Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients

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.

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.

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.

Evidence and Controversies in Geriatric Odontoid Fracture Management

Geriatric odontoid fractures are some of the most common spine injuries in our aging population, and their prevalence is only continuing to increase. Despite several investigational studies, treatment remains controversial and there is limited conclusive evidence regarding the management of odontoid fractures. These injuries typically occur in medically complex and frail geriatric patients with poor bone quality, making their treatment particularly challenging. In this article, we review the evidence for conservative management as well as surgical intervention and discuss various treatment strategies. Given the high morbidity and mortality associated with odontoid fractures in the elderly, thoughtful consideration and an emphasis on patient-centered goals of treatment are critical to maximize function in this vulnerable population.

Posterior-only approach for treatment of irreducible traumatic Atlanto-axial dislocation, secondary to type-II odontoid fracture; report of a missed case, its management and review of literature

INTRODUCTION AND IMPORTANCE

Odontoid fracture (OF) is among the most common and challenging cervical spine fractures in regards to the treatment and surgical approach. Atlanto-axial dislocation (AAD) is considered a significant complication after failed non-surgical treatment of OF. Traditionally, it requires anterior odontoidectomy followed by posterior C1-C2 reduction and fusion. In latest studies, Atlanto-axial joint (AAJ) remodeling in a posterior-only approach has got attention.

CASE PRESENTATION

We herein present a 30-year-old man with missed type-II OF, presenting with irreducible anterior AAD and progressive neurological deficit. Old non-united OF with dorsal callous formation, compressing spinal cord, was detected. The patient underwent correction of the deformity and reduction of the fracture utilizing the posterior-only approach. AAJ remodeling, callous release and C1-C2 fusion was performed in standard prone position, under fluoroscopic guide and intraoperative electrophysiological monitoring. The patient had uneventful surgery and postoperative course and was neurologically intact with appropriate alignment in 6-month follow-up.

CLINICAL DISCUSSION

The irreducible AAD following type-II OF could be successfully treated with posterior-only approach (C1-C2 fusion).

CONCLUSION

Type-II OF is considered unstable requiring surgical management. Close follow-up and appropriate patient education is mandatory in non-surgical treatment. Irreducible AAD has been managed with anterior odontoid resection and posterior fusion. Several complications of anterior surgery, makes posterior-only approach a noticeable choice.

Analysis of radiological measurement parameters that can predict the type of treatment to be applied in odontoid fractures: Clinical research

Introduction

Although various conservative and surgical treatment methods have been proposed, treatment options for patients with odontoid fractures remain controversial. This study was conducted to determine some demographic and radiological measurement parameters that can predict treatment options in patients with odontoid fractures.

Materials and Methods

The patients were separated into the surgery (-) group (n = 9) and the surgery (+) group (n = 10). Patient data were recorded of age, gender, type of odontoid fracture, morphological measurement results obtained from computed tomography images, treatment regimens, duration of stay in the hospital, and mortality rate. In the operating room, a halo-vest corset or Philadelphia-type cervical collar was applied to the surgery (-) patients after the reduction of the fracture under fluoroscopy. Anterior odontoid lag screw fixation was performed on surgery (+) patients.

Results

The amount of displacement of the fractured odontoid, the distance between the C1 vertebra and the odontoid process, the angle between the posterior wall of the odontoid process and the posterior wall of the clivus, the slip angle, and the anterior to posterior width of the spinal canal were not different between the groups. No difference was determined between the groups in respect of the amount of lateral displacement of the odontoid process in the spinal canal in the axial plane and the angle of the fractured odontoid process with the C2 vertebral body.

Conclusion

This preliminary study showed that the demographic data and radiological measurement parameters analyzed in the present study could not be used as predictive markers either in decision-making for treatment modality or mortality risk.

A Predictive Model to Identify Treatment-related Risk Factors for Odontoid Fracture Nonunion Using Machine Learning

STUDY DESIGN

Multicenter retrospective analysis of routinely collected data.

OBJECTIVE

The underlying aim of this study was to identify potential treatment-related risk factors for odontoid fracture nonunion while accounting for known patient- and injury-related risk factors.

SUMMARY OF BACKGROUND DATA

Type II and III odontoid fractures represent the most common cervical spine fracture in elderly patients and are associated with a relatively high nonunion rate. The management of odontoid fractures is controversial and treatment strategies range from conservative treatment to extensive surgical stabilization and fusion.

METHODS

A total of 415 individuals who sustained odontoid fracture and were treated in either of four tertiary referral centers in Austria and Germany were included in the study. We included the following potential contributing factors for fracture nonunion in cross-validated extreme gradient boosted (XGBoost) and binary logistic regression models: age, gender, fracture displacement, mechanism of injury (high vs. low energy), fracture classification (Anderson II vs. III), presence of comorbidities (Charlson comorbidity index), and treatment (conservative, anterior screw fixation with one or two screws, posterior C1/C2 spondylodesis, cervico-occipital C0-C4 fusion).

RESULTS

In our cohort, 187 (45%) had radiologically confirmed odontoid nonunion six months postinjury. The odds for nonunion increase significantly with age, and are lower in type III compared to type II fractures. Also, odds for nonunion are significantly lower in posterior C1/C2 spondylodesis, and C0-C4 fusion compared to conservative treatment. Importantly, odds are not statistically significantly lower in the group treated with anterior screw fixation compared to conservative treatment. The factors gender, fracture displacement, mechanism of injury, and the presence of comorbidities did not produce significant odds.

