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Foote CW, Salottolo K, Doan XL, Vanier C, Betancourt AJ, Bar-Or D, Palacio CH. Operative Management Improves Near-term Survival of Patients With Odontoid Type II Fractures: A Propensity-matched National Registry Analysis. Clin Spine Surg 2024; 37:15-22. [PMID: 37651564 PMCID: PMC10810352 DOI: 10.1097/bsd.0000000000001511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/19/2023] [Indexed: 09/02/2023]
Abstract
STUDY DESIGN National Trauma Data Bank (NTDB) review and propensity-matched analysis. OBJECTIVE To evaluate differences in clinical outcomes by operative management. SUMMARY OF BACKGROUND DATA Odontoid type II fractures are the most prevalent cervical fracture. Operative intervention on these fractures is frequently debated; surgical risks are compounded by clinical severity, patient age, and comorbidities. METHODS This registry review included index admissions for odontoid type II fractures [International Classification of Diseases (ICD)-10 codes beginning with S12.11] from 1/1/2017 to 1/1/2020; patients who died in the emergency department (ED) were excluded. Propensity score techniques were used to match patients 1:1 by surgical management, using a caliper distance of 0.05, after matching on the following covariates that differed significantly between surgical and nonsurgical patients: age, sex, race, cause of injury, transfer status, injury severity score, ED Glasgow coma score, ED systolic blood pressure, presence of transverse ligamentous injury, cervical dislocation, and 8 comorbidities. The following outcomes were analyzed with McNemar tests and Wilcoxon signed-rank tests: near-term survival (discharged from the hospital to locations other than morgue or hospice), intensive care unit (ICU) admission, hospital complications, median hospital length of stay (LOS), and median ICU LOS. RESULTS There were 16,607 patients, 2916 (17.6%) were operatively managed and 13,691 were nonoperatively managed. Before matching, survival was greater for patients managed operatively compared with nonoperatively (95.0% vs. 88.2%). The matched population consisted of 5334 patients: 2667 patients in the operative group (91.5% of this population) and 2667 well-matched patients in the nonoperative group. After matching, there was a survival benefit for patients who were operatively managed compared with nonoperative management (94.8% vs. 91.4% P <0.001). However, operative management was associated with greater development of complications, ICU admission, and longer hospital and ICU LOS. CONCLUSION Compared with nonoperative management, operative management demonstrated a significant near-term survival benefit for patients with odontoid type II fractures in select patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Christopher W. Foote
- South Texas Health System Trauma Department, McAllen Medical Center, McAllen, TX
- Valley Health System General Surgery Residency Program, Las Vegas, NV
| | | | - Xuan-Lan Doan
- South Texas Health System Trauma Department, McAllen Medical Center, McAllen, TX
- Valley Health System General Surgery Residency Program, Las Vegas, NV
| | - Cheryl Vanier
- Touro University Nevada College of Osteopathic Medicine, Henderson, NV
| | | | - David Bar-Or
- Trauma Research Department, McAllen Medical Center, McAllen, TX
| | - Carlos H. Palacio
- South Texas Health System Trauma Department, McAllen Medical Center, McAllen, TX
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Lee S, Hur JW, Oh Y, An S, Yun GY, Ahn JM. Current Concepts in the Treatment of Traumatic C2 Vertebral Fracture : A Literature Review. J Korean Neurosurg Soc 2024; 67:6-13. [PMID: 37461838 PMCID: PMC10788552 DOI: 10.3340/jkns.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 01/17/2024] Open
Abstract
The integrity of the high cervical spine, the transition zone from the brainstem to the spinal cord, is crucial for survival and daily life. The region protects the enclosed neurovascular structure and allows a substantial portion of the head motion. Injuries of the high cervical spine are frequent, and the fractures of the C2 vertebra account for approximately 17-25% of acute cervical fractures. We review the two major types of C2 vertebral fractures, odontoid fracture and Hangman's fracture. For both types of fractures, favorable outcomes could be obtained if the delicately selected conservative treatment is performed. In odontoid fractures, as the most common fracture on the C2 vertebrae, anterior screw fixation is considered first for type II fractures, and C1-2 fusion is suggested when nonunion is a concern or occurs. Hangman's fractures are the second most common fracture. Many stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIA and III fractures require surgical stabilization. No result proves that either anterior or posterior surgery is superior, and the surgeon should decide on the surgical method after careful consideration according to each clinical situation. This review will briefly describe the basic principles and current treatment concepts of C2 fractures.
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Affiliation(s)
- Subum Lee
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Junseok W Hur
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Younggyu Oh
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sungjae An
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Gi-Yong Yun
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae-Min Ahn
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Huybregts JGJ, Barot KA, Recio C, Doucette J, Mekary RA, Vleggeert-Lankamp CLA. The optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3434-3449. [PMID: 37439865 DOI: 10.1007/s00586-023-07779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/12/2023] [Indexed: 07/14/2023]
Abstract
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.
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Affiliation(s)
- Jeroen G J Huybregts
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, PO Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands.
| | | | - Camila Recio
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rania A Mekary
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Carmen L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Neurosurgery, Spaarne Hospital Haarlem/Hoofddorp, Hoofddorp, The Netherlands
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Huybregts JGJ, Polak SB, Jacobs WCH, Krekels-Huijbregts IA, Smeets AYJM, Arts MP, Slooff WBM, Öner FC, Peul WC, van Santbrink H, Vleggeert-Lankamp CLA. Low-Threshold-For-Surgery Versus Primarily-Conservative Treatment for Odontoid Fractures in the Elderly: Evaluating Practice Variation in The Netherlands. Global Spine J 2023:21925682231194818. [PMID: 37552933 DOI: 10.1177/21925682231194818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Odontoid fractures are the most common cervical spine fractures in the elderly. The optimal treatment remains controversial. The aim of this study was to compare results of a low-threshold-for-surgery strategy (surgery for dislocated fractures in relatively healthy patients) to a primarily-conservative strategy (for all patients). METHODS Patient records from 5 medical centers were reviewed for patients who met the selection criteria (e.g. age ≥55 years, type II/III odontoid fractures). Demographics, fracture types/characteristics, fracture union/stability, clinical outcome and mortality were compared. The influence of age on outcome was studied (≥55-80 vs ≥80 years). RESULTS A total of 173 patients were included: 120 treated with low-threshold-for-surgery (of which 22 primarily operated, and 23 secondarily) vs 53 treated primarily-conservative. No differences in demographics and fracture characteristics between the groups were identified. Fracture union (53% vs 43%) and fracture stability (90% vs 85%) at last follow-up did not differ between groups. The majority of patients (56%) achieved clinical improvement compared to baseline. Analysis of differences in clinical outcome between groups was infeasible due to data limitations. In both strategies, patients ≥80 years achieved worse union (64% vs 30%), worse stability (97% vs 77%), and - as to be expected - increased mortality <104 weeks (2% vs 22%). CONCLUSIONS Union and stability rates did not differ between the treatment strategies. Advanced age (≥80 years) negatively influenced both radiological outcome and mortality. No cases of secondary neurological deficits were identified, suggesting that concerns for the consequences of under-treatment may be unjustified.
