Early Complications of Surgical Versus Conservative Treatment of Isolated Type II Odontoid Fractures in Octogenarians: A Retrospective Cohort Study

Surgical management of spinal pathologies in the octogenarian: a narrative review

Optimal management paradigms of spinal pathologies in the octogenarian population are controversial given the higher incidence of comorbidities with concern for poor prognosis and fear of increased complications associated with surgical management. In this narrative review, we aim to detail the complex clinical considerations when approaching odontoid screw fixation/instrumented fusion, spinal decompression, and spinal fusion in the octogenarian. Literature review was conducted via Google Scholar and PubMed databases, with literature selected based on statistical power and clinical relevance to the following pathologies/surgical techniques: odontoid fracture, surgical decompression, and surgical fusion in the octogenarian. The aforementioned pathologies were selected based on prevalence in the advanced-age population in which surgical screening techniques and management remain nonuniform. Preoperative evaluation of the octogenarian patient increasingly includes frailty, sarcopenia, and osteopenia/osteoporosis assessments. In cases of odontoid fracture, conservative management appears to provide beneficial clinical outcomes with lower rates of complication compared to surgery; however, rates of radiographic odontoid fusion are far lower in conservatively managed patients. Regarding surgical decompression and fusion, the presence of comorbidities may be more predictive of outcome rather than age status, with the advent of minimally invasive techniques providing safety and efficacy in the surgical management of this age cohort. Age status may be less pertinent than previously thought in the decision to pursue spinal surgery for odontoid fracture, spinal decompression, or spinal fusion; however, each of these procedures has respective risks and benefits that must be considered within the context of each patient's comorbidity profile.

A Comprehensive Prospective Analysis of Surgical Outcomes and Adverse Events in Spinal Procedures Among Octogenarians: A Detailed Analysis From a German Tertiary Center

STUDY DESIGN

Prospective case series.

OBJECTIVES

Drawing from prospective data, this study delves into the frequency and nature of adverse events (AEs) following spinal surgery specifically in octogenarians, shedding light on the challenges and implications of treating this specific cohort as well as on risk factors for their occurrence.

METHODS

Octogenarians who received spinal surgery and were discharged between January 2019 and December 2022 were proactively included in our study. An AE was characterized as any incident transpiring within the initial 30 days after surgery that led to an unfavorable outcome.

RESULTS

From January 2020 to December 2022, 184 octogenarian patients (average age: 83.1 ± 2.8 years) underwent spinal surgeries. Of these, 81.5% were elective and 18.5% were emergencies, with 69.0% addressing degenerative pathologies. Using the Charlson Comorbidity Index, the mean score was 8.1 ± 2.2, highlighting cardiac diseases as predominant. Surgical details show 71.2% had decompression, with 28.8% receiving instrumentation. AEs included wound infections 3.1% for degenerative, 13.3% for tumor and dural leaks. The overall incidence of dural leaks was found to be 2.7% (5/184 cases), and each case underwent surgical revision. Pulmonary embolism resulted in two fatalities post-trauma. Wound infections (26.7%) were prevalent in infected spine cases. Significant AE risk factors were comorbidities, extended surgery durations, and instrumentation procedures.

CONCLUSIONS

In octogenarian spinal surgeries, AEs occurred in 15.8% of cases, influenced by comorbidities and surgical complexities. The 2.2% mortality rate wasn't linked to surgeries. Accurate documentation remains crucial for assessing outcomes in this age group.

Surgical Outcomes in Octogenarians with Central Cord Syndrome: A Propensity-Score Matched Analysis

OBJECTIVE

Central cord syndrome (CCS) is a traumatic cervical spine injury that is treated with surgical decompression. In octogenarians (80-89), surgeons often opt for conservative management instead due to fears of postoperative complications and prolonged recovery times. This study aims to assess the in-hospital complications and outcomes in octogenarians undergoing surgery compared to those undergoing nonsurgical management for CCS.

METHODS

The National Trauma Data Bank was queried from 2017 to 2019 for octogenarians with CCS. Patients who received surgical fusion or decompression were divided into the surgery group and the remaining into the nonsurgical group. The surgery group was sampled and propensity score matched with the non-surgery group. Student t tests and Pearson χ2 tests were used to test for group differences.

RESULTS

A total of 759 octogenarians with CCS were identified. Following sampling and propensity score matching, 225 patients were identified in each group. The surgery group experienced longer intensive care unit (6.8 days vs. 3.21 days, P < 0.001) and hospital (13.79 days vs. 7.8 days, P < 0.001) lengths of stay and higher rates of deep vein thrombosis (4.89% vs. 0.44%, P = 0.02) and ventilator-associated pneumonia (4% vs. 0%, P = 0.02). Patients did not otherwise differ in mortality rate, other hospital complications, and discharge disposition.

CONCLUSIONS

Octogenarians undergoing surgery for CCS experience longer length of stay and complications consistent with prolonged hospitalization but otherwise have similar mortality, hospital complications, and discharge disposition compared to non-surgical treatment. Given the relative lack of short-term drawbacks, surgery should be considered first-line management when the long-term benefits are substantive.

Risk factors for in-hospital mortality in geriatric patients aged 80 and older with axis fractures: a nationwide, cross-sectional analysis of concomitant injuries, comorbidities, and treatment strategies in 10,077 cases

PURPOSE

To investigate the association between treatment, comorbidities, concomitant injuries, and procedures with in-hospital mortality in patients aged 80 years or older with axis fractures.

METHODS

Data were extracted from the German InEK (Institut für das Entgeltsystem im Krankenhaus) GmbH database (2019-2021) for patients aged 80 years or older with axis fractures and the in-hospital mortality rate was calculated. Differences in comorbidities and concomitant diseases and injuries were analyzed using the Chi-square test. In surgically treated patients, odds ratios (OR) with 95% confidence intervals (95% CI) were used to analyze potential risk factors for in-hospital mortality.

RESULTS

Among 10,077 patients, the in-hospital mortality rate was 8.4%, with no significant difference between surgically (9.4%) and non-surgically treated patients (7.9%; p = 0.103). The most common comorbidities were essential hypertension (67.3%), atrial fibrillation (28.2%), and chronic kidney disease (23.3%), while the most common concomitant injuries were head and face wounds (25.9%), concussions (12.8%), and atlas fractures (11.6%). In surgically treated patients, spinal cord injury (OR = 4.62, 95% CI: 2.23-9.58), acute renal failure (OR = 3.20, 95% CI: 2.26-4.53), and acute bleeding anemia (OR = 2.06, 95% CI: 1.64-2.59) were associated with increased in-hospital mortality (all p < 0.01). Screw-rod-system fixation of one segment (OR = 0.74, 95% CI: 0.56-0.97) and intraoperative navigation (OR = 0.45, 95% CI: 0.16-0.71) were identified as potential protective factors (both p < 0.05).

CONCLUSION

Comprehensive geriatric assessment and optimization of comorbidities during treatment are crucial. The indication for surgical treatment must be carefully individualized. Future studies should focus on the choice of surgical technique, perioperative blood management, and intraoperative navigation as potential protective factors.

Morbidity and mortality related to type II odontoid fractures in octogenarians undergoing surgery: a retrospective study with 5 year follow up

Introduction

The prevalence of trauma is increasing in the geriatric population. The optimal therapy for type II odontoid fractures in the elderly is controversial. This study aims to assess the morbidity and mortality associated with odontoid fractures in octogenarians undergoing C1/C2 posterior screw fixation and describe the perioperative and post-operative complications and risk factors associated with mortality.

Materials and methods

Electronic medical records from a single institution pertaining to the period between September 2005 and December 2020 were retrieved. Data on patient demographics, neurological conditions, surgical characteristics, complications, hospital course, and 90-day mortality were collected.

