Cervical spine injuries in the elderly: acute postoperative mortality

Predictors of early mortality following surgical or nonsurgical treatment of subaxial cervical spine fractures: a retrospective nationwide registry study

BACKGROUND

Traumatic subaxial cervical spine fractures are a significant public health concern due to their association with spinal cord injuries (SCI). Despite being mostly caused by low-energy trauma, these fractures significantly contribute to morbidity and mortality. Currently, research regarding early mortality based on the choice of treatment following these fractures is limited. Identifying predictors of early mortality may aid in postoperative patient monitoring and improve outcomes.

PURPOSE

This study aimed to identify predictors of 30-days, 90-days, and 1-year mortality in adults treated for subaxial fractures.

STUDY DESIGN

A retrospective review of the nationwide Swedish Fracture Register (SFR).

PATIENT SAMPLE

All adult patients in the SFR who underwent treatment for a subaxial cervical fracture (n = 1,963).

OUTCOME MEASURES

Analyzed variables included age, sex, injury mechanism, neurological function, fracture characteristics, and treatment type. The primary endpoints were 30-days, 90-days, and 1-year mortality.

METHODS

About 1,963 patients in the SFR, treated for subaxial cervical fractures between 2013 and 2021, were analyzed. Surgical procedures included anterior, posterior, or anteroposterior approaches. Nonsurgical treatment included collar treatment or medical examinations without intervention. Stepwise regression and Cox regression analysis were used to determine predictors. Model performance was tested using the area under the receiver operating characteristic curve (AUC).

RESULTS

620 patients underwent surgery and 1,343 received nonsurgical treatment. Surgical cases had primarily translation fractures, with 323 (52%) displaying no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 22/620 (3.5%), 35/620 (5.6%), and 53/620 (8.5%), respectively. Age and SCI were predictors of mortality. Nonsurgically treated patients mostly had compression fracture, with 1,214 (90%) experiencing no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 41/1,343 (3.1%), 71/1,343 (5.3%), and 118/1,343 (8.7%). Age, male sex, SCI and fractures occurring at the C3 or C6 levels were predictors of mortality. An intact neurological function was a positive predictor of survival among nonsurgically treated patients (AUC >0.78).

CONCLUSIONS

Age and SCI emerged as significant predictors of early mortality in both surgically and nonsurgically treated patients. An intact neurological function served as a protective factor against early mortality in nonsurgically treated patients. Fractures at C3 or C6 vertebrae may impact mortality.

A perioperative predictive model of early mortality in acute cervical spinal cord injury: A prospective cohort study

Background

Traumatic cervical spine injury is common among spinal cord injury which requires an intensive, multidisciplinary approach which can affect the immediate postoperative hospital survival rate. By identifying the risk factors leading to early mortality in cervical spine trauma patients, the prognosis of patients with TCSCI can be better predicted.

Objective

The study aims to analyze the variables influencing in-hospital mortality in cervical spine trauma patients treated at a Level I trauma Center.

Methods

Prospective study was conducted on subaxial cervical spine injuries from July 2019 to March 2022. Patients were divided into two groups: Group A, with in-hospital mortality, and Group B, who got discharged from hospital, and mortality predictors were reviewed and analyzed for as potential risk factors for in-hospital mortality.

Results

Out of 105 patients, 83.8 % were male with mean age of 40.43 ± 12.62 years. On univariate analysis, AIS (p-value: <0.01), ICU stay (p-value: <0.01), level of injury (p-value: <0.01), and MRI parameters like the extent of Parenchymal damage (p-value: <0.01), MSCC (p-value: <0.01), and MCC (p-value: <0.01) were potential risk factors for in-hospital mortality. On multivariate regression analysis AIS at presentation (p-value: 0.02) was the only significant independent parameter for in-hospital mortality.

Conclusions

AIS grading at presentation, duration of ICU stay, level of injury, rate of tracheostomy, and MRI parameters like the extent of parenchymal damage, MCC, and MSCC influence and predicts in-hospital mortality, whereas AIS is the only independent risk factor.

Risk Factors for Early Mortality in Older Patients with Traumatic Cervical Spine Injuries-A Multicenter Retrospective Study of 1512 Cases

For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries.

Predicting Mortality in Elderly Spine Trauma Patients

STUDY DESIGN

Retrospective analysis on prospectively collected data.

OBJECTIVE

The aim of this study was to construct a clinical prediction model for 90-day mortality in elderly patients with traumatic spine injuries.

SUMMARY OF BACKGROUND DATA

Spine trauma in the elderly population is increasing. Comparing elderly spine trauma patients to younger patients with similar injuries proves challenging due to the extensive comorbidities and frailty found in the elderly. There is a paucity of evidence to predict survival of elderly patients following traumatic spinal injuries.

METHODS

All patients 65+ with spine trauma presenting to a level I trauma center from 2010 to 2019 were reviewed from a prospectively maintained trauma registry. Retrospective chart review was performed to record injury, frailty scores, comorbidities, presence of spinal cord injury, imaging evidence of sarcopenia and osteopenia, mortality, and complications. We preselected 13 variables for our multivariable logistic regression model: hypotension on admission, gender, marital status, age, max Abbreviated Injury Scale, Modified Frailty Index, surgical treatment, hematocrit, white blood count, spinal cord injury, closed head injury, injury level and presence of high energy mechanism. The performance of the prediction model was evaluated using a concordance index and calibration plot. The model was internally validated via bootstrap approach.

RESULTS

Over the 9-year period, 1746 patients met inclusion criteria; 359 (20.6%) patients died within 90 days after presenting with spine trauma. The most important predictors for 90-day mortality were age, hypotension, closed head injury, max Abbreviated Injury Scale and hematocrit. There was an optimism-corrected C-index of 0.77. A calculator was created to predict a personalized mortality risk.

CONCLUSION

The incidence of spine trauma in elderly patients continues to increase. Previous publications described preexisting conditions that imply increased mortality, but ours is the first to develop a predictive calculator. Prospective research is planned to externally validate this model to better determine its predictive value and utility in the clinical setting.