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Affiliation(s)
- Jeroen G J Huybregts
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands
| | - Samuel B Polak
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
| | | | - Ilse A Krekels-Huijbregts
- Department of Neurosurgery, Maastricht University Medical Center, Academic Neurosurgical Center Limburg, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Academic Neurosurgical Center Limburg, Heerlen, The Netherlands
| | - Anouk Y J M Smeets
- Department of Neurosurgery, Maastricht University Medical Center, Academic Neurosurgical Center Limburg, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Academic Neurosurgical Center Limburg, Heerlen, The Netherlands
| | - Mark P Arts
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands
| | - Willem-Bart M Slooff
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Cumhur Öner
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands
| | - Henk van Santbrink
- Department of Neurosurgery, Maastricht University Medical Center, Academic Neurosurgical Center Limburg, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Academic Neurosurgical Center Limburg, Heerlen, The Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Carmen L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
- Department of Neurosurgery, Spaarne Gasthuis, Haarlem, The Netherlands
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Florman JE, Gerstl JVE, Kilgallon JL, Riesenburger RI. Fibrous Nonunion of Odontoid Fractures: Is It Safe To Accept Nonoperative Management? A Systematic Review. World Neurosurg 2022; 164:298-304. [PMID: 35659587 DOI: 10.1016/j.wneu.2022.05.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Nonoperative management of odontoid fractures can result in solid fusion, unstable nonunion, and fibrous nonunion. Odontoid fractures with fibrous nonunion will not demonstrate dynamic instability on imaging studies. However, the safety of accepting this outcome has been debated. We have provided, to the best of our knowledge, the first systematic review of the existing literature to explore the safety of allowing fibrous nonunion as an acceptable outcome for odontoid fractures. METHODS The PubMed and Embase databases were searched in January 2022. The outcomes were extracted and categorized according to the mortality, neurologic sequelae, pain, neck disability index, and satisfaction. RESULTS Of a total of 700 abstracts screened, the full text of 79 reports was assessed, with 13 studies included. Of the included patients, 141 had had a fibrous nonunion, all described in observational studies. The follow-up ranged from 0.6 to 5.8 years. None of the 141 patients had experienced a neurologic event. One patient had died of trauma-related issues; however, causality was not reported. Most of the studies had reported good to excellent pain scores. Most of the neck disabilities reported had ranged from mild to moderate in severity. However, 1 study of 5 patients had reported severe disability. All the patients reported good or excellent satisfaction. CONCLUSIONS The evidence we found supports that it is safe to forgo surgery for carefully selected patients with nonunited odontoid fractures when near-anatomic alignment is present, dynamic instability is lacking on imaging studies, the neurologic examination findings are normal, and the risk of neck injury is low. Further study is needed to define the full natural history of fibrous nonunion of odontoid fractures.
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Affiliation(s)
- Jeffrey E Florman
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA.
| | - Jakob V E Gerstl
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John L Kilgallon
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
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Stacoffe N, Pialat JB, Heidelberg D, Adnane S, Lavigne J, Cotton F, Confavreux CB, Grange S. Percutaneous osteosynthesis for the treatment of traumatic odontoid fractures in elderly patients. Diagn Interv Imaging 2022; 103:378-380. [DOI: 10.1016/j.diii.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/03/2022]
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Watts A, Athanassacopoulos M, Breakwell L, Chiverton N, Cole A, Ivanov M, Tomlinson J. Management of C2 odontoid peg fragility fractures - A UK survey of spinal surgeons. Injury 2022; 53:1057-1061. [PMID: 34635337 DOI: 10.1016/j.injury.2021.09.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 07/23/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Patients sustaining fragility fractures of the C2 odontoid peg have 30-day mortality rates as high as 10% rising up to 34.1% at 1 year. Substantial controversy exists regarding optimal management of these fractures and there is a lack of national guidance to inform best practice. The aim of this study was to determine current practice in the management of these fractures throughout the United Kingdom. METHODS A UK wide, cross sectional survey was conducted, asking 10 questions regarding the initial management, imaging and follow-up of an elderly patient with a type 2 fragility odontoid peg fracture. This was publicised through the British Orthopaedic Association website and sent to all members of the Society of British Neurological Surgeons (SBNS) via email. RESULTS 107 Responses were received. 56% from orthopaedic consultants, 29% from neurosurgical consultants and 15% from senior spine fellows. 86% (92) of respondents choose treatment with a cervical orthosis, with 84% (77) of these opting for a semi rigid Aspen or Philadelphia collar compared to 16% (15) opting for a soft cervical collar. Three (3%) opted for operative intervention with a further three (3%) choosing Halo fixation. Nine respondents (8%) opted for no orthosis and treatment with analgesia alone. Length of immobilisation in cervical orthosis ranged from 6 to 12 weeks. Initial follow-up ranged from 1 week to 6 weeks, with 6% (6) discharged without follow up. There was also marked variation in the use of follow-up imaging with 17% (18) using plain radiographs, 62% (66) requesting lateral flexion / extension radiographs, 10% (11) using CT and 11% (12) not performing any imaging at final follow up. In 60% (64) of cases respondents did not change subsequent management as a result of imaging. CONCLUSION Type-2 fragility peg fractures have high morbidity and mortality. There is marked variation in the treatment modalities used, follow-up regime and use of imaging throughout the UK. Given the rapidly increasing incidence of these injuries and the associated mortality this should be a high priority field for further research. Further large scale studies are urgently required to inform best practice and standardise management of these injuries.
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Affiliation(s)
- Anna Watts
- Speciality Registrar Trauma and Orthopaedics, Sheffield Teaching Hospital NHS Foundation Trust, England.
| | | | - Lee Breakwell
- Consultant Spinal Surgeon, Sheffield Teaching Hospital NHS Foundation Trust.
| | - Neil Chiverton
- Consultant Spinal Surgeon, Sheffield Teaching Hospital NHS Foundation Trust.
| | - Ashley Cole
- Consultant Spinal Surgeon, Sheffield Teaching Hospital NHS Foundation Trust.
| | - Marcel Ivanov
- Consultant Spinal Surgeon, Sheffield Teaching Hospital NHS Foundation Trust.
| | - James Tomlinson
- Consultant Spinal Surgeon, Sheffield Teaching Hospital NHS Foundation Trust.
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Kumar S, Jain A, Tawari M, Rathore L, Sahana D, Mishra H, Sahu R. An experience with Goel-Harms C1-C2 fixation for type II odontoid fractures. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:175-181. [PMID: 35837432 PMCID: PMC9274684 DOI: 10.4103/jcvjs.jcvjs_22_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/14/2022] [Indexed: 11/04/2022] Open
Abstract
Objective: Type II odontoid fractures need surgical stabilization for disabling neck pain and instability. Anterior odontoid screw fixation is a well-known technique. However, certain patients require posterior fixation. We present our surgical results and experiences with nine cases managed by the Goel-Harms technique. Materials and Methods: This is a retrospective review of nine patients operated on between January 2019 and December 2021 for Type II odontoid fractures with posterior fixation technique. Their clinical profile was collected from case files. The radiological data were retrieved from radiology archives. The indications for surgery were instability and refractory neck pain. The surgical decision for posterior fixation was guided by fracture morphology. Results: The mean age of presentation was 37.22 ± 9.85 years. Seven patients had Type II, and two had Type IIa odontoid fracture. All patients presented with unbearable neck pain. One patient had a quadriparesis. The fracture line was anterior-inferior sloping in six, posterior-inferior sloping in two, and transverse in one case. The anterior-posterior displacement of fracture ranged from 0 to 7 mm (mean 2.44 ± 2.18 mm). Partial transverse ligament tear without the Atlanto Axial Dislocation was present in three patients. The C1-C2 joint distraction was required in five cases. C1-C2 joint spacer was required in two cases. Following surgery, neck pain was relieved in all cases. Complete fracture alignment was achieved in eight patients. There were no postoperative complications. At the mean follow-up of 16.22 ± 9.61 months, there was no implant failure. Conclusions: Posterior C1-C2 fixation by the Goel-Harms technique is an excellent alternative to anterior fixation in selected cases.
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Ma F, Fan Y, Liao Y, Tang Q, Tang C, Xu S, Wang Q, Lan Y, Zhong D. Management of fresh odontoid fractures using posterior C1-2 fixation without fusion: a long-term clinical follow-up study. J Neurosurg Spine 2021:1-11. [PMID: 34920424 DOI: 10.3171/2021.9.spine21822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior C1-2 fixation without fusion makes it possible to restore atlantoaxial motion after removing the implant, and it has been used as an alternative technique for odontoid fractures; however, the long-term efficacy of this technique remains uncertain. The purpose of the present study was to explore the long-term follow-up outcomes of patients with odontoid fractures who underwent posterior C1-2 fixation without fusion. METHODS A retrospective study was performed on 62 patients with type II/III fresh odontoid fractures who underwent posterior C1-2 fixation without fusion and were followed up for more than 5 years. The patients were divided into group A (23 patients with implant removal) and group B (39 patients without implant removal) based on whether they underwent a second surgery to remove the implant. The clinical outcomes were recorded and compared between the two groups. In group A, the range of motion (ROM) of C1-2 was calculated, and correlation analysis was performed to explore the factors that influence the ROM of C1-2. RESULTS A solid fracture fusion was found in all patients. At the final follow-up, no significant difference was found in visual analog scale score or American Spinal Injury Association Impairment Scale score between the two groups (p > 0.05), but patients in group A had a lower Neck Disability Index score and milder neck stiffness than did patients in group B (p < 0.05). In group A, 87.0% (20/23) of the patients had atlantoodontoid joint osteoarthritis at the final follow-up. In group A, the C1-2 ROM in rotation was 6.1° ± 4.5° at the final follow-up, whereas the C1-2 ROM in flexion-extension was 1.8° ± 1.2°. A negative correlation was found between the C1-2 ROM in rotation and the severity of tissue injury in the atlantoaxial region (r = -0.403, p = 0.024) and the degeneration of the atlantoodontoid joint (r = -0.586, p = 0.001). CONCLUSIONS Posterior C1-2 fixation without fusion can be used effectively for the management of fresh odontoid fractures. The removal of the implant can further improve the clinical efficacy, but satisfactory atlantoaxial motion cannot be maintained for a long time after implant removal. A surgeon should reconsider the contribution of posterior C1-2 fixation without fusion and secondary implant removal in preserving atlantoaxial mobility for patients with fresh odontoid fractures.