Results

Over a 16-year period, 60 patients aged ≥80 years diagnosed with type II odontoid fractures were enrolled in the study. The mean age was 85.0 ± 1.9 years. The mean Charlson Comorbidity Index (CCI) was >6 indicating a poor baseline reserve (8.5 ± 1.9), while cardiovascular diseases were the most prevalent among comorbidities. The mean surgical duration was 217.5 ± 65.9 min, with a mean blood loss of 725.5 ± 275.7 mL. The in-hospital was 5-0% and the 90-day mortality rates increased at 10.0%. No revision surgery was needed in any of the cases. Intraoperative and post-operative X-ray and computed tomography (CT) imaging revealed correct screw placement. Proper alignment of the atlantoaxial spine and fusion could be achieved in all cases. The unique risk factors for mortality included the presence of comorbidities and the occurrence of post-operative complications.

Conclusion

The complication and mortality rates associated with odontoid fractures in octogenarians are relatively high. However, the therapeutic goals in this population also include bone union and preservation of neurological status. Despite the often-high comorbidity rate, we still recommend that surgery should be considered in patients over 80 years. However, it is necessary to evaluate several approaches when treating such frail patients.

Surgery Decreases Nonunion, Myelopathy, and Mortality for Patients With Traumatic Odontoid Fractures: A Propensity Score Matched Analysis

BACKGROUND

Existing literature suggests that surgical intervention for odontoid fractures is beneficial but often does not control for known confounding factors.

OBJECTIVE

To examine the effect of surgical fixation on myelopathy, fracture nonunion, and mortality after traumatic odontoid fractures.

METHODS

We analyzed all traumatic odontoid fractures managed at our institution between 2010 and 2020. Ordinal multivariable logistic regression was used to identify factors associated with myelopathy severity at follow-up. Propensity score analysis was used to test the treatment effect of surgery on nonunion and mortality.

RESULTS

Three hundred and three patients with traumatic odontoid fracture were identified, of whom 21.6% underwent surgical stabilization. After propensity score matching, populations were well balanced across all analyses (Rubin's B < 25.0, 0.5 < Rubin's R < 2.0). Controlling for age and fracture angulation, type, comminution, and displacement, the overall rate of nonunion was lower in the surgical group (39.7% vs 57.3%, average treatment effect [ATE] = -0.153 [-0.279, -0.028], P = .017). Controlling for age, sex, Nurick score, Charlson Comorbidity Index, Injury Severity Score, and selection for intensive care unit admission, the mortality rate was lower for the surgical group at 30 days (1.7% vs 13.8%, ATE = -0.101 [-0.172, -0.030], P = .005) and at 1 year was 7.0% vs 23.7%, ATE = -0.099 [-0.181, -0.017], P = .018. Cox proportional hazards analysis also demonstrated a mortality benefit for surgery (hazard ratio = 0.587 [0.426, 0.799], P = .0009). Patients who underwent surgery were less likely to have worse myelopathy scores at follow-up (odds ratio = 0.48 [0.25, 0.93], P = .029).

CONCLUSION

Surgical stabilization is associated with better myelopathy scores at follow-up and causes lower rates of fracture nonunion, 30-day mortality, and 1-year mortality.

Reverse Total Shoulder Arthroplasty in Patients Who Exceeded Their Life-Expectancy: A Retrospective Study

Background

Reverse total shoulder arthroplasty (RTSA) has become an established treatment for cuff arthropathy, severe osteoarthritis and in certain fracture cases. Due to the increasingly aging population, patients who have already exceeded their life-expectancy pose a significant challenge to the shoulder surgeon.

Methods

Patients older than 83 years who received a RTSA were included. Elective cases were compared to fracture cases. Patient demographics, hospital stay length, complication rate, functional outcome, patient reported outcome scores and mortality were assessed retrospectively.

Results

We included 110 cases, 48 in the elective group and 62 in the fracture group. The average age at time of surgery was 86.6 ± 3.5 years. Mean follow-up was 30 months. Elective cases had a significant shorter hospital stay length (P = .014). Functional outcome scores showed better results for the elective group with ASES 79 ± 12 vs 69 ± 19 (P = .07), QuickDASH 29 ± 16 vs 37 ± 21 (P = .22), subjective shoulder value 86 ± 14 vs 75 ± 19 (P = .04*) and VAS .7 ± 1.5 vs 2.1 ± 2.5 (P = .02*). There was no significant difference in ROM and mean quality-adjusted-life-years (QALY) with 3.2 ± 1.8 vs 3.5 ± 2.5 years (P = .69). The complication rate requiring surgical intervention was 2.4% in the elective and 6.5% in the fracture group. The 1-year mortality was 3 (6%) respectively 9 (15%).

Conclusion

RTSA in elderly patients can be successful with good functional outcomes. Age should not be a contraindication. Instead, the patient's activity level and quality of life should be taken into account. Elective RTSA show better functional outcome scores and lower complication rates compared to RTSA in proximal humeral fractures.

Duration of External Neck Stabilisation (DENS) following odontoid fracture in older or frail adults: protocol for a randomised controlled trial of collar versus no collar

INTRODUCTION

Fractures of the odontoid process frequently result from low impact falls in frail or older adults. These are increasing in incidence and importance as the population ages. In the UK, odontoid fractures in older adults are usually managed in hard collars to immobilise the fracture and promote bony healing. However, bony healing does not always occur in older adults, and bony healing is not associated with quality of life, functional, or pain outcomes. Further, hard collars can cause complications such as skin pressure ulcers, swallowing difficulties and difficulties with personal care. We hypothesise that management with no immobilisation may be superior to management in a hard collar for older or frail adults with odontoid fractures.

METHODS AND ANALYSES

This is the protocol for the Duration of External Neck Stabilisation (DENS) trial-a non-blinded randomised controlled trial comparing management in a hard collar with management without a collar for older (≥65 years) or frail (Rockwood Clinical Frailty Scale ≥5) adults with a new odontoid fracture. 887 neurologically intact participants with any odontoid process fracture type will be randomised to continuing with a hard collar (standard care) or removal of the collar (intervention). The primary outcome is quality of life measured using the EQ-5D-5L at 12 weeks. Secondary outcomes include pain scores, neck disability index, health and social care use and costs, and mortality.

ETHICS AND DISSEMINATION

Informed consent for participation will be sought from those able to provide it. We will also include those who lack capacity to ensure representativeness of frail and acutely unwell older adults. Results will be disseminated via scientific publication, lay summary, and visual abstract. The DENS trial received a favourable ethical opinion from the Scotland A Research Ethics Committee (21/SS/0036) and the Leeds West Research Ethics Committee (21/YH/0141).

TRIAL REGISTRATION NUMBER

NCT04895644.

Cervical fusion for adult patients with atlantoaxial rotatory subluxation

BACKGROUND

Atlantoaxial rotatory subluxation (AARS) is a rare injury of the C1/C2 junction. It is often associated with trauma in adults. Treatment may depend on the duration of symptoms and clinical presentation, but there is no consensus regarding the ideal management of these injuries. Our objective is to ascertain the prevalence of neurological deficit, complications, and outcomes of patients diagnosed with AARS undergoing cervical fusion (CF) versus those treated without CF.

METHODS

The 2016-2019 National Inpatient Sample (NIS) was queried using International Classification of Diseases, 10th revision (ICD-10) for adult patients with C1/C2 subluxation. Patients undergoing CF were defined through ICD-10 procedure codes. Baseline health and acute illness severity was calculated using the 11-point modified frailty index (mFI-11). Presenting characteristics, treatment complications, and outcomes were evaluated of CF vs. non-CF patients.

RESULTS

Of 990 adult patients with AARS, 720 were treated without CF and 270 were treated with CF. CF patients were more often myelopathic. Patients that had undergone CF treatment were negatively associated with having had extensive trauma. Patients undergoing CF experienced significantly longer length of stay (LOS), increased healthcare resource utilization, and decreased inpatient mortality. Sepsis had a negative association with patients that underwent CF treatment while pneumonia had a positive association.

CONCLUSIONS

Adult patients undergoing CF for AARS demonstrated an increase in healthcare resource utilization but also a significant decrease in mortality. Extent of acute injury appears to have a strong influence on decision making for CF. Further study of decision making for treatment of this rare injury in adults is warranted.

Evaluation of external stabilization of type II odontoid fractures in geriatric patients-An experimental study on a newly developed cadaveric trauma model

Background

Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar.

Methods

Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed.