A New Scale for Predicting the Risk of In-hospital Mortality in Patients With Traumatic Spinal Cord Injury

Purpose

To analyze the relative factors influencing in-hospital mortality in patients with traumatic spinal cord injury (TSCI), and develop a score scale for predicting the risk of in-hospital mortality.

Method

We reviewed the medical records from 59 spine centers in mainland China from 1 January 2018 to 31 December 2018. The inclusion criteria were (1) confirmed diagnosis of TSCI, (2) hospitalization within 7 days of injury, and (3) affecting neurological level from C1 to L1. The exclusion criteria were (1) readmission, and (2) incomplete data. Included patients were classified into the survival and non-survival groups according to their status at discharge. Univariate and multivariate logistic regressions were performed to identify the factors related to in-hospital mortality in patients with TSCI. A new scale was developed, and the mortality rate in each risk group was calculated.

Results

Of the 3,176 participants, 23 (0.7%) died in the hospital, and most of them died from respiratory diseases (17/23, 73.9%). After univariate and multivariate logistic regression analysis, cervical spinal cord injury [odds ratio (OR) = 0.264, 95% confidence interval (CI): 0.076–0.917, P = 0.036], abdominal visceral injury (OR = 3.778, 95% CI: 1.038–13.755, P = 0.044), the American Spinal Injury Association (ASIA) score on admission (A: reference; B:OR = 0.326, 95% CI: 0.093–1.146, P = 0.081; C:OR = 0.070, 95% CI: 0.016–0.308, P < 0.001; D:OR = 0.069, 95% CI: 0.019–0.246, P < 0.001), and surgery (OR = 0.341, 95% CI: 0.146–0.796, P = 0.013) were significantly associated with in-hospital mortality. Scores for each of the four factors were derived according to mortality rates. The sum of the scores from all four factors was included in the scoring system and represented the risk of in-hospital mortality. The in-hospital mortality risk of the low-risk (0–3 points), moderate-risk (4–5 points), and high-risk groups (6–8 points) was 0.3, 2.7, and 9.7%, respectively (P < 0.001).

Conclusions

Cervical spinal cord injury, abdominal visceral injury, ASIA score on admission, and surgery were significantly associated with in-hospital mortality in patients with TSCI and stable condition. The scale system may be beneficial for clinical decision-making and for communicating relevant information to patients and their families.

The effect of age and injury severity on clinical prediction rules for ambulation among individuals with spinal cord injury

BACKGROUND CONTEXT

While several models for predicting independent ambulation early after traumatic spinal cord injury (SCI) based upon age and specific motor and sensory level findings have been published and validated, their accuracy, especially in individual American Spinal Injury Association [ASIA] Impairment Scale (AIS) classifications, has been questioned. Further, although age is widely used in prediction rules, its role and possible modifications have not been adequately evaluated until now.

PURPOSE

To evaluate the predictive accuracy of existing clinical prediction rules for independent ambulation among individuals at spinal cord injury model systems (SCIMS) Centers as well as the effect of modifying the age parameter from a cutoff of 65 years to 50 years.

STUDY DESIGN

Retrospective analysis of a longitudinal database.

PATIENT SAMPLE

Adult individuals with traumatic SCI.

OUTCOME MEASURES

The FIM locomotor score was used to assess independent walking ability at the 1-year follow-up.

METHODS

In all, 639 patients were enrolled in the SCIMS database between 2011 and 2015, with complete neurological examination data within 15 days following the injury and a follow-up assessment with functional independence measure (FIM) at 1-year post injury. Two previously validated logistic regression models were evaluated for their ability to predict independent walking at 1-year post injury with participants in the SCIMS database. Area under the receiver operating curve (AUC) was calculated for the individual AIS categories and for different age groups. Prediction accuracy was also calculated for a new modified LR model (with cut-off age of 50).

RESULTS

Overall AUC for each of the previous prediction models was found to be consistent with previous reports (0.919 and 0.904). AUCs for grouped AIS levels (A+D, B+C) were consistent with prior reports, moreover, prediction for individual AIS grades continued to reveal lower values. AUCs by different age categories showed a decline in prognostication accuracy with an increase in age, with statistically significant improvement of AUC when age-cut off was reduced to 50.

CONCLUSIONS

We confirmed previous results that former prediction models achieve strong prognostic accuracy by combining AIS subgroups, yet prognostication of the separate AIS groups is less accurate. Further, prognostication of persons with AIS B+C, for whom a clinical prediction model has arguably greater clinical utility, is less accurate than those with AIS A+D. Our findings emphasize that age is an important factor in prognosticating ambulation following SCI. Prediction accuracy declines for older individuals compared with younger ones. To improve prediction of independent ambulation, the age of 50 years may be a better cutoff instead of age of 65.

Blunt Versus Penetrating Neck Trauma: A Retrospective Cohort Study

OBJECTIVES/HYPOTHESIS

Despite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital-level characteristics that impact these outcomes.

STUDY DESIGN

Retrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database.

METHODS

Adult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in-hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level.

RESULTS

In a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals [0.564, 0.788]), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals [0.880, 0.954]).

CONCLUSIONS

Blunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 131:E1109-E1116, 2021.