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Affiliation(s)
- Fei Ma
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
| | - Yuanhe Fan
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
| | - Yehui Liao
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
| | - Qiang Tang
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
| | - Chao Tang
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
| | - Shicai Xu
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
| | - Qing Wang
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
| | - Yongshu Lan
- 2Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Dejun Zhong
- 1Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; and
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Carlstrom LP, Helal A, Perry A, Lakomkin N, Graffeo CS, Clarke MJ. Too frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy. J Clin Neurosci 2021; 93:48-53. [PMID: 34656260 DOI: 10.1016/j.jocn.2021.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
| | - Ahmed Helal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Chibbaro S, Mallereau CH, Ganau M, Zaed I, Teresa Bozzi M, Scibilia A, Cebula H, Ollivier I, Loit MP, Chaussemy D, Coca HA, Dannhoff G, Romano A, Nannavecchia B, Gubian A, Spatola G, Signorelli F, Iaccarino C, Pop R, Proust F, Baloglu S, Todeschi J. Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome. Neurosurg Rev 2021; 45:709-718. [PMID: 34232408 DOI: 10.1007/s10143-021-01594-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/01/2021] [Accepted: 05/13/2021] [Indexed: 11/27/2022]
Abstract
Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75 years) with Type II odontoid fracture managed conservatively during the last 10 years. All patients underwent CT scan on admission and at 3 months; if indicated, selected patient had CT scan at 6 and 12 months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6 weeks, 3, 6, 12, and 24 months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12 months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83 years. Patients were followed up for a minimum of 24 months: 247 (95%) showed an excellent functional outcome within 6 weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12 weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.
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Affiliation(s)
- Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | | | - Mario Ganau
- Department of Neurosurgery, Oxford University Hospital, Oxford, UK
| | - Ismail Zaed
- Department of Neurosurgery, Humanitas University Hospital, Rozzano, Italy
| | - Maria Teresa Bozzi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Antonino Scibilia
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Helene Cebula
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Irene Ollivier
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Marie-Pierre Loit
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Dominique Chaussemy
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Hugo-Andres Coca
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Guillaume Dannhoff
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Antonio Romano
- Department of Neurosurgery, Parma University Hospital, Parma, Italy
| | | | - Arthur Gubian
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Giorgio Spatola
- Department of Neurosurgery, Poli-Ambulanza Hospital, Brescia, Italy
| | | | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Division of Neurosurgery, University Hospital of Modena, Modena, Italy
| | - Raoul Pop
- Neuroradiology Unit, Strasbourg University Hospital, Strasbourg, France
| | - François Proust
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Seyyid Baloglu
- Neuroradiology Unit, Strasbourg University Hospital, Strasbourg, France
| | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
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12
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Rizvi SAM, Helseth E, Aarhus M, Harr ME, Mirzamohammadi J, Rønning P, Mejlænder-Evjensvold M, Linnerud H. Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients. Spine J 2021; 21:1149-1158. [PMID: 33577924 DOI: 10.1016/j.spinee.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/01/2021] [Accepted: 02/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The recommended primary treatment for type III odontoid fractures (OFx) is external immobilization, except for patients having major displacement of the odontoid fragment. The bony fusion rate of type III OFx has been reported to be >85%. High compliance to treatment recommendations is favorable only if the treatment leads to a good outcome. PURPOSE The primary aim of this study was to determine the long-term outcome after conservative and surgical treatment of type III OFx and to reaffirm that primary external immobilization is the best treatment for most type III fractures. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred twelve consecutive patients with type III OFx treated at Oslo University Hospital over an 8-year period (2009-2017). OUTCOME MEASURES Long-term rates of bony fusion, crossover from primary conservative treatment to surgical fixation, new onset spinal cord injury (SCI), severe persistent neck pain (visual analogue scale - VAS), and persistent disability measured with Neck Disability index (NDI). METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures from a general population. During the years 2018 to 2019 long-term follow-up of alive patients was performed (median follow-up time was 38.0 months; range 3.0-108.0 months). The follow-up included neurological examination, radiological examination and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new onset SCI, neck pain, and Neck Disability Index (NDI score). RESULTS In this consecutive series of 212 patients with type III acute OFx, median patient age was 72 years, 56% had severe preinjury comorbidities (ASA score ≥3) and 22% lived dependently. Severe comorbidities and dependent living were significantly associated with increasing age (p<.001). The trauma mechanism was fall injury in 82%. The median age of patients injured by falls was significantly higher than in patients with a nonfall injury (p<.001). At the time of diagnosis, 4% had an OFx related SCI. Primary treatment was external immobilization alone in 95.3% and open surgical fixation in 4.7%. Patients treated with primary external immobilization alone presented with significantly less translation of the odontoid fragment (p<.001) and less angulation of the odontoid fragment (p=.025) than patients treated with primary surgery. Subsequent crossover to surgical fixation was performed in 5.4%. At long-term follow-up, 95.7% of patients had bony fusion of the OFx, 80.5% had minimal/no neck pain, and none developed new onset SCI. There was no significant difference in long-term follow-up VAS (p=.444) or NDI (p=.562) between the primary external immobilization group and the primary surgical group. CONCLUSION This study reaffirms that nonsurgical treatment remains the preferable option in the majority of patients with type III OFx.
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Affiliation(s)
- Syed Ali Mujtaba Rizvi
- Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
| | - Eirik Helseth
- Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Mads Aarhus
- Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | | | - Pål Rønning
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Hege Linnerud
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
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13
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Ma F, Liao Y, Tang Q, Tang C, Luo N, He H, Yang S, Wang Q, Zhong D. Morphometric Analysis of the Lateral Atlantoaxial Joints in Patients with an Old Type II Odontoid Fracture and Atlantoaxial Dislocation: A Study Based on CT Analysis. Spine (Phila Pa 1976) 2021; 46:726-733. [PMID: 33337679 DOI: 10.1097/brs.0000000000003894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
MINI The morphological features of the lateral atlantoaxial joints (LAJs) in patients with old type II odontoid fractures and atlantoaxial dislocation have not been fully analyzed. Our study found the changes in morphological features of the LAJs in some patients, and revealed the causes and consequences of the changes in morphological features of the LAJs.
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Affiliation(s)
- Fei Ma
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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14
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Koshimizu H, Nakashima H, Ito K, Ando K, Kobayashi K, Kato F, Sato K, Deguchi M, Matsubara Y, Inoue H, Kanemura T, Urasaki T, Yoshihara H, Wakao N, Shinjo R, Imagama S. Risk factors of non-union in Anderson-D'Alonzo type III odontoid fractures with conservative treatment. J Orthop 2021; 24:280-283. [PMID: 33897130 DOI: 10.1016/j.jor.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/24/2021] [Indexed: 11/28/2022] Open
Abstract
Objective The purpose of this study was retrospectively to analyze the risk factors for non-union in Anderson-D'Alonzo type III odontoid fractures with conservative treatment. Methods 25 patients with type III fractures were analyzed. Coronal and sagittal tilt as well as sagittal and lateral mass gaps were measured by using computed tomography. Results The non-union group had significantly higher age, greater coronal tilt and lateral mass gap. Especially, the lateral mass gap was >2 mm in all cases with non-union. Conclusions Higher age, coronal tilt, and lateral mass gap were significant risk factors for non-union.