Results

The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion (p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced (p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced (p = 0.0137) from 48° to 18°.

Conclusions

In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending.

[Early intraoperative and postoperative complications of C1-C2 fixation using the Goel-Harms technique : How often? Which? Why?]

Fractures of the axis are among the most frequent spinal injuries. Posterior C1-C2 fixation according to Goel-Harms is an accepted alternative to the more traditional procedures: initial stability has been shown and there is a wide range of indications but there is a paucity of data on possible complications. Such knowledge, however, is essential in order to improve outcomes.Thus, the aim of the study was:1. to describe the frequency, type and severity of early postoperative complications following C1-C2 fixation according to Goel-Harms,2. to investigate whether there is a correlation between frequency and severity of complications,3. to detect risk factors for complications.Patients included in this study were treated surgically using the C1-C2 fixation according to Goel-Harms between March 2011 and July 2018. Data were taken from our hospital database and checked via OPS 10 code "S12.1". We analyzed age, sex, ASA score, blood loss, operating time and complications. These data were extracted from clinical data sheets.A total of 134 patients were detected, 54% female, mean age 75 years and mean ASA score 3. There were 122 complications. All these complications were observed in 50% of the patients. These were mainly minor complications (32%), and 18% severe complications. Mortality was 2%. We found that patients with more severe complications also had significantly more complications when compared to patients with minor complications (Fisher's exact test, p = 0.001). Preoperative ASA score was the only risk factor to significantly influence the number (p = 0.001) and severity (p = 0.002) of postoperative complications. Each increase of the preoperative ASA score increased the risk to get one more complication by a factor of 2.55 (odds ratio 2.55) and increased the risk to get a severe complication by a factor of 2.43 (odds ratio 2.43). Intraoperative blood loss, patient age and duration of surgery, however, were not identified as risk factors for complications.

Too frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy

Type-II odontoid fractures are common and highly morbid injuries, particularly among elderly patients. However, few risk stratification resources exist to predict outcomes and guide management decision making. Frailty indices have been increasingly utilized for these purposes in elective surgery, but have not been assessed for trauma. A single-center prospective trauma registry identified patients aged ≥ 80 years with type-II odontoid fractures. Frailty was the independent variable, using three independent indices: modified-5-item frailty (mFI-5), modified Charlson comorbidity (mCCI), and Davies. 97 patients had complete frailty data and sufficient follow up information, with median mIF-5 of 2 (range 0-4; 34 frail, mFI-5 > 2), median mCCI score of 6 (range 4-14), and median Davies score of 2 (range 0-7). For all indices, increasing score was associated with mortality, mIF-5 (HR = 1.76, 95%CI = 1.06-2.88), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Median post-injury survival among patients with mIF-5 of ≤ 2 was 10-fold longer than patients with mIF-5 of > 2 (70 vs. 710 days, p = 0.0026). After adjusting for initial treatment strategy, frailty status remained an independent predictor of patient mortality; mIF-5 (HR = 1.72, 95%CI = 1.02-2.80), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Among octogenarian patients with type-II odontoid fractures, frailty was associated with increased mortality, independent of treatment strategy.

Morbidity and Mortality in Patients over 90 Years of Age Following Posterior Stabilization for Acute Traumatic Odontoid Type II Fractures: A Retrospective Study with a Mean Follow-Up of Three Years

Odontoid type II fractures represent the most common cervical spine injuries in the elderly. The decision for surgical treatment in very elderly patients is still controversial. The aim of this study was to assess morbidity and mortality in patients over 90 years of age undergoing CT-guided posterior stabilization for unstable odontoid type II fractures. A total of 15 patients with an acute traumatic odontoid type II fracture who received surgical treatment for unstable odontoid type II fractures were retrospectively analyzed. Complications, morbidity, and mortality as well as length of ICU and hospital stay were determined. Clinical follow-up evaluation was based on outpatient presentation and information from family members and general practitioners. Finally, we conducted a comparison of complications rates between patients over 90 years of age and patients between 65 and 89 years old with a type II odontoid fracture after CT-guided posterior stabilization in our institution. The mean age was 91.4 years. Patients were predominately female (87%). In-hospital deaths did not occur. The average length of the hospital stay was 13.4 days and 1.9 days for the ICU. Blood transfusion was necessary in two patients (13%). Two patients (13%) developed urinary tract infection, one patient (7%) a delirium, and another epistaxis (7%). One patient (7%) developed pneumonic sepsis and fully recovered within several weeks. The mean follow-up was 36 months (range 9–72 months). Implant-related complications developed in one patient (7%). Five patients died during the follow-up period, with an average time to death of 26.6 months. Postoperative bracing was not needed in any of the patients. Posterior stabilization of unstable odontoid fractures type II using CT-guided navigation in patients over 90 years of age is a safe and effective procedure with low complications and mortality rates.

Posterior fusion for fragility type 2 odontoid fractures

OBJECTIVE

The purpose of this study was to evaluate the outcomes of elderly patients with type 2 odontoid fractures treated with an instrumented posterior fusion.

METHODS

Ninety-three consecutive patients older than 65 years of age in whom a type 2 odontoid fracture had been treated with a variety of C1-2 posterior screw fixation techniques were retrospectively reviewed.

RESULTS

The average age was 78 years (range 65-95 years). Thirty-seven patients had an additional fracture, 30 of which involved C1. Three patients had cervical spinal cord dysfunction due to their injury. All patients had comorbidities. The average total hospitalization was 9.6 days (range 2-37 days). There were 3 deaths and 19 major complications, the most common of which was pneumonia. No patient suffered a vertebral artery injury. Imaging studies were obtained in 64 patients at least 12 months postsurgery (mean 19 months). Fusion was assessed by dynamic radiographs in all cases and with a CT scan in 80% of the cases. Four of the 64 patients did not achieve fusion (6.25% overall). All patients in whom fusion failed had undergone C1 lateral mass fixation and C2 pars (1/29, 3.4%) or laminar (3/9, 33.3%) fixation.

CONCLUSIONS

Instrumented posterior cervical fusions may be performed in elderly patients with acceptable morbidity and mortality. The fusion rate is excellent except when bilateral C2 translaminar screws are used for axis fixation.

A biomechanical comparison of a cement-augmented odontoid screw with a posterior-instrumented fusion in geriatric patients with an odontoid fracture type IIb

PURPOSE

Possible surgical therapies for odontoid fracture type IIb include odontoid screw osteosynthesis (OG) with preservation of mobility or dorsal C1/2 fusion with restriction of cervical rotation. In order to reduce material loosening in odontoid screw osteosynthesis in patients with low bone density, augmentation at the base of the axis using bone cement has been established as a suitable alternative. In this study, we compared cement-augmented OG and C1/2 fusion according to Harms (HG).

METHODS

Body donor preparations of the 1st and 2nd cervical vertebrae were randomized in 2 groups (OG vs. HG). The range of motion (ROM) was determined in 3 principle motion plains. Subsequently, a cyclic loading test was performed. The decrease in height of the specimen and the double amplitude height were determined as absolute values as an indication of screw loosening. Afterward, the ROM was determined again and loosening of the screws was measured in a computed tomography.

RESULTS

A total of 16 were included. Two groups of 8 specimens (OG vs. HG) from patients with a median age of 80 (interquartile range (IQ) 73.5-85) years and a reduced bone density of 87.2 (IQ 71.2-104.5) mg/cc dipotassium hydrogen phosphate were examined for their biomechanical properties. Before and after exposure, the OG preparations were significantly more mobile. At the time of loading, the OG had similar loading properties to HG decrease in height of the specimen and the double amplitude height. Computed tomography revealed similar outcomes with regard to the screw loosening rate (62.5 vs. 87.5%, p = 0.586).

CONCLUSION

In patients with an odontoid fracture type IIb and reduced bone density, cement-augmented odontoid screw yielded similar properties in the loading tests compared to the HG. It may, therefore, be considered as a primary alternative to preserve cervical mobility in these patients.

The use of Grauer classification in the management of type II odontoid fracture in elderly: Prognostic factors and outcome analysis in a single centre patient series

OBJECTIVE

To evaluate the results of Type II odontoid fractures management in the elderly, according to the Grauer classification.