In-Hospital Mortality for the Elderly with Acute Traumatic Spinal Cord Injury

As the incidence of traumatic spinal cord injury (tSCI) in the elderly rises, clinicians are increasingly faced with difficult discussions regarding aggressiveness of management, likelihood of recovery, and survival. Our objective was to outline risk factors associated with in-hospital mortality in elderly surgical and non-surgical patients following tSCI and to determine those unlikely to have a favorable outcome. Data from elderly patients (≥ 65 years of age) in the Canadian Rick Hansen SCI Registry from 2004 to 2017 were analyzed using descriptive analysis. Survival and mortality groups in each of the surgical and non-surgical group were compared to explore factors associated with in-hospital mortality and their impact, using logistical regression. Of 1340 elderly patients, 1018 had surgical data with 826 having had surgery. In the surgical group, the median time to death post-injury was 30 days with 75% dying within 50 days compared with 7 days and 20 days, respectively, in the non-surgical group. Significant predictors for in-hospital mortality following surgery are age, comorbidities, neurological injury severity (American Spinal Injury Association [ASIA] Impairment Scale [AIS]), and ventilation status. The odds of dying 50 days post-surgery are six times higher for patients ≥77 years of age versus those 65–76 years of age, five times higher for those with AIS A versus those with AIS B/C/D, and seven times higher for those who are ventilator dependent. An expected probability of dying within 50 days post-surgery was determined using these results. In-hospital mortality in the elderly after tSCI is high. The trend with age and time to death and the significant predictors of mortality identified in this study can be used to inform clinical decision making and discussions with patients and their families.

Subaxial Cervical Spine Injury in the Elderly and Treatment-Related Mortality - Anterior or Posterior Approach

BACKGROUND

Subaxial cervical spine injury especially in the elderly can be associated to severe complications and disability. Until today there is no consensus concerning the best operative treatment. A potential superiority of anterior or posterior fixation is the subject of controversial discussions.

OBJECTIVES

The aim of this study was to compare the outcome of anterior and posterior fixation after subaxial cervical spine trauma in the elderly focussing on the postoperative mortality.

MATERIAL AND METHODS

A retrospective cohort analysis was performed to analyse the data of 43 patients. Especially mortality data were collected.

RESULTS

A total of 43 patients was identified. Anterior fixation was performed in 21 patients, posterior fixation was performed in 22 patients. There were no significant differences between these groups. Although statistical significance was not reached, a slightly higher mortality was found among patients undergoing anterior fixation (52,4 vs. 31,8%). Furthermore the male sex, a higher age, translation injuries, long duration of operation and hospitalisation as well as postoperative complications were slightly associated to a higher mortality.

CONCLUSIONS

Subaxial cervical spine trauma is associated to a high mortality in the elderly. Although neither anterior nor posterior fixation could show a significant superiority, every surgical decision making should be performed individually for each patient balancing the advantages and disadvantages of each method.

Is Spinal Surgery Safe for Elderly Patients Aged 80 and Above? Predictors of Mortality and Morbidity in an Asian Population

OBJECTIVE

We aimed to determine the 2-year mortality and morbidity rates following spine surgery in elderly patients (age ≥80 years) and to study the associated risk factors.

METHODS

The records of patients ≥80 years of age who underwent spine surgery during the years 2003-2015 at Tan Tock Seng Hospital, Singapore were retrospectively reviewed. Information was collected on their demographic characteristics, comorbidities, diagnosis, general and neurological status, type of surgery, and outcomes. The mortality and morbidity rates over a 2-year period were analyzed. Bivariate analyses were carried out to identify factors associated with mortality.

RESULTS

We selected 47 patients (mean age, 83.3 years; range, 80-91 years) who were followed up for a mean duration of 27.7 months. The mortality rates at 30 days, 6 months, 1 year, and 2 years following surgery were 2.1%, 8.5%, 10.6%, and 12.8%, respectively. The factors significantly associated with mortality included multiple comorbidities, nondegenerative aetiology, and vertebral fractures. The overall morbidity rate was 48.9%, and 17% of this cohort had major complications.

CONCLUSION

Surgeons should strategize management protocols with due consideration of the mortality and morbidity rates, and be wary of operating on patients with multiple comorbidities, nondegenerative conditions, and vertebral fractures.

Traumatic spinal cord injuries in geriatric population: etiology, management, and complications

Background

The relationship of traumatic spinal cord injury (SCI) and the geriatric population is not emphasized in current literature. Our objective was to evaluate mechanisms of injury, outcomes, and complications of geriatric patients with traumatic SCI.

Methods

Patients with traumatic spinal cord injuries admitted to the inpatient rehabilitation unit of a level I trauma center from 2003 to 2013 were reviewed. Inclusion criteria were ages ≥65 years old and availability of complete medical records. Patient demographics, mechanism of injury, diagnoses, American Spinal Injury Association (ASIA) grade, management (surgical, nonsurgical), complications, and mortality were evaluated.

Results

Seven hundred and fifty-seven SCI patients were identified and 53 met our inclusion criteria, with 35 (66.0%) males and 18 (34.0%) females. The average age was 74-years (range, 65 to 91 years). A proportion of 24.5% were 65-69 years of age, 30.2% were 70-74, 22.6% were 75-79, and 22.6% were 80 or older. Thirty-four (64.2%) underwent surgery. The two most common diagnoses of SCI were fractures (43.4%) and central cord syndrome (28.3%). ASIA grading was: A 5 (9.4%); B 3 (5.7%); C 5 (9.4%); D 40 (75.5%). The most severe SCI (ASIA score A and B) primarily occurred in the younger geriatric populations (ages 65-74), as did the highest rates of major complications or major and minor complications (15.4% and 46.2%, respectively, in the 65-69 group). Surgical management increased with age from 46.2% in the 65-69 group to 83.3% in the 75-79 group but subsequently decreased in the ≥80 group (66.7%).

Conclusions

Fractures and central cord syndrome were the most common diagnoses and typically due to falls. The complication rate in this population is high and due to complex causes. SCI in patients aged 65-69 was associated with increased rate of ASIA score A and increased rate of major complications.

Cervical spine immobilisation in the elderly: a literature review

Developed populations are ageing rapidly and by 2040, approximately 1 in 4 adults will be over 65 years of age. This is resulting in higher incidence of traumatic injury in older patients. Cognitive and physical comorbidities in this group can pose significant challenges. Due to mechanisms of injury and pre-existing degenerative spinal disease, cervical spine fractures are particularly prevalent in elderly patients. These are associated with significant morbidity and mortality. In this literature review we examine current evidence surrounding the use of cervical spine immobilisation in elderly patients in the pre-hospital and emergency department setting and also as a treatment option for cervical spine fractures. We explore evidence surrounding the complications that can arise from cervical spine immobilisation, including the development of pressure sores, raised intracranial pressure, dysphagia, breathing difficulties, delirium, compliance issues, mobility and functional outcome.

