Clinical features and early post-operative complications of isolated C2 odontoid fractures: a retrospective analysis using a national inpatient database in Japan

Immobilization protocols for the treatment of cervical spine fracture: a scoping review

BACKGROUND

Current protocols on cervical immobilization postcervical spine fracture are widely accepted in the acute rehabilitation of older adults, however consensus on its overall effectiveness remains lacking.

PURPOSE

Summarize information from original studies on available cervical immobilization protocols following a cervical fracture and to answer the questions; Which types of study designs have been used to assess the effectiveness of these protocols? What are the currently reported cervical immobilization protocols following cervical fracture in adults? What is the effectiveness of these protocols? What adverse events are associated with these protocols?

STUDY DESIGN

Scoping review was performed.

PATIENT SAMPLE

Searches were performed on the following online databases from inception to February 23, 2023: EMBASE, MEDLINE, CINAHL, and CENTRAL. Databases were searched for articles pertaining to collar use post cervical spine fracture.

OUTCOME MEASURES

Effectiveness of the cervical fracture immobilization protocols was the primary outcome, examined by various measures including union rates and disability indexes.

METHODS

4 databases were searched; EMBASE, MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) beginning on February 23, 2023, where 5,127 studies were yielded and 32 were extracted based on studies of adults (≥18 years) with a diagnosis of a cervical fracture (C0-C7) managed with a rigid external orthosis to prevent instability and surgery (collar, or cervicothoracic orthosis). Risk of bias was assessed using the guidelines set out by the Joanna Briggs Institute.

RESULTS

This scoping review yielded low-level prospective (18%) and retrospective (69%) cohort studies, case-control studies (3%), and case series (6%) from 1987 to 2022, patient age ranged from 14 to 104 years. Findings were difficult to summarize based on the lack of randomized controlled trials, leading to no clear conclusions drawn on the presence of standardized cervical immobilization protocols with no information on the duration of treatment or transition in care. Most included articles were retrospective cohort studies of poor to moderate quality, which have significant risk of bias for intervention questions. The effectiveness of these protocols remains unclear as most studies evaluated heterogeneous outcomes and did not present between-group differences. Mortality, musculoskeletal (MSK) complications, and delayed surgery were common adverse events associated with cervical collar use.

CONCLUSION

This scoping review highlights the need for higher levels of evidence as there is currently no standardized immobilization protocol for cervical spine fractures as a primary treatment, the effectiveness of cervical immobilization protocols is unclear, and mortality, MSK complications, and delayed surgery are common adverse events. No sources of funding were used for this scoping review.

Effects of early surgery for cervical fracture dislocation on 30-day mortality using the Japanese Diagnosis Procedure Combination database

STUDY DESIGN

Retrospective study of data abstracted from the Diagnosis Procedure Combination (DPC) database.

PURPOSE

This study aimed to investigate the effects of surgery in the early phase.

OVERVIEW OF LITERATURE

The optimal timing of surgery for cervical fracture dislocation (CFD) remains unclear because only a few clinical studies with approximately 100 patients have been published.

METHODS

This study included 4,653 adult patients with a definitive diagnosis of CFD from the DPC database. The database contains nationwide inpatient data collected from >1,000 acute care hospitals in Japan. The DPC database contains information regarding hospitalization, such as diagnosis, treatment, medical history, complications, and hospitalization outcomes. This study identified 460 pairs of patients after one-to-one propensity-score matching (PSM). Treatment outcomes were compared between patients who underwent surgery for CFD within 72 hours (early group) and later (delayed group) after admission. The main outcomes included 30-day mortality, inhospital death, and major complications. The secondary outcomes were improvement in the Barthel index, length of hospital stay, and discharged home rate.

RESULTS

After adjusting for PSM, the early group had a significantly higher 30-day mortality rates than the delayed group (3.0% vs. 0.4%, p=0.006). In the multivariate logistic regression analysis after PSM, the early group was associated with an increased risk of 30-day mortality (odds ratio, 8.05; 95% confidence interval, 2.15-5.26; p=0.007).

CONCLUSIONS

This study indicated that early surgery for CFD resulted in increased 30-day mortality.

The epidemiology of odontoid fractures: a study from the Swedish fracture register

PURPOSE

The objective of this study is to characterize the occurrence of odontoid fractures within a Swedish population.

METHODS

Prospective data of adults diagnosed with an odontoid fracture between 2015 and 2021 were retrieved from the Swedish Fracture Register (SFR). Epidemiologic data including age, sex, injury mechanism, injury type, fracture type (Anderson and D'Alonzo classification), neurological status and treatment type were requested from the SFR. Data pertinent to osteoporosis was retrieved from the Swedish National Patient Register.