METHODS

Consecutive patients with type II odontoid fracture, age > 65 years and follow-up longer than 3 months were included. Fracture management was proposed according to Grauer classification. Peri-surgical risk factors, NDI, VAS and rate of fusion were evaluated according to the treatment modality and compared between conservative and surgical groups.

RESULTS

Thirty-four patients were considered eligible for the study; 2 patients showed a Type IIa fracture, 30 patients a type IIb, and 2 patients a type IIc. Type IIa patients underwent conservative treatment that resulted in failure. A conservative management was adopted in 9 cases with type IIb due to patient preference or anaesthesiologic reasons with a treatment success at 6 months of 11%. Trans-odontoid stabilization was adopted in 21 type IIb cases with an evidence of bony or fibrous union at 6 months of 95% and a median NDI of 20%. A posterior approach was reserved for 2 type IIc fracture patients and in 6 cases as rescue surgery (bony union at 6 months of 100%; median NDI 37%). Higher Lakshmanan grade, gap and displacement of the fracture were found as significant risk factor for fracture non-union (p < 0.05).

CONCLUSIONS

The surgical group presented better clinical and radiological outcome and the anterior approach proved to achieve the best results in type IIb fractures. The presence of osteoporosis and fracture spatial features should be duly considered in the decision-making process.

Determination and optimization of ideal patient candidacy for anterior odontoid screw fixation

Background:

Odontoid process fractures are one of the most common spine fractures, especially in patients over age 70. There is still much controversy over the ideal candidate for anterior odontoid screw fixation (AOSF), with outcomes affected by characteristics such as fracture morphology, nonideal body habitus, and osteoporosis. Therefore, this systematic review seeks to discuss the optimal criteria, indications, and adverse postoperative considerations when deciding to pursue AOSF.

Methods:

This investigation was conducted from experiential recall and article selection performed using the PubMed electronic bibliographic databases. The search yielded 124 articles that were assessed and filtered for relevance. Following the screening of titles and abstracts, 48 articles were deemed significant for final selection.

Results:

AOSF is often utilized to treat Type IIB odontoid fractures, which has been shown to preserve atlantoaxial motion, limit soft-tissue injuries/blood loss/vertebral artery injury/reduce operative time, provide adequate osteosynthesis, incur immediate spinal stabilization, and allow motion preservation of C1 and C2. However, this technique is limited by patient characteristics such as fracture morphology, transverse ligament rupture, remote injuries, short neck or inability to extend neck, barrel chested, and severe spinal kyphosis, in addition to adverse postoperative outcomes such as dysphagia and vocal cord paralysis.

Conclusion:

Due to the fact that odontoid fractures have a significant morbidity in elderly population, treatment with AOSF is generally recommended for this population with higher risk for nonoperative fusion. Considerations should be made to achieve fracture stability and fusion, while lowering the risk for operative and postoperative complications.

Identifying factors influencing mortality in patients aged over 65 following an acute type II odontoid process fracture. A retrospective cohort study

OBJECTIVE

Compare short-term mortality rates following operative and nonoperative management of geriatric patients following an acute type II odontoid process fracture.

METHODS

One hundred forty-one patients with a type II odontoid fracture were identified from a single centre between 2002 and 2018. Patient demographics, details of injury and management, plus mortality data were collected. The incidence of mortality at 3 and 12 months was calculated, and a multivariate model built which included the treatment modality variable and allowed adjustment for six individual confounders.

RESULTS

Of the 141 patients with a type II odontoid process fracture, 39 were managed operatively, while 102 were managed nonoperatively. Relative to the nonoperative group, the operative group was younger (79.0 ± 7.0 vs. 83.7 ± 7.6), more likely to have odontoid angulation > 15^° (74.4% vs. 43.1%, p < 0.01), and a greater proportion having fracture displacement > 2 mm (74.4% vs. 31.4%, p < 0.01). Both groups were comparable for gender, comorbidities, and associated injuries. On univariate analysis of treatment modality, the odds ratio of 3-month mortality with nonoperative management was 2.55 (95% CI: 0.82-7.92; p = 0.08), whilst at 12-months it was 3.12 (95% CI: 1.11-8.69; p = 0.02). On multivariate analysis of 12-month mortality, however, treatment modality was not found to be significant. This multivariate analysis suggested that increasing age, male gender, and injury severity were significant predictors of 12-month mortality.

CONCLUSION

In contrast to the findings of a number of previous studies, operative management may not influence survival at 3- and 12-months.

A Nationwide Analysis of Geriatric Odontoid Fracture Incidence, Complications, Mortality, and Cost

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

To identify nationwide temporal trends in management of geriatric odontoid fractures and to compare comorbidities, inpatient complications, hospital characteristics, and cost between patients receiving operative versus nonoperative management.

SUMMARY OF BACKGROUND DATA

The treatment of geriatric odontoid fractures remains controversial with some studies demonstrating decreased mortality and improved functional outcomes associated with operative management and significant morbidity associated with halo devices during nonoperative management.

METHODS

Patients between ages 65 to 90 years with odontoid fractures who underwent operative or nonoperative management between the years 2003 and 2017 were identified in the National Inpatient Sample (NIS) database. Year of injury, demographic variables, comorbidities, inpatient complications, mortality, length of stay, inpatient cost, and hospital characteristics were compared between operative and nonoperative treatment groups.

RESULTS

Thirty two thousand four hundred nineteen patients (average age 77 yr, 54% female) were included in the final analysis. Operative treatment occurred in 21,954 (67%) patients and nonoperative treatment occurred in 10,465 (32%). In 2003, operative treatment occurred in 46% of patients and nearly doubled to 86% in 2017, with an average increase of 3.7% per year (P < 0.001). Patients undergoing operative management had a lower prevalence of at least one major medical comorbidity (76% vs. 83%, P < 0.001). Patients undergoing operative treatment demonstrated higher odds of developing most complications, particularly pulmonary, gastrointestinal, and renal (P < 0.01). Inpatient mortality was 3.6% in patients receiving operative treatment and 5.9% in patients receiving nonoperative treatment (P < 0.001). Average cost per episode of care during the study period was $131,855 for operative treatment and $65,374 for nonoperative treatment (P < 0.001).

CONCLUSION

This study demonstrates a clear national paradigm shift in the management of geriatric odontoid fractures, wherein operative management nearly doubled from 46% in 2003 to 86% in 2017.Level of Evidence: 3.

Predictors of 30-Day Unplanned Readmissions, Complications, and Mortality Following Operative Management of C2 Fractures

STUDY DESIGN

Retrospective database review.

OBJECTIVES

To determine factors associated with unplanned readmission, complications, and mortality in patients undergoing operative management for C2 fractures.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS NSQIP) was queried between 2007 and 2014. Unplanned readmission, any complication, and mortality were the outcomes of interest. Bivariate statistics were calculated, and multivariate regression models were estimated.

RESULTS

A total of 285 patients were enrolled. Readmission data was available for 199 patients and 11 patients (5.5% of 199 patients) had an unplanned readmission. Overall, 60 patients (21% of 285 patients) had at least 1 complication and 15 patients (5.3% of 285 patients) died. Five factors were associated with complications: transferred from another facility (odds ratio [OR] 3.00, 95% confidence interval [CI]1.51-5.98; P < .01); operative time ≥180 minutes (OR 2.43, 95% CI 1.11-5.36; P = .03); at least 1 patient comorbidity (OR 2.50, 95% CI 1.01-6.18; P < .05); American Society of Anesthesiologists (ASA) class 3 (OR 4.86, 95% CI 1.19-19.88; P = .03); and ASA class 4 (OR 7.24, 95% CI 1.66-31.66; P = .01). The only factor associated with unplanned readmission was having at least one postoperative complication (OR 7.10, 95% CI 1.04-48.59; P < .05), while patients who were partially or totally dependent from a functional standpoint were at increased odds of death (OR 3.98, 95% CI 1.12-14.08; P = .03).

CONCLUSIONS

Patients with functional limitations have increased odds of death, while patients with postoperative complications have increased odds of unplanned readmission. Being transferred from an outside facility, having an operative time ≥180 minutes, having at least one comorbidity, and being classified as ASA class 3 or 4 increase patient odds of complication.

