Variations in Treatment of C2 Fractures by Time, Age, and Geographic Region in the United States: An Analysis of 4818 Patients

[Conservative treatment of trauma-associated fractures of the cervical spine with orthoses-A review]

BACKGROUND

Traumatic injuries of the cervical spine are common and can significantly differ in the prognosis and treatment depending on the structure affected. We present the current evidence for conservative treatment of these fractures with orthoses in this review.

METHODOLOGY

The literature search followed the PRISMA protocol. The risk of bias was assessed using ROBINS‑I and evidence levels were determined according to AHCPR.

RESULTS

A total of 22 studies were identified. The level of evidence according to AHCPR is limited (IIb, III and IV) and every study had a serious risk of bias in at least one subdivision. Of the authors 11 presented conservative treatment concepts for C2 dens fractures, 7 studies focussed on vertebral arch fractures and 9 on vertebral body fractures. Radiological parameters (kyphosis angle, bone consolidation) and the neurological status were frequently reported as endpoints.

CONCLUSION

Stable C2 dens fractures without relevant clinical restrictions allow conservative treatment in a rigid cervical orthosis under radiological monitoring every 1-4 weeks. Type II fractures require special attention due to the risk of instability. Hangman's fractures can be safely treated in rigid cervical orthoses. The current state of knowledge does not allow any recommendation for conservative treatment of Hangman's fractures with orthoses. Stable vertebral body fractures without involvement of the spinal canal can also be treated conservatively with orthotic devices. Randomized controlled studies are required to develop a secure state of evidence and are currently not available.

Risk Factors Associated with 90-Day Readmissions Following Occipitocervical Fusion-A Nationwide Readmissions Database Study

BACKGROUND

Occipitocervical fusion (OCF) procedures are increasing due to an aging population and the prevalence of trauma, rheumatoid arthritis, and tumors. Reoperation rates and readmission risk factors for cervical fusions have been established, but in relation to OCF they have not been explored. This study investigates the patterns of readmissions and complications following OCF using a national database.

METHODS

The 2016 U.S. Nationwide Readmissions Database was used for sample collection. Adults (>18 years) who underwent OCF were identified using the 2016 ICD-10 coding system, and we examined the readmission rates (30-day and 90-day) and reoperation rates.

RESULTS

Between January and September 2016, a total of 477 patients underwent OCF; the 30-day and 90-day readmission rates were 10.4% and 22.4%, respectively. The 90-day reoperation rate related to the index surgery was 5.7%. Mean age (68.58 years) was significantly greater in the readmitted group versus nonreadmitted group (61.76 years) (P < 0.001). The readmitted group had a significantly higher Charlson Comorbidity Index and Elixhauser Comorbidity Index (5.00 and 2.41, respectively) than the nonreadmitted group (3.25 and 1.15, respectively; P < 0.001). Nonelective OCF showed a higher readmission rate (29.18%) versus elective OCF (12.23%) (P < 0.001). Medicare and Medicaid patients showed the highest rates of readmission (27.27% and 20.41%, respectively). Readmitted patients had higher total health care costs.

CONCLUSIONS

Nonelective OCF was found to have a readmission rate of almost 2½× that of elective OCF. Understanding risk factors associated with OCF will help with operative planning and patient optimization.

Variations in treatment of C1 fractures by time, age, and geographic region in the United States: An analysis of 985 patients

The purpose of this investigation was to evaluate the variations in the treatment of C1 fractures over time, by age group, and by geographic region using a nationwide database. The Nationwide Emergency Department Sample (NEDS) database was queried to identify patients ≥18 years who sustained C1 fracture from 2006-2012. Patients were filtered based on the intervention they received: collar, halo, or surgery. Regions of hospital used in analysis were defined as Northeast, Midwest, South, and West. Surgical intervention for C1 fracture increased from 27.1% of cases in 2006 to 55.4% of cases in 2012 (P<0.001). The rate of collar treatment increased with increasing age. In contrast, rate of halo use decreased with increasing age. A greater proportion of patients in the Northeast were treated by collar compared to all other regions (P<0.001). We can conclude that there is considerable variation in the treatment of C1 fractures with regards to age and geographic region. Surgical treatment of these fractures is increasing over time. Future considerations should be given to developing treatment guidelines to decrease variation and potentially create cost-savings.