Mini-open anterior approach for cervicothoracic junction fracture: technical note

Elderly patients with diffuse idiopathic skeletal hyperostosis are at high risk for falls, and 3-column unstable fractures present multiple challenges. Unstable fractures across the cervicothoracic junction are associated with significant morbidity and require fixation, which is commonly performed through a posterior open or percutaneous approach. The authors describe a novel, navigated, mini-open anterior approach using intraoperative cone-beam CT scanning to place lag screws followed by an anterior plate in a 97-year-old patient. This approach is less invasive and faster than an open posterior approach and can be considered as an option for management of cervicothoracic junction fractures in elderly patients with high perioperative risk profile who cannot tolerate being placed prone during surgery.

Impact of associated injuries in conjunction with fracture of the axis vertebra on inpatient outcomes and postoperative complications: a Nationwide Inpatient Sample analysis from 2002 to 2011

BACKGROUND CONTEXT

There are limited data available on the impact of associated spinal (other spinal injuries [OSIs]) and extra-spinal injuries (ESIs) occurring in conjunction with fractures of the axis vertebra (C2) on clinical outcomes.

PURPOSE

This study aimed to compare outcomes in patients with isolated C2 fractures versus patients with associated injuries in conjunction with C2 fractures.

STUDY DESIGN/SETTING

A retrospective cohort study.

PATIENT SAMPLE

A total of 30,472 adult patients with C2 fractures (International Classification of Diseases, Ninth Revision, Clinical Modification code 805.02) registered in the Nationwide Inpatient Sample (NIS) database (2002-2011) comprised the patient sample.

OUTCOME MEASURES

Inpatient mortality, unfavorable discharge, prolonged length of stay (LOS) and high-end hospital charges in the non-operative and operative cohorts, and postoperative complications (deep venous thrombosis [DVT]; acute renal failure [ARF]; respiratory complications and wound infections) for the operative cohort were the outcome measures.

METHODS

Patients were stratified into four categories based on injury type: (1) isolated C2 fracture (n=10,135; 33.3%); (2) C2 fracture+OSI (8.7%); (3) C2 fracture+ESI (37.2%); and (4) C2 fracture+OSI+ESI (20.8%). Multivariable logistic regression fitted with generalized estimating equations using the sandwich variance-covariance matrix estimator to account for clustering of similar outcomes within hospitals was used to examine the association of primary endpoints for each of the associated injury categories with reference to isolated C2 fractures.

RESULTS

Mean age of the cohort was 66.27±21.67 years and 52% were female. Of the cohort, 52% underwent surgical intervention for C2 fracture. In a pooled regression analysis involving the operative cohort, the risks for inpatient mortality (odds ratio [OR]: 3.77; 95% confidence interval [CI]: 3.02-4.70; p<.001), unfavorable discharge (OR: 1.83; 95% CI: 1.66-2.01; p<.001), prolonged LOS (OR: 1.33; 95% CI: 1.18-1.50; p<.001), high hospital charges (OR: 1.49; 95% CI: 1.31-2.69; p<.001), DVT (OR: 2.08; 95% CI: 1.61-2.68; p<.001), and ARF (OR: 1.46; 95% CI: 1.16-1.83; p=.001) were significantly higher in patients with additional injuries when compared with patients with C2 fractures alone. Likewise, increased chances of inpatient mortality (OR: 1.40; 95% CI: 1.21-1.62; p<.001), unfavorable discharge (OR: 1.24; 95% CI: 1.15-1.34; p<.001) and high hospital charges (OR: 1.31; 95% CI: 1.21-1.43; p<.001) were observed in a pooled analysis of patients with concomitant associated injuries in the non-operative cohort.

CONCLUSIONS

Associated injuries occurring concomitantly with C2 fractures adversely influence postoperative outcomes. In comparison to isolated C2 fractures, patients with associated injuries tend to have a greater propensity for higher health-care resource use because of more complicated and longer hospital inpatient stay.

Management of upper cervical spine fractures in elderly patients: current trends and outcomes

Upper cervical spine fractures in the elderly represent serious injuries. Their frequency is on the rise. Their early accurate diagnosis might be compromised by the existence of extensive degenerative changes and deformities. Adequate stabilisation allowing fracture healing is of paramount importance. However, the debate is ongoing as to the best protocol that can be applied taking into consideration the presence of comorbidities and the increase risk of mortality in this frail patient population. A literature review, based on PubMed, related to protocols reporting on fracture fixation of the upper cervical spine, fractures (C1-C2) was carried out. Papers including information about type of fracture, treatment carried out, complication rates, mortality and morbidities were eligible to be included in this study. Fourteen papers met the inclusion criteria. Six reported on all types of injuries of the upper cervical spine, and eight only odontoid fractures (C2). Overall mortality rate ranged between 0 to 31.4%. Overall morbidity rate was from 10.3 to 90.9%. No significant difference was identified between three types of treatment (rigid collar cuff without fracture reduction, halo cast with reduction of fracture displacement, and surgical treatment). Halo-cast got the highest rate of complications. Surgical treatment got a mortality rate from 0 to 40.0%, and a morbidity rate from 10.3 to 62.5%. Non-union rate ranged between 8.9 to 62.5%. Elderly patients with upper cervical spine fractures must be notified that these injuries are associated with high incidence of non-union, morbidity and mortality.

Reliability of the STIR sequence for acute type II odontoid fractures

BACKGROUND AND PURPOSE

The STIR sequence is routinely used to assess acute traumatic osseous injury. Because the composition of the odontoid in older individuals may be altered with osteopenia and decreased vascularity, the STIR sequence may not accurately depict the acuity of an odontoid fracture. The purpose of this study was to evaluate the reliability of the STIR sequence to differentiate acute-versus-chronic type II odontoid fractures in older patients, particularly those with osteopenia.