RESULTS

A total of 1,154 odontoid fractures were identified, of which 30 were type I fractures, 583 type II fractures, and 541 type III fractures. The mean (Standard Deviation [SD]) age was 77.2 (13.8) years. The prevalence of osteoporosis and neurological deficits did not differ between the fracture types. The majority of patients were treated non-surgically (81%). Male sex and patient age 18-30 years were commonly associated with a high-injury mechanism, especially motor vehicle accidents. In the type II fracture group, significantly more patients had fallen from standing height or less than in the type III group (66% vs. 58%, p = 0.01) while in contrast, motor vehicle accidents were more common in the type III fracture group (12% vs. type II: 8%, p = 0.04).

CONCLUSION

Based on the SFR, the typical odontoid fracture patient is older and suffers a type II fracture. Most injuries were caused by low-energy trauma although in younger patients and males, they were associated with motor vehicle accidents. Across the patient population, odontoid fractures were usually treated non-surgically.

Perioperative complications and cost of posterior decompression with fusion in thoracic spine for ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum -a comparative study using a national inpatient database

BACKGROUND

Although posterior decompression with fusion (PDF) are effective for treating thoracic myelopathy, surgical treatment has a high risk of various complications. There is currently no information available on the perioperative complications in thoracic ossification of the longitudinal ligament (T-OPLL) and thoracic ossification of the ligamentum flavum (T-OLF). We evaluate the perioperative complication rate and cost between T-OPLL and T-OLF for patients underwent PDF.

METHODS

Patients undergoing PDF for T-OPLL and T-OLF from 2012 to 2018 were detected in Japanese nationwide inpatient database. One-to-one propensity score matching between T-OPLL and T-OLF was performed based on patient characteristics and preoperative comorbidities. We examined systemic and local complication rate, reoperation rate, length of hospital stays, costs, discharge destination, and mortality after matching.

RESULTS

In a total of 2,660 patients, 828 pairs of T-OPLL and T-OLF patients were included after matching. The incidence of systemic complications did not differ significantly between the T-OPLL and OLF groups. However, local complications were more frequently occurred in T-OPLL than in T-OLF groups (11.4% vs. 7.7% P = 0.012). Transfusion rates was also significantly higher in the T-OPLL group (14.1% vs. 9.4%, P = 0.003). T-OPLL group had longer hospital stay (42.2 days vs. 36.2 days, P = 0.004) and higher medical costs (USD 32,805 vs. USD 25,134, P < 0.001). In both T-OPLL and T-OLF, the occurrence of perioperative complications led to longer hospital stay and higher medical costs. While fewer patients in T-OPLL were discharged home (51.6% vs. 65.1%, P < 0.001), patients were transferred to other hospitals more frequently (47.5% vs. 33.5%, P = 0.001).

CONCLUSION

This research identified the perioperative complications of T-OPLL and T-OLF in PDF using a large national database, which revealed that the incidence of local complications was higher in the T-OPLL patients. Perioperative complications resulted in longer hospital stays and higher medical costs.

Effect of Intraoperative Tranexamic Acid on Perioperative Major Hemorrhage Requiring Transfusion in Patients Undergoing Elective Spine Surgery: A Propensity Score-Matched Analysis Using a National Inpatient Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to examine whether the use of intravenous TXA in elective spine surgery is associated with reduced perioperative massive hemorrhage requiring transfusion.

METHODS

We extracted all patients who underwent decompression with or without fusion surgery for the cervical, thoracic, and lumbar spine between April 2012 and March 2019. The primary outcome was the occurrence of massive hemorrhage requiring transfusion, defined as at least 560 mL of blood transfusion within 2 days of spine surgery or the requirement of additional blood transfusion from 3-7 days postoperatively. Secondary outcomes were the occurrence of thrombotic complications (pulmonary embolism, acute coronary syndrome, and stroke) and postoperative hematoma requiring additional surgery.

RESULTS

We identified 83,821 eligible patients, with 9747 (12%) patients in the TXA group. Overall, massive hemorrhage requiring transfusion occurred in 781 (.9%) patients. Propensity score matching yielded 8394 pairs. In the matched cohort, the TXA group had a lower proportion of massive hemorrhage requiring transfusion than the control group (.7% vs 1.1%; P = .002). There was no significant difference in the occurrence of thrombotic complications and postoperative hematoma requiring additional surgery between both groups. The multivariable regression analysis also showed that the use of TXA was associated with significantly lower proportions of massive hemorrhage requiring transfusion (odds ratio, .62; 95% confidence interval, .43-.90; P = .012).

CONCLUSIONS

In this analysis using real-world data, TXA use in elective spinal surgery was associated with reduced perioperative massive hemorrhage requiring transfusion without increasing thrombotic complications.