Change in rates of primary atlantoaxial spinal fusion surgeries in the United States (1993-2015)

OBJECTIVE

The objective of this study was to investigate revision burden and associated demographic and economic data for atlantoaxial (AA) fusion procedures in the US.

METHODS

Patient data from the National Inpatient Sample (NIS) database for primary AA fusion were obtained from 1993 to 2015, and for revision AA fusion from 2006 to 2014 using ICD-9 procedure codes. Data from 2006 to 2014 were used in comparisons between primary and revision surgeries. National procedure rates, hospital costs/charges, length of stay (LOS), routine discharge, and mortality rates were investigated.

RESULTS

Between 1993 and 2014, 52,011 patients underwent primary AA fusion. Over this period, there was a 111% increase in annual number of primary surgeries performed. An estimated 1372 patients underwent revision AA fusion between 2006 and 2014, and over this time period there was a 6% decrease in the number of revisions performed annually. The 65-84 year-old age group increased as a proportion of primary AA fusions in the US from 35.9% of all AA fusions in 1997 to 44.2% in 2015, an increase of 23%. The mean hospital cost for primary AA surgery increased 32% between 2006 and 2015, while the mean cost for revision AA surgery increased by 35% between 2006 and 2014. Between 2006 and 2014, the mean hospital charge for primary AA surgery increased by 67%; the mean charge for revision surgery over that same period increased by 57%. Between 2006 and 2014, the mean age for primary AA fusions was 60 years, while the mean age for revision AA fusions was 52 years. The mean LOS for both procedures decreased over the study period, with primary AA fusion decreasing by 31% and revision AA fusion decreasing by 24%. Revision burden decreased by 21% between 2006 and 2014 (mean 4.9%, range 3.2%-6.4%). The inpatient mortality rate for primary AA surgery decreased from 5.3% in 1993 to 2.2% in 2014.

CONCLUSIONS

The number of primary AA fusions between 2006 and 2014 increased 22%, while the number of revision procedures has decreased 6% over the same period. The revision burden decreased by 21%. The inpatient mortality rate decreased 62% (1993-2014) to 2.2%. The increased primary fusion rate, decreased revision burden, and decreased inpatient mortality determined in this study may suggest an improvement in the safety and success of primary AA fusion.

Surgery vs conservative treatment for type II and III odontoid fractures in a geriatric population: A meta-analysis

BACKGROUND

It is unclear whether surgery or conservative treatment is more suitable for elderly patients with type II and type III odontoid fractures. We performed this meta-analysis to compare the efficacy of surgical and conservative treatments for type II and type III odontoid fractures.

METHODS

A literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library in January 2017. Only articles comparing surgery with conservative treatment in elderly patients with type II and type III odontoid fractures were selected. After 2 authors independently assessed the retrieved studies, 18 articles were included in this meta-analysis, and the primary endpoints were the nonunion rate and mortality rate. The secondary outcomes were patient satisfaction, complications, and the length of the hospital stay. The quality of the included studies was evaluated using the modified Newcastle-Ottawa scale. Sensitivity analyses were performed for high-quality studies, and the publication bias was evaluated using a funnel plot.

RESULTS

Lower nonunion (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.18-0.40, P < .05) and mortality rates (OR: 0.52, 95% CI: 0.34-0.79, P < .05) confirmed the superiority of surgery in treating type II and type III fractures. The secondary outcomes differed. Patients in the surgery group felt more satisfied with the outcome (OR: 3.44, 95% CI: 1.19-9.95, P < .05), and the complications were similar in the 2 groups (OR: 1.14, 95% CI: 0.78-1.68, P = .5), whereas patients in conservative groups spent less time in the hospital (OR: 5.10, 95% CI: 2.73-7.47, P < .05). The results of the subgroup analyses and sensitivity analysis were similar to the original outcomes, and no obvious publication bias was observed in the funnel plot.

CONCLUSION

Most elderly (younger than 70 years) patients with type II or type III odontoid fractures should be considered candidates for surgical treatment, due to the higher union rate and lower mortality rate, while statistically significant differences were not observed in the population with an advanced age (older than 70 years). Therefore, the selection of the therapeutic approach for elderly patients with odontoid fractures requires further exploration. Simultaneously, based on our meta-analysis, a posterior arthrodesis treatment was significantly superior to the anterior odontoid screw treatment.

Fusion rates for odontoid fractures after treatment by anterior odontoid screw versus posterior C1-C2 arthrodesis: a meta-analysis

OBJECTIVE

For odontoid fractures, surgical treatment approaches including anterior odontoid screw fixation approach and the posterior C1-C2 arthrodesis approach are generally adopted in practice. However, the choice of different surgical procedures remains controversial. In addition to surgical technique, the fusion rate is an important factor contributing to the clinical efficacy. Therefore, this study was aimed to investigate the discrepancy in fusion rate between these two surgical approaches through synthesizing the currently available evidence on the topic.

METHODS

A computerized search of Ovid, Medline, Embase, and the Cochrane library up to December 2017 for literature on the complication rate during odontoid fracture treatment was conducted. Risk ratio (RR) with its 95% confidence interval (CI) was pooled to assess fusion rates after surgical treatments, including anterior odontoid screw fixation approach or posterior C1-2 arthrodesis procedure, for patients with odontoid fractures.

RESULTS

Thirteen studies were enrolled in the meta-analysis. Results show that no significant difference was found in the overall fusion rate (RR = 0.96, 95% CI 0.90-1.01). There was no significant heterogeneity among the studies (p value = 0.60). As to age- and economic-level subgroups, there was no statistical evidence to suggest an association of the patient age and economy development level with the choice of surgical approach. However, it is shown that better fusion rates of patients (≥ 60 years) in developed countries received a better fusion rates after posterior fixation compared with anterior group using the fixed-effect model (RR = 0.88, 95% CI 0.79-0.98).

CONCLUSION

Elderly patients (≥ 60 years) underwent posterior C1-2 arthrodesis fixation shows higher fusion rates in developed countries comparing with patients who underwent anterior odontoid screw fixation. Overall, there is no significant discrepancy between these two surgical approaches. However, the conclusion should be verified by further study enrolling larger sample size.

Treatment of Odontoid Type II Fractures in Octogenarians: Balancing Two Different Treatment Strategies

OBJECTIVE

Demographic changes have led to a higher incidence of C-2 fractures, especially in elderly patients. For patients with type II fractures, treatment remains controversial, as discussed by Anderson and D'Alonzo, due to the rising morbidity and mortality rates for any treatment. The aim of this study was to compare conservative and surgical management in patients with type II C-2 fractures regarding outcomes, complications, and the mortality rate.

METHODS

A retrospective analysis was performed of the medical records, X-rays, and/or computed tomography scans of patients ≥80 years of age with type II fractures who were admitted to our Department of Neurosurgery between January 1990 and December 2017. The success of treatment was evaluated 3 months after surgery.

RESULTS

In total, 125 patients were included, of whom 98 were treated surgically and 27 were treated conservatively. Surgical treatment was successful in 90.8% of cases, while conservative treatment was successful in 70.0%. The in-hospital mortality was 14.29% and the 3-month mortality was 27.8% in the surgical group, compared to 3.7% and 20% in the conservatively treated group. The in-hospital complication rate was 22.4% in the surgically treated patients and 7.4% in the conservatively treated patients.

CONCLUSION

Surgical treatment of type II fractures seemed to be associated with higher success and complication rates than conservative treatment. Nevertheless, 3-month mortality was comparable in both groups. Therefore, we conclude that surgical treatment for type II fractures in elderly patients is superior to conservative management, although conservative treatment remains a valuable option in elderly patients with severe comorbidities.

Morbidity and mortality in cervical spine injuries in the elderly

BACKGROUND

The aim of our study was to identify the demographics and complications in elderly cervical spine injuries and predictive factors for surgery, complications and mortality. We hypothesized younger healthier patients were more likely to undergo surgical intervention.

METHODS

A retrospective review of 225 consecutive patients aged 65 years and over with cervical spine injuries was carried out over a 3-year period.

