted. The preoperative severe neck pain of the patient was diminished immediately after the surgery. The patient achieved bone union in a short time and had a good clinical result for at least 3 years. Some biomechanical studies showed that the compression force of Acutrak standard screws was stronger than that of both 4.0-mm cancellous screws inserted with the lag screw technique and Herbert screws, and other studies showed that the compression force of Acutrak 4/5 screws was equivalent to that of 4.5-mm cortical screws. However, there has been no clinical report of surgery using an Acutrak 4/5 screw for odontoid fractures. This is the first clinical report of fixation by an Acutrak 4/5 screw.

Complications of upper cervical spine trauma in elderly subjects. A systematic review of the literature

The frequency of cervical spine trauma in elderly patients is increasing with most injuries occurring in the upper cervical spine. These fractures are associated with a risk of sometimes life-threatening complications, although very few studies have specifically analyzed this. The goal of this study was to identify the incidence of complications in the literature (mortality and morbidity) following upper cervical spine trauma in elderly patients.

METHODS

A systematic search was performed on the MEDLINE database without limiting the search by language or date to identify all studies reporting the rate of complications after upper cervical spine trauma in patients over the age of 60.

RESULTS

Twenty-four observational studies were included, four were comparative. These studies included a total of 857 patients, mean age 76. Nearly all traumas were odontoid process fractures, and most were treated surgically (57%). The median mortality rate was 9.2% (Q1-Q3: 2.5-19.6) and the median rate of short-term complications was 15.4% (Q1-Q3: 5.8-26.9). The main late stage complication was nonunion, which developed in a mean 10 to 12% depending on the type of treatment.

CONCLUSION

Complications following cervical spine trauma are frequent in elderly patients whatever the type of treatment. Knowledge of the rate of complications in the literature and the potential risk factors is essential for the clinician to improve the information provided to patients and to prevent complications.

TYPE OF STUDY

Systematic review of the literature. Level of evidence IV.

The optimal treatment of type II and III odontoid fractures in the elderly: a systematic review

PURPOSE

Odontoid fractures are the most common cervical spine fractures in the elderly. As the population ages, their incidence is expected to increase progressively. The optimal treatment of this condition is still the subject of controversy. The objective of this review is to summarize and compare the outcome of surgical and conservative interventions in the elderly (≥ 65 years).

METHODS

A comprehensive search was conducted in nine databases of medical literature, supplemented by reference and citation tracking. Clinical status was considered the primary outcome. Fracture union and stability rates were considered secondary outcomes.

RESULTS

A total of nineteen studies met the inclusion criteria. All studies were performed retrospectively and were of limited quality. There was insufficient data, especially from direct comparisons, to determine the difference in clinical outcome between surgical and conservative interventions. Osseous union was achieved in 66-85 % of surgically treated patients and in 28-44 % of conservatively treated patients. Fracture stability was achieved in 82-97 % of surgically patients and in 53-79 % of conservatively treated patients.

CONCLUSIONS

There was insufficient data to determine a potential difference in clinical outcome between different treatment groups. Surgically treated patients showed higher osseous union rates compared to conservatively treated patients, possibly because of different selection mechanisms. The majority of patients appears to achieve fracture stability regardless of the applied treatment. A prospective trial with appropriate sample size is needed to identify the optimal treatment of odontoid fractures in the elderly and predictors for the success of either one of the available treatments.