LEVEL OF EVIDENCE

Prognostic Level Ⅲ.

Estimated number of spine surgeries and related deaths in Japan from 2014 to 2020

BACKGROUND

The total number of spine surgeries per year and their related deaths in Japan has not been adequately estimated in the literature.

METHODS

We retrospectively reviewed the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) between April 2014 to March 2021, which covers 99.9 % of health insurance claim receipts by general practitioners. The annual number of surgeries was counted using K codes, a procedure classification unique to Japan, and classified into the following six categories; percutaneous vertebroplasty, endoscopic surgery, open discectomy, laminoplasty/laminectomy, instrumentation surgery, and others. The data distribution was also summarized by sex and age. Additionally, by reviewing DPC database-related papers for evaluation of the mortality rate after spine surgery in Japan, the number of spine surgery-related deaths was calculated.

RESULTS

The NDB showed that the number of spine surgeries analyzed in this study increased from 170,081 in 2014 to 193,903 in 2019, with a slight decrease in 2020. The ratio of instrumentation surgery increased from 33.0 % in 2014 to 37.9 % in 2020. The rate of patients aged 75 or older increased 31.6 % to 39.6 %. Combining these findings with DPC data showing a mortality rate of 0.1 % to 0.4 % revealed that the estimated number of deaths related to spine surgery in Japan ranged from 200 to 800 per year.

CONCLUSIONS

Approximately 200,000 spine surgeries and 200 to 800 spine surgery-related inpatient deaths were estimated to have occurred in Japan around 2020.

Risk factors for early mortality in elderly patients with unstable isolated C2 odontoid fracture treated with halo-vest or surgery

The aim of this study was to compare in-hospital mortality of three procedures -halo-vest immobilization, anterior spinal fixation (ASF), and posterior spinal fixation (PSF)- in the treatment of elderly patients with isolated C2 odontoid fracture. We extracted data for elderly patients who were admitted with C2 odontoid fracture and treated with at least one of the three procedures (halo-vest immobilization, ASF, or PSF) during hospitalization. We conducted a generalized propensity score-based matching weight analysis to compare in-hospital mortality among the three procedures. We further investigated independent risk factors for in-hospital death. The study involved 891 patients (halo-vest, n = 463; ASF, n = 74; and PSF, n = 354) with a mean age of 78 years. In-hospital death occurred in 45 (5.1%) patients. Treatment type was not significantly associated with in-hospital mortality. Male sex (odds ratio 2.98; 95% confidence interval 1.32-6.73; p = 0.009) and a Charlson comorbidity index of ≥ 3 (odds ratio 9.18; 95% confidence interval 3.25-25.92; p < 0.001) were independent risk factors for in-hospital mortality. In conclusion, treatment type was not significantly associated with in-hospital mortality in elderly patients with isolated C2 odontoid fracture. Halo-vest immobilization can help to avoid adverse events in patients with C2 odontoid fracture who are considered less suitable for surgical treatment.

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

STUDY DESIGN

Systematic review/expert consensus.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perioperative Complications of Anterior Decompression with Fusion in Degenerative Cervical Myelopathy-A Comparative Study between Ossification of Posterior Longitudinal Ligament and Cervical Spondylotic Myelopathy Using a Nationwide Inpatient Database

For ossification of the posterior longitudinal ligament (OPLL) and cervical spondylotic myelopathy (CSM), anterior decompression with fusion (ADF) can accurately achieve spinal decompression. However, the difference in perioperative complications in ADF between OPLL and CSM is poorly described. This study aimed to investigate the perioperative complication rates of patients with degenerative cervical myelopathy undergoing ADF, represented by OPLL and CSM, using a large national inpatient database. In the OPLL and CSM groups, postoperative complication (systemic and local) rates, reoperation rates, medical costs during hospitalization, and mortality after propensity score matching were compared. After matching, 1197 matched pairs were made. The incidence of total systemic complications was similar between both groups (OPLL, 12.4%; CSM, 12.2%). In the OPLL group, more perioperative local complications (cerebrospinal fluid leakage: CSFL, [OPLL, 2.7%; CSM, 0.3%] and surgical site infection: SSI [OPLL, 2.1%; CSM, 0.9%]) were detected, and the hospitalization cost was approximately $3200 higher than that in the CSM group. Moreover, medical costs were significantly higher in patients who experienced complications in both OPLL and CSM. The frequency of perioperative complications of OPLL and CSM in ADF was detailed using large real-world data. Compared to CSM, OPLL had more perioperative complications such as CSFL and SSI, and higher medical costs. Regardless of the disease, medical costs were significantly increased when perioperative complications occurred.