MATERIALS AND METHODS

A retrospective review was performed for patients with type II odontoid fractures during a 10-year period with both CT and MR imaging performed within 24 hours of injury. Patients were paired with controls of similar ages and were grouped by age. The STIR images were evaluated in a blinded fashion for the presence of hyperintensity in the odontoid. Demographic and clinical characteristics were also recorded.

RESULTS

Seventy-five patients with type II odontoid fracture and 75 healthy controls (mean and median age of 57 years) were identified. The sensitivity of STIR to detect fracture in the age group 57 years and older was significantly worse than that in the age group younger than 57 years (54% and 82%, respectively; P = .018).

CONCLUSIONS

Older patients, particularly those with osteopenia, may have acute odontoid injuries without corresponding STIR hyperintensity. Additionally, interobserver agreement in STIR interpretation decreases with increasing patient age. As such, in this patient population, in which the presence of bone marrow edema as an indicator of fracture acuity may impact therapeutic decisions, correlation with CT findings and clinical history is crucial.

Cement-augmented anterior screw fixation of Type II odontoid fractures in elderly patients with osteoporosis

BACKGROUND CONTEXT

Closed reduction and internal fixation by an anterior approach is an established option for operative treatment of displaced Type II odontoid fractures. In elderly patients, however, inadequate screw purchase in osteoporotic bone can result in severe procedure-related complications.

PURPOSE

To improve the stability of odontoid fracture screw fixation in the elderly using a new technique that includes injection of polymethylmethacrylat (PMMA) cement into the C2 body.

STUDY DESIGN

Retrospective review of hospital and outpatient records as well as radiographs of elderly patients treated in a university hospital department of orthopedic surgery.

PATIENT SAMPLE

Twenty-four elderly patients (8 males and 16 females; mean age, 81 years; range, 62-98 years) with Type II fractures of the dens.

OUTCOME MEASURES

Complications, cement leakage (symptomatic/asymptomatic), operation time, loss of reduction, pseudarthrosis and revision surgery, patient complaints, return to normal activities, and signs of neurologic complications were all documented.

METHODS

After closed reduction and anterior approach to the inferior border of C2, a guide wire is advanced to the tip of the odontoid under biplanar fluoroscopic control. Before the insertion of one cannulated, self-drilling, short thread screws, a 12 gauge Yamshidi cannula is inserted from anterior and 1 to 3 mL of high-viscosity PMMA cement is injected into the anteroinferior portion of the C2 body. During polymerization of the cement, the screws are further inserted using a lag-screw compression technique. The cervical spine then is immobilized with a soft collar for 8 weeks postoperatively.

RESULTS

Anatomical reduction of the dens was achieved in all 24 patients. Mean operative time was 64 minutes (40-90 minutes). Early loss of reduction occurred in three patients, but revision surgery was indicated in only one patient 2 days after primary surgery. One patient died within the first eight postoperative weeks, one within 3 months after surgery. In five patients, asymptomatic cement leakage was observed (into the C1-C2 joint in three patients, into the fracture in two). Conventional radiologic follow-up at 2 and 6 months confirmed anatomical healing in 16 of the 19 patients with complete follow-up. In two patients, the fractures healed in slight dorsal angulation; one patient developed a asymptomatic pseudarthrosis. All patients were able to resume their pretrauma level of activity.

CONCLUSIONS

Cement augmentation of the screw in Type II odontoid fractures in elderly patients is technically feasible in a clinical setting with a low complication rate. This technique may improve screw purchase, especially in the osteoporotic C2 body.

Concepts of aging with paralysis: implications for recovery and treatment

This chapter deals with the impact of age on the occurrence, clinical presentation, outcome, and course of a spinal cord injury (SCI). This is of importance in a society where the population of elderly people continuously increases. The chapter is focused first, on the actual problems of a SCI in elderly subjects and second, on age-specific sequelae after a SCI. The etiology and clinical presentation of a SCI differs in elderly subjects compared to young subjects. With advanced age, incomplete cervical lesions following falls or due to spondylotic degeneration of the cervical spine and non-traumatic SCI occur more frequently. Research pertaining to the comparison of different age groups is prone to bias due to survival and treatment cohort effects. There is an increased risk of complications and mortality after a complete SCI in elderly people. Surprisingly, the recovery of the neurological deficit does not depend on age. However, elderly subjects with SCI have more problems in transferring an improvement in motor score into a functional improvement in their ability to carry out the activities of daily living. With increasing age after a SCI the completeness and level of injury determine the occurrence of complications and outcome restrictions. In addition, problems in general health (e.g., in circulation, kidney function, diabetes mellitus) may affect the functional independence of elderly subjects with SCI.

Predictors for mortality in elderly patients with cervical spine injury: a systematic methodological review

STUDY DESIGN

Systematic methodological review.

OBJECTIVE

Identify predictors for cervical spine injury (CSI) mortality in elderly patients by reviewing the available literature.

SUMMARY OF BACKGROUND DATA

The proportion of active elderly individuals in society is increasing. This population is at high risk for CSI mortality. The results of studies identifying predictors for CSI mortality in the elderly population are often inconclusive or even conflicting. Currently, there is no set of predictors that can adequately identify and describe CSI mortality risk for the elderly. Thus, we performed a systematic review to identify the predictors for mortality in elderly patients with CSI.

METHODS

We performed searches in the MEDLINE, EMBASE, ScienceDirect, and OVID databases (articles published prior to May 2012) for noninterventional studies that evaluated predictors for CSI mortality in the elderly. Only those observational studies with eligible data were included. Study quality was assessed using a modified quality assessment tool that was designed previously for an observational study. Study outcomes were combined with study quality scores using a best-evidence synthesis model.