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Affiliation(s)
- Hiroyuki Koshimizu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Keigo Ito
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Fumihiko Kato
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Koji Sato
- Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Masao Deguchi
- Department of Orthopaedic Surgery, Nagano Red Cross Hospital, Nagano, Nagano, Japan.,Nagoya Spine Group, Japan
| | - Yuji Matsubara
- Department of Orthopaedic Surgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Hidenori Inoue
- Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Tokumi Kanemura
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Konan, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Tetsuya Urasaki
- Department of Orthopaedic Surgery, Chutoen General Medical Center, Kakegawa, Shizuoka, Japan.,Nagoya Spine Group, Japan
| | - Hisatake Yoshihara
- Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Norimitsu Wakao
- Department of Orthopaedic Surgery, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Ryuichi Shinjo
- Department of Orthopaedic Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan.,Nagoya Spine Group, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Nagoya Spine Group, Japan
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15
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Farah K, Meyer M, Reyre A, Cot K, Fuentes S. PICA injury secondary to anterior odontoid screw fixation: Case report of an exceptional complication. Neurochirurgie 2021; 67:310-314. [PMID: 33753130 DOI: 10.1016/j.neuchi.2021.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/15/2021] [Accepted: 02/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Odontoid fracture is a common injury in the upper cervical spine that can sometimes be managed by anterior odontoid screw fixation. CASE DESCRIPTION We report the first case of iatrogenic postero-inferior cerebellar artery (PICA) injury while performing anterior odontoid screw fixation for a type II odontoid fracture in a 22-year-old man. Fisher grade 4 subarachnoid hemorrhage secondary to iatrogenic pseudoaneurysm formation was managed by the endovascular neuroradiologist. Odontoid fracture was then managed posteriorly using Harm's technique. Postoperative 12-month follow-up revealed good clinical and radiological results. CT scan showed fusion. Complete exclusion of the pseudo aneurysm with a mild stroke in the inferior left cerebellar hemisphere were noted on the MRI. There were no cerebellar ataxia or swallowing disorders. CONCLUSION To the best of our knowledge, this is the first case report of iatrogenic PICA injury in anterior odontoid screw fixation. The patient was well managed in our institution within a multidisciplinary team. We recommend that surgical management of odontoid fractures should be performed in expert centres.
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Affiliation(s)
- K Farah
- Neurosurgery department, Aix-Marseille University, APHM, CHU Timone, Marseille, France.
| | - M Meyer
- Neurosurgery department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - A Reyre
- Endovascular neuroradiology department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - K Cot
- Anesthesiology-intensive care department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - S Fuentes
- Neurosurgery department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
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16
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Yang S, Liu YJ, Jiang WM. Experience in surgical treatment of type Ⅱ odontoid fractures: A report of two cases and review of the literature. Chin J Traumatol 2021; 24:57-62. [PMID: 31757743 PMCID: PMC7878463 DOI: 10.1016/j.cjtee.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/15/2019] [Accepted: 10/05/2019] [Indexed: 02/04/2023] Open
Abstract
Two cases of type Ⅱ odontoid fractures were reported to share our experience in surgery treatment of such cases. A 33-year-old woman with comminuted type Ⅱ odontoid fracture and a 42-year-old man with fracture end hardened type Ⅱ odontoid fracture received surgical treatment in our hospital. Though imaging examination suggested that these two patients were suitable for anterior screw fixation, we encountered difficulties during the operation. The two patients eventually underwent posterior C1-C2 fusion surgery and recovered well. According to the experience of these two cases, we found that the fracture line angle and the degree of comminution are two important factors affecting surgical decision-making. Although anterior screw fixation is the ideal choice for type Ⅱ odontoid fractures with anterior superior to posterior inferior fracture line, it may not be the best choice for comminuted or fracture end hardened type Ⅱ odontoid fractures.
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Affiliation(s)
- Sen Yang
- Department of Orthopaedic Surgery, First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yi-Jie Liu
- Department of Orthopaedic Surgery, First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Wei-Min Jiang
- Department of Orthopaedic Surgery, First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
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17
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McIlroy S, Lam J, Khan MF, Mirza AB, Philip JA, Grahovac G, Bell D. Conservative Management of Type II Odontoid Fractures in Older People: A Retrospective Observational Comparison of Osseous Union Versus Nonunion. Neurosurgery 2020; 87:E648-E654. [PMID: 32570274 DOI: 10.1093/neuros/nyaa256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Type II odontoid fractures are a common cervical fracture in older people. Lower osseous-union rates are reported in those treated conservatively compared to surgically; however, the clinical relevance of a nonunion is unknown. OBJECTIVE To compare pain, disability, and quality of life in older people following conservative management of type II odontoid fractures demonstrating osseous-union and nonunion. METHODS Electronic records were searched from 2008 to 2018 for adults ≥65 yr with type II odontoid fracture, managed in a semi-rigid collar. Clinical and demographic data were retrieved from electronic patient notes. Surviving patients were invited to complete questionnaires to assess pain, disability, and quality of life. Ethical approval was granted. RESULTS A total of 125 patients were identified: 36 (29%) demonstrated osseous-union, 89 (71%) had nonunion, of which 33 (40%) had radiological instability. Mean age at fracture was 84 yr (osseous-union 83 yr; nonunion 84 yr). A total of 53 had deceased (41 nonunion). Median length of survival was 77 mo for osseous-union vs 50 mo for nonunion; P = .02. No patient developed myelopathy during the follow-up period. Questionnaire response rate was 39 (58%). There were no statistically significant differences between the groups in terms of pain, disability, or quality of life (P > .05). Both groups reported mild disability and pain but low quality of life. CONCLUSION Management with a semi-rigid collar in older people with type II odontoid fracture is associated with low levels of pain and disability without statistically significant differences between those demonstrating osseous-union or stable or unstable nonunions. Conservative management appears to be a safe treatment for older people with type II fractures.
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Affiliation(s)
- Suzanne McIlroy
- Physiotherapy Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jordan Lam
- University College London, London, United Kingdom
| | - Muhammad Faheem Khan
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Asfand Baig Mirza
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jerry Ajayi Philip
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gordan Grahovac
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - David Bell
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
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18
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Comparative study of 3D printed navigation template-assisted atlantoaxial pedicle screws versus free-hand screws for type II odontoid fractures. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:498-506. [DOI: 10.1007/s00586-020-06644-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
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19
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Ricciardi L, Trungu S, Scerrati A, De Bonis P, Rustemi O, Mazzetto M, Lofrese G, Cultrera F, Barrey CY, Di Bartolomeo A, Piazza A, Miscusi M, Raco A. Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study. J Neurosurg Spine 2020; 34:27-31. [PMID: 33007754 DOI: 10.3171/2020.6.spine20318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures. METHODS The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma. RESULTS Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not. CONCLUSIONS Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.
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Affiliation(s)
- Luca Ricciardi
- 1UO di Neurochirurgia, Ospedale Cardinal G. Panico, Tricase
- 2UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome
| | - Sokol Trungu
- 1UO di Neurochirurgia, Ospedale Cardinal G. Panico, Tricase
- 2UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome
| | - Alba Scerrati
- 3Dipartimento di Neurochirurgia, Azienda Ospedaliero, Universitaria S. Anna, Ferrara
| | - Pasquale De Bonis
- 3Dipartimento di Neurochirurgia, Azienda Ospedaliero, Universitaria S. Anna, Ferrara
| | | | | | - Giorgio Lofrese
- 5UOC di Neurochirurgia, Ospedale M. Bufalini, Cesena, Italy; and
| | | | | | - Alessandro Di Bartolomeo
- 2UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome
- 6Hôpital Pierre Wertheimer, Lyon, France
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20
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Case series on isolated type 2 odontoid fracture. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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21
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Conservative versus Surgical Treatment for Odontoid Fracture: Is the Surgical Treatment Harmful? Systematic Review and Meta-Analysis. World Neurosurg 2020; 141:490-499.e2. [DOI: 10.1016/j.wneu.2020.02.169] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 02/07/2023]
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22
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The impact of odontoid screw fixation techniques on screw-related complications and fusion rates: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:475-497. [DOI: 10.1007/s00586-020-06501-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/29/2020] [Accepted: 06/07/2020] [Indexed: 02/06/2023]
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23
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Minimally Invasive Percutaneous C1-C2 Fixation Using an Intraoperative Three-Dimensional Imaging–Based Navigation System for Management of Odontoid Fractures. World Neurosurg 2020; 137:266-271. [DOI: 10.1016/j.wneu.2019.12.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 12/10/2019] [Indexed: 11/23/2022]
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Catalino MP, Pate V, Stürmer T, Bhowmick DA. Comparative Propensity-Weighted Mortality After Isolated Acute Traumatic Axis Fractures in Older Adults. Geriatr Orthop Surg Rehabil 2020; 11:2151459320911867. [PMID: 32284902 PMCID: PMC7133078 DOI: 10.1177/2151459320911867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/27/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In older patients with axis fractures, the survival benefit from surgery is unclear due to high baseline mortality. Comparative effectiveness research can provide evidence from population level cohorts. Propensity weighting is the preferred methodology for reducing bias when analyzing national administrative cohort data for these purposes but has not yet been utilized for this important surgical conundrum. We estimate the effect of surgery on mortality after isolated acute traumatic axis fracture in older adults. MATERIALS AND METHODS We used a retrospective population-based cohort of Medicare patients and generated a propensity score-weighted nonsurgical cohort and compared mortality with and without surgery. This balanced the comorbid conditions of the treatment groups. Incident fractures were defined using a predetermined algorithm based on enrollment, code timing, and billing location. The primary outcome was adjusted all-cause 1-year mortality. RESULTS From 12 372 beneficiaries with 1-year continuous enrollment and a coded axis fracture, 2676 patients met final inclusion/exclusion criteria. Estimated incidence was 16.5 per 100 000 person-years overall in 2014 (95% confidence interval [CI]: 15.0-18.0) and was stable from 2008 through 2014. Patients with axis fracture had a mean age of 82.8 years, 30.2% were male, and 91.9% were Caucasian. Mortality was 3.8 times higher (CI 3.6-4.1) compared with the general population of older US adults. Propensity-weighted mortality at 1 year for nonsurgical patients was 26.7 of 100 (CI: 24.5-29.0). Mortality for surgical patients was significantly lower (19.7/100; CI 14.5-25.0). Risk difference was 7.0 fewer surgical deaths per 100 patients (CI: 1.3-12.7). Surgical patients aged 65 to 74 years had the largest difference in mortality with 11.2 fewer deaths per 100 (CI: 1.1-21.3). DISCUSSION Patients with axis fractures are predominantly older Caucasian women and have a higher mortality rate than the general population. Propensity-weighted mortality at 1-year was lower in the surgical patients with the largest risk difference occurring in patients 65 to 74 years old. CONCLUSIONS Surgery may provide an independent survival benefit in patients aged 65 to 75 years, and the mortality difference diminishes thereafter.
