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

Trends in management of odontoid fractures 2010-2021

Background Context

Odontoid fractures are relatively common. However, the literature is unclear how these fractures are best managed in many scenarios. As such, care is varied and poorly characterized.

Purpose

To investigate the trends and predictive factors of surgical versus nonsurgical treatment and anterior versus posterior stabilization of odontoid fractures.

Study Design/Setting

Retrospective database cohort study.

Patient Sample

Adult patients with odontoid fractures between 2010 and 2021.

Outcome Measures

Yearly trends and predictors of odontoid fracture management.

Methods

Adult patients with odontoid fractures were abstracted from the large, national, administrative M161Ortho Pearldiver dataset. For operative versus nonoperative care of odontoid fractures, yearly rates were determined (since 2016 based on coding limitations). For anterior versus posterior stabilization, yearly rates were determined (2010-2021). Univariate and multivariable analyses were performed for both sets of comparisons.

Results

For assessment of nonsurgical versus surgical management from 2016 to 2021, a total of 42,754 patients with odontoid fracture were identified, of which surgical intervention was done for 7.9%. Predictive factors of surgical intervention included being managed by a neurosurgeon (OR:1.29), being from Midwest United States (OR:1.35 relative to West), male sex (OR:1.20), and decreasing age (OR: 0.82 per decade) (p < .001 for each). Of those undergoing surgical intervention, 33.6% had anterior surgery while 66.4% had posterior surgery (anterior surgery decreased from 36.4% in 2010 to 27.2% in 2021, p < .001). Predictive factors of undergoing anterior versus posterior approach include having a neurosurgeon surgeon (OR:1.98), being from the Southern (OR:1.61 relative to Northeast), and having Medicare insurance (OR: 1.31) (p < .001 for each).

Conclusions

The overall rate of surgery for odontoid fractures has remained similar over the past years. Of those undergoing surgery, less are being done from anterior. While these decisions were predicted by some clinical factors, both also correlated with nonclinical factors suggesting room for more consistent algorithms.

Surgical versus conservative treatment for odontoid fractures in older people: an international prospective comparative study

BACKGROUND

The optimal treatment for odontoid fractures in older people remains debated. Odontoid fractures are increasingly relevant to clinical practice due to ageing of the population.

METHODS

An international prospective comparative study was conducted in fifteen European centres, involving patients aged ≥55 years with type II/III odontoid fractures. The surgeon and patient jointly decided on the applied treatment. Surgical and conservative treatments were compared. Primary outcomes were Neck Disability Index (NDI) improvement, fracture union and stability at 52 weeks. Secondary outcomes were Visual Analogue Scale neck pain, Likert patient-perceived recovery and EuroQol-5D-3L at 52 weeks. Subgroup analyses considered age, type II and displaced fractures. Multivariable regression analyses adjusted for age, gender and fracture characteristics.

RESULTS

The study included 276 patients, of which 144 (52%) were treated surgically and 132 (48%) conservatively (mean (SD) age 77.3 (9.1) vs. 76.6 (9.7), P = 0.56). NDI improvement was largely similar between surgical and conservative treatments (mean (SE) -11 (2.4) vs. -14 (1.8), P = 0.08), as were union (86% vs. 78%, aOR 2.3, 95% CI 0.97-5.7) and stability (99% vs. 98%, aOR NA). NDI improvement did not differ between patients with union and persistent non-union (mean (SE) -13 (2.0) vs. -12 (2.8), P = 0.78). There was no difference for any of the secondary outcomes or subgroups.

CONCLUSIONS

Clinical outcome and fracture healing at 52 weeks were similar between treatments. Clinical outcome and fracture union were not associated. Treatments should prioritize favourable clinical over radiological outcomes.

Clinical Outcomes Following Operative and Nonoperative Management of Odontoid Fractures Among Elderly Individuals with Dementia

BACKGROUND

The incidence of odontoid fractures among the elderly population has been increasing in recent years. Elderly individuals with dementia may be at increased risk for inferior outcomes following such fractures. Although surgical intervention has been maintained to optimize survival and recovery, it is unclear if this benefit extends to patients with dementia. We hypothesized that patients with dementia who were treated operatively for odontoid fractures would experience improved survival and lower rates of hospice admission but higher rates of delirium and of intensive interventions.

METHODS

We used Medicare claims data (2017 to 2018) to identify community-dwelling individuals with dementia who sustained type-II odontoid fractures. We considered treatment strategy (operative or nonoperative) as the primary predictor and survival as the primary outcome. The secondary outcomes consisted of post-treatment delirium, hospice admission, post-treatment intensive intervention, and post-discharge admission to a nursing home or a skilled nursing facility. In all models, we controlled for age, biological sex, race, Elixhauser Comorbidity Index, Frailty Index, admission source, treating hospital, and dual eligibility. Adjusted analyses for survival were conducted using Cox proportional hazards regression. Adjusted analyses for secondary outcomes were performed using generalized estimating equations. To address confounding by indication, we performed confirmatory analyses using inverse probability of treatment weighting.