RESULTS

Twenty-three observational studies involving 2325 patients were included. These studies were published between 1993 and 2011. According to the quality assessment criteria, 8 studies were of high quality, 11 studies were of moderate quality, and 4 studies were of low quality. We identified 3 strong evidence predictors for CSI mortality, including pre-existing comorbidities, spinal cord injury, and age. We also identified 3 moderate evidence predictors, 7 limited evidence predictors and 1 conflicting evidence predictor.

CONCLUSION

Although there is no conclusive evidence regarding the mortality of elderly patients with CSI, these data provide information that can help us to make recommendations and to counsel patients and their families. Special attention should be paid to the 3 strong predictors. Further studies will be required to validate these predictors.

Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland

Although currently there are many different recommendations and strategies in the therapy of odontoid fractures in the elderly, there are still no generally accepted guidelines for a structured and standardised treatment. Moreover, the current opinion of spine surgeons regarding the optimal treatment of odontoid fractures Type II of the elderly is unknown. In order to have an objective insight into the diverging strategies for the management of Anderson Type II odontoid fractures and form a basis for future comparisons, this study investigated the current concepts and preferences of orthopaedic, neuro- and trauma surgeons. Spine surgeons from 34 medical schools and 8 hospitals in Germany, 4 university hospitals in Austria and 5 in Switzerland were invited to participate in an online survey using a 12-item 1-sided questionnaire. A total of 44 interviewees from 34 medical institutions participated in the survey, consisting of trauma (50%), orthopaedic (20.5%) and neurosurgeons (27.3%). Out of these, 70.5% treated 1-20 fractures per year; 63.6% favoured the anterior screw fixation as therapy for Type II odontoid fractures, the open posterior Magerl transarticular C1/C2 fusion, the posterior Harms C1/C2 fusion, and conservative immobilisation by cervical orthosis was preferred by 9.1% in each case. 59.1% preferred the anterior odontoid screw fixation as an appropriate treatment of Anderson Type II odontoid fractures in the elderly. 79.5% chose cervical orthosis for postsurgical treatment. Following operative treatment, nonunion rates were reported to be <10% and <20% by 40.9% and 70% of the surgeons, respectively. 56.8% reported changing from primary conservative to secondary operative treatment in <10% of cases. The most favoured technique in revision surgery of nonunions was the open posterior Magerl transarticular fusion technique, chosen by 38.6% of respondents. 18.2% preferred the posterior Harms C1/C2 fusion technique, 11.4% the percutaneous posterior Magerl technique and the anterior odontoid screw fixation in each case. This study discovered major variations in the treatment of Anderson Type II odontoid fractures in the elderly in terms of indication for conservative and operative treatment between several treatment centres in 3 European countries. Difficulty and complexity in formulating general guidelines based on multicenter studies is conceivable.

Low Force Fracture of the Odontoid, with Discussion of High Force Cervical Fracture

Cervical fracture may occur with a high force mechanism of injury such as a motor vehicle crash, or with a low force mechanism of injury such as a ground level fall. To better characterize and understand low force cervical fractures and their significance, case files from the Travis County Medical Examiner's office covering a 5-year time period were retrospectively reviewed for fatal cervical fracture occurring with an accidental ground level fall. Thirty such fatal cervical fractures were identified, all occurring in elderly individuals (>65 years of age), with odontoid type 2 fracture of the C2 vertebra identified as the most frequent type of fracture. Odontoid fracture should be included in the list of craniocervical injury that may result from not only motor vehicle crashes and other high force mechanisms of injury, but also low force mechanisms of injury such as a ground level fall with head impact in an elderly individual.

Spinal cord trauma and the molecular point of no return

A mechanical trauma to the spinal cord can be followed by the development of irreversible and progressive neurodegeneration, as opposed to a temporary or partially reversible neurological damage. An increasing body of experimental and clinical evidence from humans and animal models indicates that spinal cord injury may set in motion the development of disabling and at times fatal neuromuscular disorders, whose occurrence is not normally associated with any major environmental event. This outcome appears to be dependent on the co-occurrence of a particular form of mechanical stress and of a genetically-determined vulnerability. This increased vulnerability to spinal cord injury may depend on a change of the nature and of the timing of activation of a number of neuroprotective and neurodestructive molecular signals in the injured cord. Among the main determinants, we could mention an altered homeostasis of lipids and neurofilaments, an earlier inflammatory response and the failure of the damaged tissue to rein in oxidative damage and apoptotic cell death. These changes could force injured tissue beyond a point of no return and precipitate an irreversible neurodegenerative process. A better knowledge of the molecular signals activated in a state of increased vulnerability to trauma can inform future treatment strategies and the prediction of the neurological outcome after spinal cord injury.

[Impact of age on mortality in patients with acute traumatic spinal cord injury requiring intensive care]

OBJECTIVE

To evaluate the impact of age (<or≥65 ans) on hospital mortality in traumatic spinal cord injury requiring intensive care.

DESIGN

Retrospective, monocenter.

PATIENTS AND METHODS

A total of 131 patients greater or equal to 15 years (<65 years, n=109 and ≥65 years, n=22) was analyzed (cervical, n=71; thoracolumbar, n=60), over a 10 years period (1998-2008). The hospital and long-term mortality were studied. The risks factors of death were searched by a uni- and multivariate analysis. Intensive care unit (ICU) discharge and long-term neurological recovery, and long-term functional independence measure (FIM) were assessed.

RESULTS

Hospital mortality was increased in patients greater or equal to 65 years (41% vs 6%, P<0.001) and long term mortality was not different between the two groups (31% vs 12%, P=0.150). The risks factors of death were age (HR=3.44; IC 95%: 1.53-7.72, P=0.028), previous coronary disease (HR=3.64; IC 95%: 1.25-10.65; P=0.018) and fall injury (HR=2.40; IC 95%: 1.15-5.00, P=0.020). Among survivors, incompletes forms (Frankel B, C, D, E) were significantly more frequent in older patients at ICU discharge and long term follow up. At long term, FIM was similar in the two groups except a better sphincter control in patient greater or equal to 65 years.