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Affiliation(s)
| | - Virginia Pate
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
| | - Til Stürmer
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
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Association Between Frailty Status and Odontoid Fractures After Traumatic Falls: Investigation of Varying Injury Mechanisms Among 70 Elderly Odontoid Fracture Patients. J Orthop Trauma 2019; 33:e484-e488. [PMID: 31365449 DOI: 10.1097/bot.0000000000001597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine significant associations between patient frailty status and odontoid fractures across common traumatic mechanisms of injuries (MOIs) in the elderly. DESIGN Retrospective review. SETTING Single, academic-affiliated hospital with full surgical services. PATIENTS/PARTICIPANTS Patients 65 years or older with traumatic odontoid fractures were included. INTERVENTION Nonoperative management (soft/hard collar, halo, traction tongs, and Minerva) and/or operative fixation. MAIN OUTCOME MEASUREMENTS Modified frailty index (mFI), MOI, concurrent injuries, inpatient length of stay (LOS), reoperation, and mortality rates. RESULTS Seventy patients were included (80.6 ± 8.5 years, 60% F, 88% European, 10% Maori/Pacific, 1.4% Asian, Charlson Comorbidity Index 5.3 ± 2.2, mFI 0.21 ± 0.15). The most common MOIs were falls (74.3%), high-speed motor vehicle accidents (MVAs) (17.1%), low-speed MVAs (5.7%), and pedestrian versus car (2.9%). Patients with traumatic falls exhibited significantly higher mFI scores (0.25) compared with low-speed MVAs (0.16), high-speed MVAs (0.08), and pedestrian versus car (0.01) (P = 0.003). Twenty-seven patients with odontoid fractures were frail, 33 were prefrail, and 10 were robust. Ninety-two percent of frail patients had a traumatic fall as their MOI, as opposed to 73% of prefrail and 30% of robust patients (P < 0.001). Prefrail and frail patients were 4.3 times more likely than robust patients to present with odontoid fractures through traumatic fall [odds ratio (OR): 4.33 (1.47-12.75), P = 0.008], and frailty increased likelihood of reoperation [OR: 4.2 (1.2-14.75), P = 0.025] and extended LOS [OR: 5.71 (1.05-10.37), P = 0.017]. Frail patients had the highest 30-day (P = 0.017) and 1-year mortality (P < 0.001) compared with other groups. CONCLUSION Patients with traumatic odontoid fractures from falls were significantly more frail in comparison with any other MOIs, with worse short- and long-term outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fan L, Ou D, Huang X, Pang M, Chen XX, Yang B, Wang QY. Surgery vs conservative treatment for type II and III odontoid fractures in a geriatric population: A meta-analysis. Medicine (Baltimore) 2019; 98:e10281. [PMID: 31689741 PMCID: PMC6946417 DOI: 10.1097/md.0000000000010281] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Lei Fan
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| | - Dingqiang Ou
- Department of Orthopaedics, The First People's Hospital of Shunde
| | - Xuna Huang
- Department of Medical Research Center, The Third Affiliated Hospital of Sun Yat-sen University
| | - Mao Pang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| | - Xiu-Xing Chen
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong Province, China
| | - Bu Yang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| | - Qi-You Wang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
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Abstract
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.
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Mortality, complication, and fusion rates of patients with odontoid fracture: the impact of age and comorbidities in 204 cases. Arch Orthop Trauma Surg 2019; 139:43-51. [PMID: 30317379 DOI: 10.1007/s00402-018-3050-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Indexed: 02/09/2023]
Abstract
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.
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Grasso G, Leone L, Torregrossa F. Management of Odontoid Cervical Fracture. World Neurosurg 2018; 123:246-247. [PMID: 30579013 DOI: 10.1016/j.wneu.2018.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni Grasso
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy.
| | - Ludovica Leone
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
| | - Fabio Torregrossa
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
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Long-term clinical outcomes following surgical management of cervical spine fractures in elderly patients. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2017.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Grabel ZJ, Armaghani SJ, Vu C, Jain A, Yoon ST. Variations in Treatment of C2 Fractures by Time, Age, and Geographic Region in the United States: An Analysis of 4818 Patients. World Neurosurg 2018; 113:e535-e541. [DOI: 10.1016/j.wneu.2018.02.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/12/2018] [Accepted: 02/14/2018] [Indexed: 11/24/2022]
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Anterior management of C2 fractures using miniplate fixation: outcome, function and quality of life in a case series of 15 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1332-1341. [DOI: 10.1007/s00586-018-5556-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 03/03/2018] [Accepted: 03/20/2018] [Indexed: 12/27/2022]
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Girardo M, Rava A, Gargiulo G, Coniglio A, Artiaco S, Massè A, Fusini F. Clinical and radiological union rate evaluation of type 2 odontoid fractures: A comparison between anterior screw fixation and halo vest in elderly patients. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 9:254-259. [PMID: 30783350 PMCID: PMC6364356 DOI: 10.4103/jcvjs.jcvjs_93_18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose: Odontoid fracture is a very common cervical injury, especially in elderly patients. Despite the high frequency, the appropriate management is still debated. The aim of this study is to evaluate clinical and radiological outcomes after anterior screw fixation or halo vest (HV) in type II odontoid fracture in elderly patients. Materials and Methods: Between January 2013 and December 2015, 135 consecutive patients affected by odontoid process were found. According to inclusion and exclusion criteria, 57 patients were included in the study. Patients were evaluated with visual analog scale (VAS), Smiley–Webster Scale (SWS), Italian Version of the Neck Disability Index (NDI), and patient satisfaction during follow-up. Furthermore, radiological data were evaluated for bone healing. Student's t-test or Fisher's exact test was used between groups, analyzing radiological and clinical results, and level of statistical significance was set at P < 0.05. Results: Seventeen patients were female and 40 were male. Twenty-seven patients were included in surgical group (SG) while 30 were included in HV group with a mean follow-up of 37.74 ± 10.52 months. A significant difference (P < 0.05) between groups was found for pseudoarthrosis, with a lower rate for SG. No significant differences in term of VAS, NDI, and SWS were found between groups (P > 0.05); SG reached higher satisfaction than HV group (P = 0.0271). Conclusions: Both treatments are equivalent in terms of clinical outcomes, and they are a valuable choice in the management of type II odontoid fracture. However, it must be considered that patients could slightly tolerate HV and may need a change of treatment.