RESULTS

There were 113 males and 112 females with an average of 79.7 years (range 65-98). The most common fracture was C2 peg type (21.8%). Five patients had complete spinal cord injury (2.2%), 25 had incomplete spinal cord injury (11.1%) and 84% were neurologically intact. Fifty-four patients were managed operatively (24%), while 171 patients were managed non-operatively (76%). The operative group had higher rates of pneumonia (odds ratio (OR) 5.3, 95% confidence interval (CI) 2.6-10.7, P < 0.01), cardiac arrhythmia (OR 4.1, 95% CI 1.5-11.2, P < 0.01) and respiratory failure (OR 2.6, 95% CI 1.2-5.5, P < 0.05). There was no difference in mortality between the operative and non-operative group (18.5% and 12.9%, P = 0.3). Patients with complete spinal cord injury had 100% mortality. Significant predictive factors for complications and death were neurological deficits, comorbidities and the presence of other injuries (P < 0.05). Surgery was not predictive for death and the operative group was younger than the non-operative group (P < 0.05).

CONCLUSIONS

In the setting of a high complication rate, consideration should be given to palliation in elderly patients with complete spinal cord injury and there must be good rational for surgery.

Surgical versus nonsurgical management for type II odontoid fractures in the elderly population: a systematic review

BACKGROUND

Odontoid process fractures, of which type II constitute the majority, are an increasingly important cause of morbidity and mortality in the elderly population. The incidence of geriatric type II fractures is steadily increasing in line with the aging population. However, the decision between surgical and non-surgical intervention for type II fractures in the elderly remains controversial.

PURPOSE

The present study aims to synthesize the current published literature comparing outcomes following surgical and non-surgical interventions for type II odontoid fractures in the elderly population (≥65 years old).

STUDY DESIGN/SETTING

Systematic review and meta-analysis were performed.

METHODS

A systematic search of MEDLINE, MEDLINE In-Progress & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to identify available evidence in English language. Studies with extractable data for all type II odontoid fractures in participants aged 65 years or older and which compared surgical and non-surgical intervention were included. Methodological quality was assessed using the Downs & Black checklist. Primary outcomes were mortality at short-term follow-up (≤3 months), mortality at long-term follow-up (predetermined study endpoint or mean follow-up length), and radiological union rate. Funding was provided by The University of Edinburgh for travel expenses to present this paper at the Society of British Neurological Sciences 2016 Conference ($170).

RESULTS

Twelve studies (n=1,098), all non-randomized, met eligibility criteria. Methodological quality was particularly poor in the confounding, bias, and power domains of assessment. Substantial methodological and statistical heterogeneity allowed only a narrative synthesis of the primary outcomes. Overall, data on mortality at short-term follow-up appeared to favor neither surgical nor non-surgical intervention. A small favorable outcome in surgically managed patients over non-surgically managed patients in terms of mortality at long-term follow-up was not proven conclusive because of considerable heterogeneity in study methodologies. Inadequate reporting of the time point of union assessment introduced the potential for significant intra- and interstudy heterogeneity and precluded assessment of union rates.

CONCLUSIONS

Evidence on this controversial topic is sparse, markedly heterogeneous, and of poor quality. Well-designed prospective trials adhering to guidance published by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative are required to inform clinical practice on this contentious but growing issue. Future randomized controlled trials should include an assessment of frailty and medical comorbidities with suitable patients subsequently randomized to surgical or non-surgical treatment.

Mortality Rates After Posterior C1-2 Fusion for Displaced Type II Odontoid Fractures in Octogenarians

STUDY DESIGN

Retrospective cohort study OBJECTIVE.: To assess 30-day and 1-year mortality rates as well as the most common complications associated with posterior C1-2 fusion in an octogenarian cohort.

SUMMARY OF BACKGROUND DATA

Treatment of unstable type II odontoid fractures in elderly patients can present challenges. Recent evidence indicates in patients older than 80 years, posterior C1-2 fusion results in improved survival as compared to other modes of treatment.

METHODS

Retrospective analysis of 43 consecutive patients (25 female and 18 male; mean age 84.3 yr, range 80-89 yr; mean Charlson Comorbidity Index 1.4, (range 1-6); mean body mass index 24.8 ± 4.2 kg/m, who underwent posterior C1-C2 fusion for management of unstable type II odontoid fracture by four fellowship trained spine surgeons at a single institution between January 2006 to June 2016.

RESULTS

Mean fracture displacement was 5.1 ± 3.6 mm and mean absolute value of angulation was 19.93° ± 12.93°. The most common complications were altered mental status (41.9%, n = 18), dysphagia (27.9%, n = 12) with 50% of those patients (6/12) requiring a feeding tube, and emergency reintubation (9.3%, n = 4). To the date of review completion, 25 of 43 patients expired (58.1%), median survival of 1.76 years from the date of surgery. Thirty-day and 1-year mortality rates were 2.3% and 18.6%, respectively. Patients who developed dysphagia were 14.5 times more likely to have expired at 1 year; dysphagia was also found to be significantly associated with degree of displacement. Fracture displacement was found to be associated with increased odds for 1-year mortality when accounting for age and requirement of a feeding tube.

CONCLUSION

Posterior C1-2 fusion results in acceptably low mortality rates in octogenarians with unstable type II odontoid fractures when compared to nonoperative management mortality rates in current literature. Initial fracture displacement is associated with higher mortality rate in this patient population.

LEVEL OF EVIDENCE

4.

Predictors of 30-Day Outcomes in Octogenarians with Traumatic C2 Fractures Undergoing Surgery

BACKGROUND

Predictors of surgical outcomes following traumatic axis (C2) fractures in octogenarians remain undercharacterized.

METHODS

Patients age ≥80 years undergoing cervical spine surgery following traumatic C2 fractures were extracted from the National Sample Program of the National Trauma Data Bank (2003-2012). Outcomes include overall inpatient complications, individual complications with an incidence >1%, hospital length of stay (HLOS), discharge disposition, and mortality. Demographics, comorbidities, and injury predictors were analyzed using multivariable regression. Odds ratios (OR), mean differences, and 95% confidence intervals (CIs) were calculated. Statistical significance was assessed at P < 0.05.

RESULTS

The cohort of 442 patients was 48.6% male and had a mean age of 84.3 ± 2.7 years. The distribution of admissions was 42.3% to the hospital floor, 40.3% to the intensive care unit (ICU), 7.7% to telemetry, 2.0% to the operating room, and 7.7% to other/unknown. Mortality was 9.7%, mean HLOS was 13.1 ± 9.2 days, the rate of complications was 38.5%, and 81.5% of survivors were discharged to a nonhome facility. Injury severity was predictive of mortality and overall complications. History of bleeding disorder/coagulopathy predicted mortality (OR, 4.02; 95% CI, 1.07-15.05), overall complications (OR, 3.01; 95% CI, 1.09-8.32), cardiac arrest (OR, 8.19; 95% CI, 1.06-63.54), and renal complications (OR, 10.36; 95% CI, 2.13-50.38). History of congestive heart failure predicted mortality (OR, 3.10; 95% CI, 1.10-8.69). ICU admission (vs. floor) predicted overall complications (OR, 2.01; 95% CI, 1.23-3.27) and pneumonia (OR, 4.65; 95% CI, 1.91-11.30). Telemetry admission (vs. floor) predicted unplanned intubation (OR, 7.76; 95% CI, 1.24-48.49).

CONCLUSIONS

In this cohort of octogenarians undergoing surgery for traumatic C2 fracture, injury severity and a history of bleeding disorder/coagulopathy were identified as risk factors for inpatient complications and mortality. Heightened surveillance should be considered for ICU and/or telemetry admissions for the development of complications. These findings warrant consideration by the clinician, patient, and family to inform clinical decisions and goals of care.