CONCLUSION

Mortality rate of older people (≥65 years) were greater than those in younger people, mainly caused by an increased hospital mortality. Among survivors, the neurological recovery was better in patients' greater or equal to 65 years, and was associated with a functional status at least comparable than in the youngest patients.

Type II odontoid fractures in the elderly: an evidence-based narrative review of management

Considerable controversy exists regarding the optimal management of elderly patients with type II odontoid fractures. There is uncertainty regarding the consequences of non-union. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. The objective of the study was to evaluate the published literature and determine the current evidence for the management of type II odontoid fractures in elderly. A search of the English language literature from January 1970 to date was performed using Medline and the following keywords: odontoid, fractures, cervical spine and elderly. The search was supplemented by cross-referencing between articles. Case reports and review articles were excluded although some were referred to in the discussion. Studies in patients aged 65 years with a minimum follow-up of 12 months were selected. One-hundred twenty-six articles were reviewed. No class I study was identified. There were two class II studies and the remaining were class III. Significant variability was found in the literature regarding mortality and morbidity rates in patients treated with and without halo vest immobilisation. In recent years several authors have claimed satisfactory results with anterior odontoid screw fixation while others have argued that this may lead to increased complications in this age group. Lately, the posterior cervical (Goel-Harms) construct has also gained popularity amongst surgeons. There is insufficient evidence to establish a standard or guideline for odontoid fracture management in elderly. While most authors agree that cervical immobilisation yields satisfactory results for type I and III fractures in the elderly, the optimal management for type II fractures remain unsolved. A prospective randomised controlled trial is recommended.

Methodological systematic review: mortality in elderly patients with cervical spine injury: a critical appraisal of the reporting of baseline characteristics, follow-up, cause of death, and analysis of risk factors

STUDY DESIGN

Methodologic systematic review.

OBJECTIVE

To determine the validity of reported risk factors for mortality in elderly patients with cervical spine injury.

SUMMARY OF BACKGROUND DATA

In elderly patients with cervical spine injury, mortality has frequently been associated with the type of treatment. To date, however, no review evaluating the validity of reported risk factors for mortality in elderly patients with cervical spine injury has been published.

METHODS

Studies evaluating the treatment of cervical spine injuries in elderly (>/=60 years of age) patients were searched through the Medline and EMBASE databases. In addition to standard methodologic details, reporting of putative confounding baseline characteristics and analysis of risk factors for mortality were appraised critically. For this purpose, patient data presented in included studies were pooled. Exploratory descriptive statistics were used for data analysis.

RESULTS

Twenty-six eligible studies were identified, including a total of 1550 pooled elderly subjects. Except for 2, all studies reported presence or absence of spinal cord injury. Details concerning the severity and/or extent of the injury were reported in 12 (46%) studies. Pre-existing comorbidities were reported in 9 studies (35%). In the pooled subjects, the cause of death was not reported in 155 of 335 deceased patients (42%). Based on own results, 18 (69%) studies reported on risk factors for mortality. Of these studies, 6 (23%) performed statistical analyses of risk factors for mortality outcomes. Only 1 study statistically adjusted potential risk factors for mortality for confounding.

CONCLUSION

Overall, pre-existing comorbidities, concomitant injuries, follow-up and cause of death have been underreported in studies investigating the treatment of cervical spine injuries in elderly patients. To strengthen the validity of risk factors for mortality in future clinical trials, adjustments for appropriately reported putative confounders by regression analysis are mandatory.

Mortality in elderly patients after cervical spine fractures

BACKGROUND

Despite an increased risk of cervical spine fractures in older patients, little is known about the mortality associated with these fractures and there is no consensus on the optimal treatment. The purposes of this study were to determine the three-month and one-year mortality associated with cervical spine fractures in patients sixty-five years of age or older and to evaluate potential factors that may influence mortality.

METHODS

We performed a retrospective review of all cervical spine fractures in patients sixty-five years of age or older from 1991 to 2006 at two institutions. Information regarding age, sex, race, treatment type, neurological involvement, injury mechanism, comorbidity, and mortality were collected. Overall risk of mortality and mortality stratified by the above factors were calculated at three months and one year. Cox proportional-hazard regression was performed to identify independent correlates of mortality.

RESULTS

Six hundred and forty patients were included in our analysis. The mean age was eighty years (range, sixty-five to 101 years). Two hundred and ninety-four patients (46%) were male, and 116 (18%) were nonwhite. The risk of mortality was 19% at three months and 28% at one year. The effect of treatment on mortality varied with age at three months (p for interaction = 0.03) but not at one year (p for interaction = 0.08), with operative treatment being associated with less mortality for those between the ages of sixty-five and seventy-four years. A higher Charlson comorbidity score, male sex, and neurological involvement were all associated with increased risk of mortality.

CONCLUSIONS

Operative treatment of cervical spine fractures is associated with a lower mortality rate at three months but not at one year postoperatively for patients between sixty-five and seventy-four years old at the time of fracture.

The impact of age on mortality, impairment, and disability among adults with acute traumatic spinal cord injury

Given the potential effects of age on mortality, impairment, and disability among individuals with traumatic spinal cord injury [(SCI), we examined these issues using a large, prospectively accrued clinical database. This study includes all patients who were enrolled in the Third National Spinal Cord Injury Study (NASCIS 3). Motor, sensory, and pain outcomes were assessed using NASCIS scores. Functional outcome was evaluated using the Functional Independence Measure (FIM). Data analyses included regression models adjusted for major potential confounders (i.e., sex, ethnicity, Glasgow Coma Scale [GCS] score, blood alcohol concentration on admission, drug protocol, cause, and level and severity of SCI). Mortality rates among older people (> or =65 years) were significantly greater than those of younger individuals at 6 weeks, at 6 months, and at 1 year following SCI (38.6% versus 3.1%; p < 0.0001). Among survivors, age was not significantly correlated with motor recovery or change in pain scores in the acute and chronic stages after SCI based on regression analyses adjusted for major confounders. However, older individuals experienced greater functional deficit (based on FIM scores) than younger individuals, despite experiencing similar rates of sensorimotor recovery (based on NASCIS scores). Our results suggest that older individuals have a substantially increased mortality rate during the first year following traumatic SCI in comparison with younger patients. Among survivors, the potential of older patients with SCI to neurologically improve within the first year post-injury does not appear to translate into similar functional recovery compared to that seen in younger individuals. Given this fact, rehabilitation protocols that are more focused on functional recovery may reduce disability among older people with acute traumatic SCI.