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Affiliation(s)
- Massimo Girardo
- Department of Orthopaedic and Trauma Surgery, Orthopaedic and Trauma Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Alessandro Rava
- Department of Orthopaedic and Trauma Surgery, Orthopaedic and Trauma Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Giosuè Gargiulo
- Department of Orthopaedic and Trauma Surgery, Orthopaedic and Trauma Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Angela Coniglio
- Department of Orthopaedic and Trauma Surgery, Orthopaedic and Trauma Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Stefano Artiaco
- Department of Orthopaedic and Trauma Surgery, Orthopaedic and Trauma Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedic and Trauma Surgery, Orthopaedic and Trauma Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Federico Fusini
- Department of Orthopaedic and Trauma Surgery, Orthopaedic and Trauma Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, University of Turin, Turin, Italy
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Ishak B, Schneider T, Gimmy V, Unterberg AW, Kiening KL. Early Complications, Morbidity, and Mortality in Octogenarians and Nonagenarians Undergoing Posterior Intra-Operative Spinal Navigation-Based C1/2 Fusion for Type II Odontoid Process Fractures. J Neurotrauma 2017. [DOI: 10.1089/neu.2017.4968] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Till Schneider
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Valerie Gimmy
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Karl L. Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Park JB, Kang SS, Yeom JS. Traumatic C1-2 posterolateral dislocation with dens fracture, injury of the transverse atlantal ligament, and unilateral facet fracture with subluxation of C6-7: A case report. Medicine (Baltimore) 2017; 96:e8913. [PMID: 29310380 PMCID: PMC5728781 DOI: 10.1097/md.0000000000008913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Traumatic C1-2 dislocation associated with contiguous or noncontiguous cervical spine injury is rare. Moreover, there have been no reports describing traumatic C1-2 dislocation associated with multiple contiguous and noncontiguous cervical injuries. PATIENT CONCERNS The authors present a case of a 20-year-old male with painful limitation of motion of the neck. This complex cervical injury occurred due to hyperextension of the head in a rotated position. The patient complained of neck pain that radiated to the left shoulder and arm, but he did not exhibit any neurological abnormalities. DIAGNOSES The diagnosis of the patients was traumatic C1-2 posterolateral dislocation associated with type II dens fracture (Anderson and D'Alonzo classification), type II injury of the transverse atlantal ligament (Dickman classification), and unilateral facet fracture with subluxation of C6-7. INTERVENTIONS The C1-2 posterolateral dislocation with type II dens fracture was successfully reduced by skull traction. The patient underwent anterior discectomy, open reduction, and fusion with plate fixation of C6-7 followed by posterior segmental fixation and fusion of C1-2. OUTCOMES At his postoperative 1-year follow-up, solid fusion was noted with improvement of clinical symptoms. This is the first report of traumatic C1-2 posterolateral dislocation associated with multiple C2 injuries and noncontiguous subaxial cervical injury. LESSONS A high index of suspicion and careful evaluation of entire cervical spine should be considered as the key to the proper diagnosis and treatment of traumatic C1-2 dislocation associated with contiguous and noncontiguous cervical injuries.
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Affiliation(s)
- Jong-Beom Park
- Department of Orthopaedic Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu
| | - Sung Shik Kang
- Department of Orthopaedic Surgery and Spine Center, Seoul National University Bundang Hospital, Sungnam, Korea
| | - Jin S. Yeom
- Department of Orthopaedic Surgery and Spine Center, Seoul National University Bundang Hospital, Sungnam, Korea
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Zhu C, Wang L, Liu H, Song Y, Liu L, Li T, Gong Q. Treatment of type II odontoid fracture with a novel technique: Titanium cable-dragged reduction and cantilever-beam internal fixation. Medicine (Baltimore) 2017; 96:e8521. [PMID: 29095313 PMCID: PMC5682832 DOI: 10.1097/md.0000000000008521] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Halo-Vest Immobilization in Elderly Odontoid Fracture Patients: Evolution in Treatment Modality and In-Hospital Outcomes. Clin Spine Surg 2017; 30:E1206-E1210. [PMID: 27906741 DOI: 10.1097/bsd.0000000000000483] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the utilization and effectiveness of halo-vest (HV) immobilization for type II odontoid fractures from 2004 to 2014. SUMMARY OF BACKGROUND DATA Controversy persists regarding the optimal treatment method for odontoid fractures in the elderly. Management options include immobilization in a cervical orthosis, HV immobilization, and operative intervention. Over the past decade, high mortality and morbidity rates have been reported following HV immobilization in this patient population. MATERIALS AND METHODS In a retrospective study, patient demographics, presentation, Charlson comorbidity index, treatment method, and outcome data for patients over 65 who had suffered type II odontoid fractures from 2004 to 2014 were compared with a historical cohort from 1997 to 2004. RESULTS One hundred twenty-six patients met inclusion criteria. The mean age was 82.7±8.8 compared with 80.7±0.9 in the 1997-2004 cohort. The in-hospital mortality rate from 2004 to 2014 was 11.1% (14/126) compared with 31% in the historical cohort, and 10 (7.9%) patients were treated with HV compared with 49%. Mortality in the HV group was higher than the surgical group (P=0.01) but no different from the orthosis group (P=0.63).There were no differences in injury severity score, Charlson comorbidity index, or complications between treatment groups. CONCLUSIONS Over the past decade, HV use for elderly odontoid fractures has decreased at our institution. Mortality and morbidity of elderly patients treated with HV has also decreased. These findings are likely the result of improved patient selection and greater attention to respiratory care. This study demonstrates that HV immobilization of odontoid fractures in elderly patients can be as safe as cervical orthosis treatment in select patients.
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Wu AM, Jin HM, Lin ZK, Chi YL, Wang XY. Percutaneous anterior C1/2 transarticular screw fixation: salvage of failed percutaneous odontoid screw fixation for odontoid fracture. J Orthop Surg Res 2017; 12:141. [PMID: 28962628 PMCID: PMC5622415 DOI: 10.1186/s13018-017-0640-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/17/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The objective of this study is to investigate the outcomes and safety of using percutaneous anterior C1/2 transarticular screw fixation as a salvage technique for odontoid fracture if percutaneous odontoid screw fixation fails. METHODS Fifteen in 108 odontoid fracture patients (planned to be treated by percutaneous anterior odontoid screw fixation) were failed to introduce satisfactory odontoid screw trajectory. To salvage this problem, we chose the percutaneous anterior C1/2 transarticular screw fixation technique in treatment of these patients. The visual analogue score (VAS) of neck pain and Neck Disability Index (NDI) of all patients were scored at pre-operation, 3 months after operation, and final follow-up. Additional, technique-related complications were recorded and collected. RESULTS Percutaneous C1/2 transarticular screw fixation was performed successfully in all 15 patients whose odontoid screw fixation failed. No technique-related complications (such as nerve injury, spinal cord injury, and esophageal injury) occurred. The VAS of neck pain and NDI score improved significantly (P = 0.000) after operation, and no significant differences were found when compared to 93 non-salvage patients who successfully performed the percutaneous anterior odontoid screw fixation. No screw loose or breakage occurred, all of the odontoid fractures achieve radiographic fusion, bony fusion bridge could be observed at the C1/2 lateral articular facet on 9/15 patients. CONCLUSIONS We suggest that percutaneous anterior C1/2 transarticular screw fixation is a good alternative salvage technique if percutaneous odontoid screw fixation failed, and it is a minimally invasive, feasible, and safe technique.