Nonoperative management of C-2 dens fractures: Single center experience and review of the literature

OBJECTIVE

The demographic change in the population leads to a rising number of patients presenting with fractures of the cervical spine, especially C-2, due to falls. With an increase of co-morbidities in these elder patients, the risk for intra- and postoperative complications is increased likewise. Thus, an alternative strategy instead of operative management of these fractures should be taken into account whenever possible. Conservative management of dens fractures in the elderly is still a subject of great controversy despite numerous studies on this topic. The aim of this study was to analyze the rate of successful osseous consolidation of C-2 fractures with conservative treatment by wearing a semi-rigid collar or halo thoracic vest without further surgical intervention.

PATIENTS AND METHODS

We analyzed the medical records and CT-scan of the cervical spine of 254 patients with C-2 fractures retrospectively, who were admitted to our department between January 1990 and September 2015. Fractures were diagnosed by CT-scan of the cervical spine and classified according to the Anderson - D`Alonzo classification. 183 patients were submitted to surgery as treatment of choice. In 71 patients a conservative management with external immobilization was chosen. The latter group was subjected to study analysis.

RESULTS

71 patients (mean age 74.08 years ± 16.06 years) were diagnosed with C-2 fractures (Typ I: 4; Typ II 36; Typ III: 31) and treated conservatively using a Philadelphia collar (n = 57), or a halo-thoracic vest (n = 14), respectively. 12 patients were lost to follow up and excluded from further analysis. Conservative treatment of the fractures was deemed successful when a bony consolidation of the fracture in follow-up CT scans was seen (45 of 59 patients; 76.3%). 20 patients with a Type II fracture (20/28, 71.4%) showed a successful ossification. In 14 patients (overall 23.7%; Typ I: 1 (7.14%), Typ II: 8 (57.14%), Typ III: 5 (35.71%)) external immobilization failed to achieve primary stability. These patients were submitted to consecutive surgery.

CONCLUSION

From our data it can be concluded that elderly patients, presenting with non-dislocated Type II fractures of the axis without accompaining neurological deficits, will have a more than 70% chance for a bony consolidation by conservative management. Consolidation rates may be estimated even higher in Type I and III fractures. Therefore, we suggest that external immobilization might be a valuable option to treat elderly patients with these fractures under certain circumstances.

Improving life expectancy: A 'broken neck' doesn't have to be a terminal diagnosis for the elderly

Background

Elderly patients with cervical spine fractures require optimal care. Treatment with a cervical collar or halo instead of surgical fixation may increase mortality. This investigation intends to describe the life expectancy after injury and evaluate the impact of surgical intervention on mortality.

Methods

Patients ≥65 years, with traumatic cervical spine fractures without cord injury were identified in the 1995-2009 California Office of Statewide Health and Planning database. Those with halo placement or surgical spine fixation were identified. Primary outcome was death, studied at the initial admission, 30 days, 1 year, and the entire study period. Univariate and multivariate regressions were performed to identify predictors of death. Kaplan-Meier survival curves were used to describe life expectancy after injury.

Results

10 938 patients were identified. Mortality rate was 10% during the initial admission, 28% at 1 year and 50% during the entire study period. A halo was placed in 14% of patients and 12% underwent surgical fixation. Mortality rates during the initial admission were 11% for patients without an intervention, 7% with halo placement and 6% with surgical fixation; at 1 year, these increased to 30%, 26% and 19%, respectively. At 1 year, more than one in four patients above 75 years of age will die.At 1 year spine fixation, female gender and admission to a trauma center predicted a lower risk of death at 1 year (OR 0.59, 0.68; p<0.001 and OR 0.89; p=0.02, respectively). Having a complication, fall mechanism, and traumatic brain injury (OR 1.84, 1.33, 1.37; p<0.001, respectively) were predictors of a higher risk of death. Halo use had no impact on death at 1 year (OR 0.98; p=0.77).

Discussion

Mortality rates after cervical spine fracture in the elderly is high. Surgical fixation is associated with improved survival; remaining true after adjusting for age and comorbidities; suggesting that surgical fixation may improve outcomes in the elderly.

Level of evidence

Level IV.

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.

Halo-Vest Immobilization in Elderly Odontoid Fracture Patients: Evolution in Treatment Modality and In-Hospital Outcomes

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the utilization and effectiveness of halo-vest (HV) immobilization for type II odontoid fractures from 2004 to 2014.

SUMMARY OF BACKGROUND DATA

Controversy persists regarding the optimal treatment method for odontoid fractures in the elderly. Management options include immobilization in a cervical orthosis, HV immobilization, and operative intervention. Over the past decade, high mortality and morbidity rates have been reported following HV immobilization in this patient population.

MATERIALS AND METHODS

In a retrospective study, patient demographics, presentation, Charlson comorbidity index, treatment method, and outcome data for patients over 65 who had suffered type II odontoid fractures from 2004 to 2014 were compared with a historical cohort from 1997 to 2004.

RESULTS

One hundred twenty-six patients met inclusion criteria. The mean age was 82.7±8.8 compared with 80.7±0.9 in the 1997-2004 cohort. The in-hospital mortality rate from 2004 to 2014 was 11.1% (14/126) compared with 31% in the historical cohort, and 10 (7.9%) patients were treated with HV compared with 49%. Mortality in the HV group was higher than the surgical group (P=0.01) but no different from the orthosis group (P=0.63).There were no differences in injury severity score, Charlson comorbidity index, or complications between treatment groups.

CONCLUSIONS

Over the past decade, HV use for elderly odontoid fractures has decreased at our institution. Mortality and morbidity of elderly patients treated with HV has also decreased. These findings are likely the result of improved patient selection and greater attention to respiratory care. This study demonstrates that HV immobilization of odontoid fractures in elderly patients can be as safe as cervical orthosis treatment in select patients.

Morbidity and Mortality Associated with Surgery of Traumatic C2 Fractures in Octogenarians

BACKGROUND: Management of axis fractures in the elderly remains controversial. As the US population increasingly lives past 80 years, published C2 fracture morbidity/mortality profiles in younger cohorts (55+) have become less applicable to octogenarians.

OBJECTIVE: To report associations between surgery and mortality, hospital length of stay and discharge disposition in octogenarians with traumatic C2 fractures.

METHODS: Retrospective cohort study of 3847 patients age ≥ 80 years representing 17 702 incidents nationwide, divided into surgery/nonsurgery cohorts, using the National Sample Program of the National Trauma Data Bank from 2003 to 2012. Inpatient complications, mortality, length of stay, and discharge disposition are characterized; multivariable regression was utilized to determine associations between surgery and outcomes.

Institutional Review Board (IRB): The National Sample Program dataset from the National Trauma Data Bank is fully deidentified and does not contain Health Insurance Portability and Accountability Act identifiers; therefore, this study is exempt from IRB review at the University of California, San Francisco.

RESULTS: Incidence of surgery was 10.3%. Surgery was associated with increased pneumonia, acute respiratory distress syndrome, and decubitus ulcer risks (P &lt; .001). Inpatient mortality was 12.8% (nonsurgery—13.0%; surgery—10.3%; P = .120). Length of stay was 8.31 ± 9.32 days (nonsurgery 7.78 ± 9.21; surgery 12.86 ± 9.07; P &lt; .001) and showed an adjusted mean increase of 5.68 days with surgery (95% confidence interval [4.74-6.61]). Of patients surviving to discharge, 26% returned home (nonsurgery—26.8%; surgery—18.8%; P = .001); surgery patients were less likely to return home (odds ratio 0.59 [0.44-0.78]).

CONCLUSION: The present study confirms that surgery of traumatic C2 fractures in octogenarians does not significantly affect inpatient mortality and increases discharge to institutionalized care. Patients undergoing surgery are more likely to require longer hospitalization and suffer increased medical complications during their stay. Given the retrospective nature of this study, it is unclear whether these conclusions reflect differences in injury severity between surgery cohorts. This question may be considered in a future prospective study.

Predictors of mortality following conservatively managed fractures of the odontoid in elderly patients

Aims

Rates of mortality as high as 25% to 30% have been described following fractures of the odontoid in the elderly population. The aim of this study was to examine whether easily identifiable variables present on admission are associated with mortality.