Cervical spine injuries

This article describes the anatomy of the cervical spine and the most common types of fractures associated with the cervical spine. Cervical spinal cord syndromes are also reviewed because such syndromes discovered during neurologic examinations frequently provide the first clue that there is an underlying spinal cord injury. Because most associated maxillofacial and spinal injuries occur in the setting of motor vehicle accidents, it is particularly important for the maxillofacial surgeon to be cognizant of the injuries, particularly in the context of the need for facial/cranial surgery. Appropriate measures are necessary to immobilize or fixate the spine before surgery to avoid exacerbating the spinal injury.

Mortality rates in geriatric patients with spinal cord injuries

OBJECT

The authors undertook this study to evaluate the incidence of spinal cord injury (SCI) in geriatric patients (> or = 70 years of age) and examine the impact of patient age, extent of neurological injury, and spinal level of injury on the mortality rate associated with traumatic SCI.

METHODS

A prospectively maintained SCI database (3481 patients) at a single institution was retrospectively studied for the period from 1978 through 2005. Parameters analyzed included patient age, admission American Spinal Injury Association (ASIA) motor score, level of SCI, mechanism of injury, and mortality data. The data pertaining to the 412 patients 70 years of age and older were compared with those pertaining to the younger cohort using a chi-square analysis.

RESULTS

Since 1980, the number of SCI-related hospital admissions per year have increased fivefold in geriatric patients and the percentage of geriatric patients within the SCI population has increased from 4.2 to 15.4%. In comparison with younger patients, geriatric patients were found to be less likely to have severe neurological deficits (greater percentage of ASIA Grades C and D injuries), but the mortality rates were higher in the older age group both for the period of hospitalization (27.7% compared with 3.2%, p < 0.001) and during 1-year follow-up. The mortality rates in this older population directly correlate with the severity of neurological injury (1-year mortality rate, ASIA Grade A 66%, Grade D 23%, p < 0.001). The mortality rate in elderly patients with SCI has not changed significantly over the last two decades, and the 1-year mortality rate was greater than 40% in all periods analyzed.

CONCLUSIONS

Spinal cord injuries in older patients are becoming more prevalent. The mortality rate in this patient group is much greater than in younger patients and should be taken into account when aggressive interventions are considered and in counseling families regarding prognosis.

Acute mortality and complications of cervical spine injuries in the elderly at a single tertiary care center

STUDY DESIGN

Retrospective database review of all traumatic cervical spine injuries at a single tertiary care center.

OBJECTIVE

To determine the acute survival of patients aged 65 and over with a variety of cervical spine injuries, regardless of operative or conservative treatment.

SUMMARY OF BACKGROUND DATA

Elderly patients with cervical spine injuries have historically suffered from high mortality rates. More recent literature has demonstrated improved outcomes among operatively treated elderly, but has suggested that the nonoperative treatment of cervical injuries in this population may itself contribute to increased mortality rates.

METHODS

One thousand seventy-three consecutive patients were identified and initial hospitalization records reviewed. Ninety-four patients were excluded for incomplete data. The remaining 979 patients were divided by age into young and elderly groups. Sex distribution, mechanism, injury type, comorbidities, and mortality and complication rates were compared. Elderly patients were further divided into operative and nonoperative groups and acute outcomes were compared.

RESULTS

The overall acute mortality rate for all patients with cervical spine injuries was 5.92%. Eighty-six percent of all patients 65 and over survived, as did 96.1% of younger patients. Seventy-three percent of elderly patients with complete injuries survived, as did 80% of those with incomplete injuries, and 95.6% of intact elderly. Acute mortality rates were statistically comparable in both the operatively and nonoperatively treated groups of elderly.

CONCLUSIONS

In this large comprehensive series of elderly patients with cervical spine injuries, statistically comparable survival rates were achieved in both operatively treated and nonoperatively treated patient populations. This finding challenges the conclusion that the nonoperative treatment of the elderly necessarily results in increased acute mortality.

Acute outcomes of cervical spine injuries in the elderly: atlantaxial vs subaxial injuries

BACKGROUND/OBJECTIVE

Recent studies have reported on the outcomes of spinal cord injuries in the elderly. Our aim was to identify acute survival differences between elderly patients with atlantoaxial injuries relative to subaxial injuries at our institution and to determine whether operative treatment is associated with improved survival rates in either population.

STUDY DESIGN

Retrospective database review of all traumatic cervical spine injuries in patients at least 65 years of age at a single tertiary care center.

METHODS

A total of 193 consecutive patients at least 65 years of age treated at a single tertiary care center over a 12-year period were identified. Initial hospitalization records were reviewed. Patients were divided by anatomic level of injury: atlantoaxial (C1 or C2) and subaxial (C3 or below). Demographics, mechanism, and mortality rates were compared. Each group was further divided by treatment (operative or nonoperative), and inpatient survival rates were compared.

RESULTS

Statistically similar survival rates were observed among patients with atlantoaxial and subaxial injuries (P = 0.10). Patients with nonoperatively treated subaxial injuries died at significantly higher rates than did their operatively treated peers (P < 0.05).

CONCLUSIONS

In this large comprehensive series of elderly patients with cervical spine injuries, survival rates were comparable regardless of anatomic level of injury. The operative treatment of subaxial injuries was associated with an improved acute survival rate vs nonoperative management. Further prospective study is needed to better assess this relationship.