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Affiliation(s)
- Ai-Min Wu
- Department of Spine Surgery, Zhejiang Spine Surgery Center, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109# XueYuan Western Road, Wenzhou, Zhejiang 325027 China
| | - Hai-Ming Jin
- Department of Spine Surgery, Zhejiang Spine Surgery Center, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109# XueYuan Western Road, Wenzhou, Zhejiang 325027 China
| | - Zhong-Ke Lin
- Department of Spine Surgery, Zhejiang Spine Surgery Center, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109# XueYuan Western Road, Wenzhou, Zhejiang 325027 China
| | - Yong-Long Chi
- Department of Spine Surgery, Zhejiang Spine Surgery Center, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109# XueYuan Western Road, Wenzhou, Zhejiang 325027 China
| | - Xiang-Yang Wang
- Department of Spine Surgery, Zhejiang Spine Surgery Center, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109# XueYuan Western Road, Wenzhou, Zhejiang 325027 China
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Radovanovic I, Urquhart JC, Rasoulinejad P, Gurr KR, Siddiqi F, Bailey CS. Patterns of C-2 fracture in the elderly: comparison of etiology, treatment, and mortality among specific fracture types. J Neurosurg Spine 2017; 27:494-500. [PMID: 28820364 DOI: 10.3171/2017.3.spine161176] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Previous studies have focused on Type II odontoid fractures and have failed to report on the effect of other C-2 fracture types on treatment and outcome. The purpose of this study was to compare patient characteristics, cause of injury, predisposing factors to fracture, treatments, and mortality rates among C-2 fracture types in a cohort of elderly patients 70 years of age and older. METHODS A retrospective cohort study design was used. Patients who sustained a C-2 fracture between 2002 and 2011 and who were admitted to the authors' Level 1 trauma center were identified using the Discharge Abstract Database and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code S12.1. Fractures were classified as odontoid Type I, II, or III; hangman's; C-2 complex (hangman's appearance on sagittal images, Type III odontoid on coronal cuts); and other (miscellaneous). Age, sex, predisposing factors to falls, cause of injury, treatment, presence of autofusion in the subaxial cervical spine, and mortality rates were compared between fracture patterns. RESULTS One hundred forty-one patients were included; their mean age was 82 years. Fractures included Type II odontoid (57%), complex (19%), Type III odontoid (11%), hangman's (8%), and other (5%). Falls from a standing height accounted for 47% of injuries, and 65% of patients had ≥ 3 risk factors for falls. Subaxial autofusion was more common in odontoid fractures (p = 0.002). Treatment was mainly nonoperative (p < 0.0001). The 1-year mortality rate was 27%. Four patients died of spinal cord injury. CONCLUSIONS Although not as common as Type II odontoid fractures, other C-2 fractures including hangman's, complex, and Type III odontoid fractures accounted for close to half of the injuries in the study cohort. There were few differences between the fracture types with respect to cause of injury, predisposing factors, or mortality rate. However, surgical treatment was more common for Type II odontoid fractures.
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Affiliation(s)
- Ingrid Radovanovic
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Jennifer C Urquhart
- Lawson Health Research Institute; and.,London Health Sciences Center, London, Ontario, Canada
| | - Parham Rasoulinejad
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Kevin R Gurr
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Fawaz Siddiqi
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
| | - Christopher S Bailey
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario.,London Health Sciences Center, London, Ontario, Canada
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40
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Scholz M, Kandziora F, Hildebrand F, Kobbe P. [Injuries of the upper cervical spine : Update on diagnostics and management]. Unfallchirurg 2017; 120:683-700. [PMID: 28776221 DOI: 10.1007/s00113-017-0380-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Injuries to the upper cervical spine represent a diagnostic and therapeutic challenge to the treating surgeon due to the complex anatomical relationships and biomechanical features. In this further education article the diagnostic principles, established classifications and therapeutic recommendations as well as injury-specific characteristics of bony and ligamentous injuries to the upper cervical spine (C0-C2) are presented.
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Affiliation(s)
- Matti Scholz
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Kandziora
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Philipp Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
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41
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Zhong D, Lee G, Liao Y, Wang Q. Is It Feasible to Treat Odontoid Fractures via Primary Posterior Reduction and Fixation without Fusion? World Neurosurg 2017. [PMID: 28647658 DOI: 10.1016/j.wneu.2017.06.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate results and feasibility of primary posterior reduction and fixation without fusion using C1-C2 screw-rod system for odontoid fractures. METHODS This study comprised a consecutive series of 46 patients with odontoid fractures. Posterior reduction and fixation without fusion using the C1-C2 screw-rod system was performed, and instrumentation was not removed. Radiologic outcomes were assessed on follow-up computed tomography or plain radiographs. Visual analog scale of neck pain, American Spinal Injury Association impairment scale, patient satisfaction, neck disability index, and range of motion of flexion extension and rotation of the cervical spine were recorded and analyzed. RESULTS Mean follow-up time was 4.1 years (range, 12 months to 8 years). Radiographic evaluation indicated solid fusion of odontoid fractures in all cases and no implant failures. No patient reported severe neck pain at follow-up. Neurologicl evaluation showed there was 1- to 2-grade improvement in patients with neurologic deficit. Of patients, 31 reported acceptable outcomes, and 15 reported good outcomes. Range of motion of rotation of the cervical spine and neck disability index score gradually improved significantly during 1 year of follow-up with no obvious change after that. Rate of neck disability index score improvement was 85%. CONCLUSIONS Posterior reduction and fixation without fusion can be successfully performed for healing of odontoid fractures with acceptable results and minimal morbidity.
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Affiliation(s)
- Dejun Zhong
- Department of Spine Surgery, the Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan Province, China
| | - Guangzhou Lee
- Department of Spine Surgery, the Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan Province, China
| | - Yehui Liao
- Department of Spine Surgery, the Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan Province, China
| | - Qing Wang
- Department of Spine Surgery, the Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan Province, China.
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Lopes A, Andrade A, Silva I, Paiva W, Brock R, Teixeira M. Brain Abscess After Halo Fixation for the Cervical Spine. World Neurosurg 2017; 104:1047.e7-1047.e11. [PMID: 28522382 DOI: 10.1016/j.wneu.2017.05.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Halo fixation is one of the possible treatments for cervical spine fractures. However, improper use of these devices may lead to many complications, such as pin loosening, halo dislocation, pin site infection, and intradural penetration. CASE DESCRIPTION We report the case of a 43-year-old man who first presented with a seizure and an altered level of consciousness 5 months after halo-vest placement for an odontoid fracture. Brain imaging showed a brain abscess, under the previous left parietal pin. The patient underwent abscess drainage and antibiotics were administered for 12 weeks. On hospital discharge, he presented with only mild impairments. CONCLUSIONS Misapplication of halo fixation devices may lead to serious complications, including intracranial pin penetration and brain abscesses. Proper use of the recommended technique may decrease the risk for complications related to the procedure.
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Affiliation(s)
| | | | - Igor Silva
- Hospital das Clínicas FMUSP, São Paulo, Brazil
| | | | - Roger Brock
- Hospital das Clínicas FMUSP, São Paulo, Brazil
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43
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Hoffman JR, Carpenter CR. Guarding Against Overtesting, Overdiagnosis, and Overtreatment of Older Adults: Thinking Beyond Imaging and Injuries to Weigh Harms and Benefits. J Am Geriatr Soc 2017; 65:903-905. [DOI: 10.1111/jgs.14737] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Jerome R. Hoffman
- Emergency Medicine; University of California Los Angeles; Los Angeles California
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44
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Robinson AL, Möller A, Robinson Y, Olerud C. C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8321680. [PMID: 28182084 PMCID: PMC5274671 DOI: 10.1155/2017/8321680] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/19/2016] [Indexed: 11/17/2022]
Abstract
The currently available data on the distribution of C2 fracture subtypes is sparse. This study was designed to identify the proportions of the second cervical vertebra (C2) fracture subtypes and to present age and gender specific incidences of subgroups. A dataset of all patients treated between 2002 and 2014 for C2 fractures was extracted from the regional hospital information system. C2 fractures were classified into odontoid fractures types 1, 2, and 3, Hangman's fractures types 1, 2, and 3, and atypical C2 fractures. 233 patients (female 51%, age 72 ± 19 years) were treated for a C2 fracture. Odontoid fractures were found in 183 patients, of which 2 were type 1, 127 type 2, and 54 type 3, while 26 of C2 fractures were Hangman's fractures and 24 were atypical C2 fractures. In the geriatric subgroup 89% of all C2 fractures were odontoid, of which 71% were type 2 and 29% type 3. There was an increasing incidence of odontoid fractures types 2 and 3 from 2002 to 2014. 40% of C2 fractures were treated surgically. This study presents reliable subset proportions of C2 fractures in a prospectively collected regional cohort. Knowledge of these proportions facilitates future epidemiological studies of C2 fractures.
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Affiliation(s)
- Anna-Lena Robinson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
- Stockholm Spine Center, Stockholm, Sweden
| | - Anders Möller
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden
| | - Yohan Robinson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Claes Olerud
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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45
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Torregrossa F, Grasso G. Conservative Management for Odontoid Cervical Fractures: Halo or Rigid Cervical Collar? World Neurosurg 2017; 97:723-724. [PMID: 27989979 DOI: 10.1016/j.wneu.2016.10.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/18/2016] [Indexed: 10/20/2022]
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Abstract
Odontoid fractures are the most common cervical fracture type among the elderly population. Several treatment options exist for these patients, ranging from immobilization with a semirigid orthosis to surgical arthrodesis. This report reviews the key points in the management of odontoid fractures in the aged patient, including diagnosis, the various forms of conservative therapies, and the options for surgical intervention.