CONCLUSION

Higher age, type II fractures, and conservative treatment are the main risk factors for odontoid nonunion. Anterior screw fixation did not differ significantly from conservative treatment in terms of fracture union.

LEVEL OF EVIDENCE

3.

Bicycle-related cervical spine injuries

Background

Bicyclists are vulnerable road users. The aim of this paper was to describe all bicycle-related traumatic cervical spine injuries (CSIs) in the South-East region of Norway (2015-2019), and to investigate whether certain types of CSIs are typical for bicyclists.

Methods

Retrospective cohort study of prospectively collected registry data of all CSIs in the South-East region of Norway (3.0 million inhabitants), from 2015 to 2019. Patient characteristics, injury types, and treatment were summarized with descriptive statistics. Bayesian multivariable logistic regression was used to identify potential factors associated with occipital condyle fractures (OC-Fx) or odontoid fractures (OFx).

Results

During the five-year study period, 2,162 patients with CSIs were registered, and 261 (12%) were bicycle-related. The incidence of bicycle-related CSIs was 1.7/100,000 person-years. The median age of the patients with bicycle-related CSIs was 55 (IQR: 22) years, 83% were male, 71% used a helmet, 16% were influenced by ethanol, 12% had a concomitant cervical spinal cord injury (SCI), and 64% sustained multiple traumas. The three most common bicycle-related CSIs were C6/C7 fracture (Fx) (28%), occipital condyle Fx (OC-Fx) (23%) and C5/C6 Fx (19%). Patients with bicycle-related CSIs compared to patients with non-bicycle related CSIs were younger, more often male, had fewer comorbidities, more likely multiple traumas, more often had OC-Fx, and less often sustained an odontoid fracture (OFx). Multivariable logistic regression of potential risk factors for OC-Fx demonstrated a significantly increased risk of OC-Fx for bicyclists compared to non-bicyclists (OR=2.8).The primary treatment for bicycle-related CSIs was external immobilization in 187/261 (71.6%) cases, open surgical fixation in 44/261 (16.8%), and no treatment in 30/261 (11.5%).

Conclusion

Bicycle crashes are a frequent cause of CSIs in the Norwegian population and should be of concern to the public society. The three most common bicycle-related CSIs were C6/C7 fracture, occipital condyle fracture and C5/C6 fracture.

Epidemiology of traumatic cervical spinal fractures in a general Norwegian population

BACKGROUND

In Western countries, the typical cervical spine fracture (CS-Fx) patient has historically been a young male injured in a road traffic accident. Recent reports and daily clinical practice clearly indicate a change in the typical patient from a young male to an elderly male or female with comorbidities. This study aimed to establish contemporary population-based epidemiological data of traumatic CS-Fx for use in health-care planning and injury prevention.

METHODS

This is a population-based retrospective database study (with prospectively collected data) from the Southeast Norway health region with 3.0 million inhabitants. We included all consecutive cases diagnosed with a CS-Fx between 2015 and 2019. Information regarding demographics, preinjury comorbidities, trauma mechanisms, injury description, treatment, and level of hospital admittance is presented.

RESULTS

We registered 2153 consecutive cases with CS-Fx during a 5-year period, with an overall crude incidence of CS-Fx of 14.9/100,000 person-years. Age-adjusted incidences using the standard population for Europe and the World was 15.6/100,000 person-years and 10.4/100,000 person-years, respectively. The median patient age was 62 years, 68% were males, 37% had a preinjury severe systemic disease, 16% were under the influence of ethanol, 53% had multiple trauma, and 12% had concomitant cervical spinal cord injury (incomplete in 85% and complete in 15%). The most common trauma mechanisms were falls (57%), followed by bicycle injuries (12%), and four-wheel motorized vehicle accidents (10%). The most common upper CS-Fx was C2 odontoid Fx, while the most common subaxial Fx was facet joint Fx involving cervical level C6/C7. Treatment was external immobilization with a stiff neck collar alone in 65%, open surgical fixation in 26% (giving a 3.7/100,000 person-years surgery rate), and no stabilization in 9%. The overall 90-day mortality was 153/2153 (7.1%).

CONCLUSIONS

This study provides an overview of the extent of the issue and patient complexity necessary for planning the health-care management and injury prevention of CS-Fx. The typical CS-Fx patient was an elderly male or female with significant comorbidities injured in a low-energy trauma. The overall crude incidences of CS-Fx and surgical fixation of CS-Fx in Southeast Norway were 14.9/100,000 person-years and 3.7/100,000 person-years, respectively.

Upper Cervical Trauma

Craniocervical injuries (CCJs) account for 10% to 30% of all cervical spine trauma. An increasing number of patients are surviving these injuries due to advancements in automobile technology, resuscitation techniques, and diagnostic modalities. The leading injury mechanisms are motor vehicle crashes, falls from height, and sports-related events. Current treatment with urgent rigid posterior fixation of the occiput to the cervical spine has resulted in a substantial reduction in management delays expedites treatment of CCJ injuries. Within CCJ injuries, there is a spectrum of instability, ranging from isolated nondisplaced occipital condyle fractures treated nonoperatively to highly unstable injuries with severely distracted craniocervical dissociation. Despite the evolution of understanding and improvement in the management of cases regarding catastrophic failure to diagnose, subsequent neurologic deterioration still occurs even in experienced trauma centers. The purpose of this article is to review the injuries that occur at the CCJ with the accompanying anatomy, presentation, imaging, classification, management, and outcomes.

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

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.

Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients

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.