RESULTS

In this study, we included 1,030 patients. The median age of the cohort was 86.5 years (interquartile range, 80.9 to 90.8 years), 60.7% of the patients were female, and 90% of the patients were White. A surgical procedure was performed in 19.8% of the cohort. Following an adjusted analysis, patients treated surgically had a 28% lower hazard of mortality (hazard ratio, 0.72 [95% confidence interval (CI), 0.53 to 0.98]), but higher odds of delirium (odds ratio, 1.64 [95% CI, 1.10 to 2.44]). These findings were preserved in the inverse probability weighted analysis.

CONCLUSIONS

We found that, among individuals with dementia who sustain a type-II odontoid fracture, surgical intervention may confer a survival benefit. A surgical procedure may be an appropriate treatment strategy for individuals with dementia whose life-care goals include life prolongation and maximizing quality of life in the short term following an injury.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Using Frailty Measures to Predict Functional Outcomes and Mortality After Type II Odontoid Fracture in Elderly Patients: A Retrospective Cohort Study

STUDY DESIGN

Single-center retrospective cohort study.

OBJECTIVES

Type II odontoid fractures occur disproportionately among elderly populations and cause significant morbidity and mortality. It is a matter of debate whether these injuries are best managed surgically or conservatively. Our goal was to identify how treatment modalities and patient characteristics correlated with functional outcome and mortality.

METHODS

We identified adult patients (>60 years) with traumatic type II odontoid fractures. We used multivariate regression controlling for patient demographics, Glasgow Coma Scale (GCS) score, Charlson Comorbidity Index (CCI), modified Rankin Scale (mRS) score, modified Frailty Index (mFI-5 and mFI-11), fracture displacement, and conservative vs operative treatment.

RESULTS

Of the 59 patients (mean age 77.9 years), 24 underwent surgical intervention and 35 underwent conservative management. Operatively managed patients were younger (73.4 vs 80.6 years, P < .001) and had higher degree of fracture displacement (3.5 vs 1.0 mm, P = .002) than conservatively managed patients but no other differences in baseline characteristics. Twenty-four patients (40.7%) died within the study period (median time to death: 376 days). There were no differences between treatment groups in functional outcomes (mRS or Frankel Grade) or mortality (33.3% in operative group vs 45.7%, P = .34). There was a statistically significant correlation between higher presentation mRS score and subsequent mortality on multivariate analysis (OR = 2.06, 95% CI 1.04-4.10, P = .039), whereas surgical intervention, age, GCS score, CCI, mFI-5, mFI-11, sex, and fracture displacement were not significantly correlated.

CONCLUSIONS

Mortality after type II odontoid fractures in elderly patients is common. mRS score at presentation may help predict mortality more accurately than other patient factors.

Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities

BACKGROUND CONTEXT

Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED).

PURPOSE

This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF).

STUDY DESIGN

This is a retrospective cohort study.

PATIENT SAMPLE

Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded.

OUTCOME MEASURES

The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs.

METHODS

Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs.

RESULTS

A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001).

CONCLUSIONS

This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.

Odontoid Fracture with Accompanying Severe Atlantoaxial Instability in Elderly Patients-Analysis of Treatment, Adverse Events, and Outcome

(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.

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.

A True Percutaneous Anterior Odontoid Screw Fixation: The Results of 42 Cases by a Single Surgeon

OBJECTIVE

This study aimed to analyze a clinical series of odontoid fractures treated with true percutaneous anterior odontoid screws. The technique we used is different from the traditional approach of using blunt dissection to arrive at the anterior surface of the vertebral body.

METHODS

Between 2004 and 2021, forty-two patients underwent anterior screw fixation of the odontoid process using the true percutaneous technique without dissection among the fascial planes. Instead, we pressed from the medial border of the sternocleidomastoideus muscle with our second and third fingers to feel the vertebrae under the skin. Thus, the carotid artery is pushed laterally, the trachea-esophageal complex is moved medially, and when no esophagus, great vessels, etc., can be felt under our fingers; we have reached the anterior surface of the spine. Advancing the Jamshidi needle between the fingers causes it to pass only through the fascial layers. The absence of a gap between the dilatation tubes prevents any tissue from escaping into the tubes.

RESULTS

We had no intraoperative complications, such as esophageal, tracheal, or carotid injury. One patient required screw revision. In total, 5 patients died during the follow-up period, and 3 were lost to follow-up. There was no residual neck pain in our cohort, and no instability was noted on flexion-extension radiographs, even in ten patients without solid bone fusion.

CONCLUSIONS

True percutaneous anterior odontoid screw fixation is a safe and reliable procedure for treating odontoid fractures. The fibrous union of odontoid fractures provides as much stability as a solid bone fusion.