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Affiliation(s)
- Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.
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47
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Oblique Axis Body Fracture: An Unstable Subtype of Anderson Type III Odontoid Fractures-Apropos of Two Cases. Case Rep Orthop 2016; 2016:7561682. [PMID: 27042372 PMCID: PMC4799810 DOI: 10.1155/2016/7561682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 02/14/2016] [Indexed: 01/29/2023] Open
Abstract
Purpose. Anderson type III odontoid fractures have traditionally been considered stable and treated conservatively. However, unstable cases with unfavorable results following conservative treatment have been reported. Methods. We present the cases of two patients who sustained minimally displaced Anderson type III fractures with a characteristic fracture pattern that we refer to as "oblique type axis body fracture." Results. The female patients aged 90 and 72 years, respectively, were both diagnosed with minimally displaced Anderson type III fractures. Both fractures had a characteristic "oblique type" fracture pattern. The first patient was treated conservatively with cervical spine immobilization in a semirigid collar. However, gross displacement was noted at the 6-week follow-up visit. The second patient was therefore treated operatively by C1-C3/4 posterior fusion and the course was uneventful. Conclusions. Oblique type axis body fractures resemble a highly unstable subtype of Anderson type III fractures with the potential of severe secondary deformity following conservative treatment, irrespective of initial grade of displacement. The authors therefore warrant a high index of suspicion for this injury and suggest early operative stabilization.
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48
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Pearson AM, Martin BI, Lindsey M, Mirza SK. C2 Vertebral Fractures in the Medicare Population: Incidence, Outcomes, and Costs. J Bone Joint Surg Am 2016; 98:449-56. [PMID: 26984912 DOI: 10.2106/jbjs.o.00468] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cervical 2 (C2) fractures in the elderly are common, and the incidence of these fractures has been increasing. Surgical and nonoperative treatments are associated with high complication and mortality rates, and these rates have not been evaluated at the population level, to our knowledge. The purpose of this study was to use the Medicare claims database to determine trends in treatment, surgical and nonoperative outcomes, and Medicare reimbursement for treatment of these fractures. METHODS We examined the Medicare claims database from 2000 to 2011 to identify patients admitted for the treatment of a C2 fracture. The incidence of fractures and the rates of nonoperative and surgical treatment were determined across the study period. We compared rates of mortality and life-threatening complications between patients treated nonoperatively and surgically. Centers for Medicare & Medicaid Services (CMS) payments for the initial admission as well as for subsequent inpatient admissions during the ninety-day post-admission period were compared between treatment groups. We used multivariate analysis to control for differences in patient characteristics between groups. RESULTS There were 81,596 admissions for C2 fracture identified, and 53,338 met inclusion criteria. The incidence of C2 fractures increased 135% from 2000 to 2011, but the rate of surgical treatment remained constant at 16%. There was significantly lower mortality at thirty days for the surgical group at 8.3% compared with the nonoperative group at 16.2% (p < 0.001) and at one year for the surgical group at 21.7% compared with the nonoperative group at 32.3% (p < 0.001). Life-threatening complications within thirty days of admission were slightly more common in the surgical group at 10.9% compared with the nonoperative group at 9.0% (p < 0.05). Medicare reimbursements for the initial inpatient admission were significantly higher (p < 0.001) in U.S. dollars for the surgical group at $21,487 compared with the nonoperative group at $8469, and this significant difference (p < 0.001) persisted in the ninety-day post-discharge period at $10,487 for the surgical group compared with $8410 for the nonoperative group. CONCLUSIONS Although the incidence of C2 fractures in the Medicare population increased from 2000 to 2011, the rate of surgery stayed relatively constant. After controlling for baseline differences, patients treated with surgery had significantly lower thirty-day and one-year mortality rates compared with patients treated nonoperatively. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Adam M Pearson
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Brook I Martin
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Matthew Lindsey
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Sohail K Mirza
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Momin E, Harsh V, Fridley J, Winnegan L, Omeis I. Reliability of treating asymptomatic traumatic type II dens fractures in patients over age 80: A retrospective series. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2015; 6:166-72. [PMID: 26692693 PMCID: PMC4660492 DOI: 10.4103/0974-8237.167859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Management of type II odontoid fractures in elderly remains controversial to whether surgical treatment is favored over conservative one. This is a study of geriatric patients with asymptomatic type II dens fractures who after sustaining a fall were initially evaluated at community hospitals. They were placed in a rigid collar and were followed up in a spine clinic. Purpose: To assess the reliability of treating very old patients with type II dens fracture conservatively and whether surgical intervention if needed would affect the clinical outcome. Study Design: Retrospective study with the literature review. Patient Sample: Consecutive patients above 80 years of age, who sustained a clinically asymptomatic type II dens fracture and were observed after a conservative treatment plan, was initiated. Outcome Measures: Outcome measures included self-reported worsening neck pain, neurological function, and radiographic measures over the follow-up period. Materials and Methods: A retrospective clinical analysis of 5 active geriatric patients with type II asymptomatic dens fracture. After evaluating them, treatment options were discussed with patients and their family members. The decision was to continue to follow them with a rigid collar very closely since they were reluctant to undergo any surgical procedure. Results: Patients were followed for an average of 29 months. They were observed for any worsening neck pain, neurological deficit, or deterioration of fracture on follow-up imaging studies. At last follow-up, 2 of 5 patients continued to be asymptomatic, the 3rd died of unrelated causes while 2 others required surgeries at least 1-year post injury. Conclusions: Treatment of type II dens fractures in the elderly is controversial. Independent elderly patients who are asymptomatic at presentation may be safe to be followed up very closely with a neck brace and serial X-ray. Converting to surgical treatment can be done safely when needed without affecting the overall clinical out.
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Affiliation(s)
- Eric Momin
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Viraat Harsh
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Jared Fridley
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Lona Winnegan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ibrahim Omeis
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
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50
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Yang Z, Yuan ZZ, Ma JX, Ma XL. Conservative versus surgical treatment for type II odontoid fractures in the elderly: Grading the evidence through a meta-analysis. Orthop Traumatol Surg Res 2015; 101:839-44. [PMID: 26494619 DOI: 10.1016/j.otsr.2015.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/26/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Odontoid fractures are common C-spine fractures in the elderly. However, the optimal treatment of odontoid fractures in the elderly is, still subject to controversy. HYPOTHESIS Surgical treatment has several advantages on conservative treatment, such as reduced mortality and lower incidence of non-union. This meta-analysis was performed to identify the efficacy of conservative treatment compared with surgical treatment and provides recommendations for using these procedures to treat type II odontoid fractures in the elderly. MATERIALS AND METHODS A systematic search of all studies published was conducted using the PubMed, EMBASE, OVID, ScienceDirect and Cochrane CENTRAL databases. The randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) that compared conservative treatment with surgical treatment and provided data on clinical effects were identified. The included trials were screened out strictly based on the criterion of inclusion and exclusion. The quality of included trials was evaluated. RevMan 5.1 was used for data analysis. RESULTS Twelve studies involving 730 patients met the inclusion criteria. There were 441 patients with conservative treatment and 289 with surgical treatment. The results of meta-analysis indicated that no difference with regard to the mortality was noted (P > 0.05) between the two procedures. However, there was statistically significant difference with respect to the non-union numbers (P < 0.05) between the two procedures. DISCUSSION Conservative treatment and surgical treatment are both effective procedures for treating type II odontoid fractures in the elderly. Compared with surgical treatment, there is no significant difference in mortality; With respect to non-union numbers, conservative treatment numbers are higher than surgical treatment. Due to the poor quality of the evidence currently available, high quality RCTs are required. Level of evidence Level II: low-powered prospective randomized trial meta-analysis.
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Affiliation(s)
- Z Yang
- Department of Orthopaedics, Tianjin Hospital, 406 Jiefang Nan Street, Hexi District, Tianjin 300211, China
| | - Z-Z Yuan
- Department of Orthopaedics, Tianjin Hospital, 406 Jiefang Nan Street, Hexi District, Tianjin 300211, China
| | - J-X Ma
- Department of Orthopaedics, Tianjin Hospital, 406 Jiefang Nan Street, Hexi District, Tianjin 300211, China
| | - X-L Ma
- Department of Orthopaedics, Tianjin Hospital, 406 Jiefang Nan Street, Hexi District, Tianjin 300211, China.
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