Patients and Methods

A consecutive series of 83 elderly patients with a fracture of the odontoid following a low-impact injury was identified retrospectively. Data that were collected included demographics, past medical history and the results of blood tests on admission. Radiological investigations were used to assess the Anderson and D’Alonzo classification and displacement of the fracture. The mean age was 82.9 years (65 to 101). Most patients (66; 79.5%) had a type 2 fracture. An associated neurological deficit was present in 11 (13.3%). All were treated conservatively; 80 (96.4%) with a hard collar and three (3.6%) with halo vest immobilisation.

Results

The rate of mortality was 16% (13 patients) at 30 days and 24% (20 patients) at one year after injury. A low serum level of haemoglobin and the presence of a neurological deficit on admission were independent predicators of mortality at 30 days on binary logistic regression analysis. A, low level of haemoglobin, admission from an institution, a neurological deficit and type 3 fractures were independent predictors of mortality at one year.

Conclusion

We suggest that these easily identifiable predictors present on admission can be used to identify patients at high risk and guide management by a multidisciplinary team. Cite this article: Bone Joint J 2017;99-B:116–21.

Deadly falls: operative versus nonoperative management of Type II odontoid process fracture in octogenarians

OBJECTIVE

Type II odontoid fracture is a common injury among elderly patients, particularly given their predisposition toward low-energy falls. Previous studies have demonstrated a survival advantage following early surgery among patients older than 65 years, yet octogenarians represent a medically distinct and rapidly growing population. The authors compared operative and nonoperative management in patients older than 79 years.

METHODS

A single-center prospectively maintained trauma database was reviewed using ICD-9 codes to identify octogenarians with C-2 cervical fractures between 1998 and 2014. Cervical CT images were independently reviewed by blinded neurosurgeons to confirm a Type II fracture pattern. Prospectively recorded outcomes included Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), additional cervical fracture, and cord injury. Primary end points were mortality at 30 days and at 1 year. Statistical tests included the Student t-test, chi-square test, Fisher's exact test, Kaplan-Meier test, and Cox proportional hazard.

RESULTS

A total of 111 patients met inclusion criteria (94 nonoperative and 17 operative [15 posterior and 2 anterior]). Mortality data were available for 100% of patients. The mean age was 87 years (range 80–104 years). Additional cervical fracture, spinal cord injury, GCS score, AIS score, and ISS were not associated with either management strategy at the time of presentation. The mean time to death or last follow-up was 22 months (range 0–129 months) and was nonsignificant between operative and nonoperative groups (p = 0.3). Overall mortality was 13% in-hospital, 26% at 30 days, and 41% at 1 year. Nonoperative and operative mortality rates were not significant at any time point (12% vs 18%, p = 0.5 [in-hospital]; 27% vs 24%, p = 0.8 [30-day]; and 41% vs 41%, p = 1.0 [1-year]). Kaplan-Meier analysis did not demonstrate a survival advantage for either management strategy. Spinal cord injury, GCS score, AIS score, and ISS were significantly associated with 30-day and 1-year mortality; however, Cox modeling was not significant for any variable. Additional cervical fracture was not associated with increased mortality. The rate of nonhome disposition was not significant between the groups.

CONCLUSIONS

Type II odontoid fracture is associated with high morbidity among octogenarians, with 41% 1-year mortality independent of intervention—a dramatic decrease from actuarial survival rates for all 80-, 90-, and 100-year-old Americans. Poor outcome is associated with spinal cord injury, GCS score, AIS score, and ISS.

Commentary on the management of type II odontoid process fractures in octogenarians: Article by Graffeo et al. and Editorial by Falavigna (J Neurosurgery Spine August 19, 2016)

Background:

Establishing a clear treatment paradigm for octogenarians with type II odontoid fractures in hampered by a literature replete with level III articles.

Methods:

In the study by Graffeo et al., the authors evaluated 111 patients over the age of 79 (average age: 87) with type II odontoid fractures undergoing nonoperative (94 patients) vs. operative intervention (17 total; 15 posterior and 2 anterior). They studied multiple variables and utilized several scales [abbreviated injury scale (AIS), injury severity score (ISS), and the Glasgow coma scale (GCS)] to determine the outcomes of nonoperative vs. operative management.

Results:

Graffeo et al. concluded that there were no significant differences between nonoperative and operative management for type II odontoid fractures in octogenarians. They found similar frequencies of additional cervical fractures, mechanisms of injury, GCS of 8 or under, AIS/ISS scores, and disposition to “nonhome” facilities. Furthermore, both appeared to have increased mortality rates at 1-year post injury; 13% during hospitalization, 26% within the first post-injury month, and 41% at 1 year.

Conclusions:

In the editorial by Falavigna, his major criticism of Graffeo's article was the marked disparity in the number of patients in the operative (17 patients) vs. the nonoperative group (94 patients), making it difficult to accept any conclusions as “significant”. He further noted that few prior studies provided level I evidence, and that most, like this one, were level III analyses that did not “significantly” advance our knowledge as to whether to treat octogenarians with type II odontoid fractures operatively vs. nonoperatively.

Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a "Hangman's Fracture." Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.

A Systematic Review of the Treatment of Geriatric Type II Odontoid Fractures

BACKGROUND

Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is controversial.

OBJECTIVE

To compare the short-term (<3 months) mortality, long-term (≥12 months) mortality, and complication rates of patients >60 years of age with a type II odontoid fracture managed either operatively or nonoperatively.

METHODS

We performed a systematic review of literature published between January 1, 2000, and February 1, 2015, related to the treatment of type II odontoid fractures in patients >60 years of age. An analysis of short-term mortality, long-term mortality, and the occurrence of complications was performed.

RESULTS

A total of 452 articles were identified, of which 21 articles with 1233 patients met the inclusion criteria. Short-term mortality (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) and long-term mortality (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) were lower in patients who underwent surgical treatment than in those who had nonsurgical treatment, and there were no significant differences in the rate of complications (odds ratio, 1.01; 95% confidence interval, 0.63-1.63). Surgical approach (posterior vs anterior) showed no significant difference in mortality or complication rate. Similarly, no difference in mortality or complication rate was identified with hard collar or a halo orthosis immobilization.

CONCLUSION

The current literature suggests that well-selected patients >60 years of age undergoing surgical treatment for a type II odontoid fracture have a decreased risk of short-term and long-term mortality without an increase in the risk of complications.

Cost Effectiveness of Operative Versus Non-Operative Treatment of Geriatric Type-II Odontoid Fracture

STUDY DESIGN

Cost-effectiveness analysis.

OBJECTIVE

To examine the cost-effectiveness of operative versus non-operative treatment of type-II odontoid fractures in patients older than 64 years old.

SUMMARY OF BACKGROUND DATA

Significant controversy exists regarding the optimum treatment of geriatric patients with type-II odontoid fractures. Operative treatment leads to lower rates of non-union but carries surgical risks. Non-operative treatment does not carry surgical risks but has higher non-union rates.

METHODS

A decision-analytic model was created to compare operative and non-operative treatment of type-II odontoid fractures among three age cohorts (65-74, 75-84, >84) based on expected costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs; cost per QALY gained). Age-specific mortality rates for both treatments, costs for treatment, and complication rates were taken from the literature, and data from 2010 US life tables were used for age-specific life expectancy. Costs of complications were estimated using data obtained at a level-I trauma center using micro-costing. Sensitivity analyses of all model parameters were conducted.

RESULTS

Among the 65- to 74-year-old cohort, operative treatment was more costly ($53,407 vs. $30,553) and more effective (12.00 vs. 10.11 QALY), with an ICER of $12,078/QALY. Among the 75- to 84-year-old cohort, operative treatment was more costly ($51,308 vs. $29,789) and more effective (6.85 vs. 6.31 QALY), with an ICER of $40,467/QALY. Among the over-84 cohort, operative treatment was dominated by non-operative treatment as it was both more costly ($45,978 vs. $28,872) and less effective (2.48 vs. 3.73 QALY). The model was robust to sensitivity analysis across reasonable ranges for utility of union, disutility of complications and delayed surgery, and probabilities of non-union and complications.

CONCLUSION

Operative treatment is cost-effective in patients age 65 to 84 when using $100,000/QALY as a benchmark but less effective and more costly than non-operative treatment in patients older than 84 years.

LEVEL OF EVIDENCE

2.