1
|
Baranto D, Steinke J, Blixt S, Gerdhem P, Beck J, Westin O, Horvath A. The epidemiology of odontoid fractures: a study from the Swedish fracture register. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:3034-3042. [PMID: 39020136 DOI: 10.1007/s00586-024-08406-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/19/2024] [Accepted: 07/08/2024] [Indexed: 07/19/2024]
Abstract
PURPOSE The objective of this study is to characterize the occurrence of odontoid fractures within a Swedish population. METHODS Prospective data of adults diagnosed with an odontoid fracture between 2015 and 2021 were retrieved from the Swedish Fracture Register (SFR). Epidemiologic data including age, sex, injury mechanism, injury type, fracture type (Anderson and D'Alonzo classification), neurological status and treatment type were requested from the SFR. Data pertinent to osteoporosis was retrieved from the Swedish National Patient Register. RESULTS A total of 1,154 odontoid fractures were identified, of which 30 were type I fractures, 583 type II fractures, and 541 type III fractures. The mean (Standard Deviation [SD]) age was 77.2 (13.8) years. The prevalence of osteoporosis and neurological deficits did not differ between the fracture types. The majority of patients were treated non-surgically (81%). Male sex and patient age 18-30 years were commonly associated with a high-injury mechanism, especially motor vehicle accidents. In the type II fracture group, significantly more patients had fallen from standing height or less than in the type III group (66% vs. 58%, p = 0.01) while in contrast, motor vehicle accidents were more common in the type III fracture group (12% vs. type II: 8%, p = 0.04). CONCLUSION Based on the SFR, the typical odontoid fracture patient is older and suffers a type II fracture. Most injuries were caused by low-energy trauma although in younger patients and males, they were associated with motor vehicle accidents. Across the patient population, odontoid fractures were usually treated non-surgically.
Collapse
Affiliation(s)
- Dawid Baranto
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Julia Steinke
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Simon Blixt
- Department of Orthopaedics and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Paul Gerdhem
- Department of Orthopaedics and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Joel Beck
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopeadics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olof Westin
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopeadics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alexandra Horvath
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Orthopeadics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| |
Collapse
|
2
|
Ribeiro PG, Fernandes F, Costa P, Quintas AC, Lourenço P, Moura DL. C1-C2 Transarticular Anterior Fixation for the Treatment of Atlantoaxial Traumatic Dislocation: A Clinical Case. Rev Bras Ortop 2024; 59:e68-e72. [PMID: 39027190 PMCID: PMC11254439 DOI: 10.1055/s-0042-1748812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/28/2022] [Indexed: 10/18/2022] Open
Abstract
Fractures of the odontoid apophysis are one of the most frequent lesions in the elderly population, and an increasingly preponderant problem with the progressive aging of the world population. In the present work, we report a clinical case of an 88-year-old male patient who suffered a fall resulting in a type-II fracture of the odontoid apophysis on the Anderson-D'Alonzo classification. Given the age and comorbidities of the patient, we decided to perform osteosynthesis of the fracture through anterior fixation with a transarticular screw in combination with fixation with an odontoid screw. This technique enables the necessary stability for the consolidation of Anderson-D'Alonzo's type II odontoid apophysis fracture, with the advantage of the lower levels of dissection of the cervical extensor musculature and hemorrhage resulting from this aggression when compared with the posterior approach; moreover, it is a readily-available technique that yields clear benefits in the treatment of this pathology in the geriatric population.
Collapse
Affiliation(s)
- Paulo Gil Ribeiro
- Setor de Coluna Vertebral, Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Francisco Fernandes
- Setor de Coluna Vertebral, Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Paulo Costa
- Setor de Coluna Vertebral, Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Ana Catarina Quintas
- Setor de Coluna Vertebral, Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Paulo Lourenço
- Setor de Coluna Vertebral, Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Diogo Lino Moura
- Setor de Coluna Vertebral, Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| |
Collapse
|
3
|
Liawrungrueang W, Cho ST, Kotheeranurak V, Pun A, Jitpakdee K, Sarasombath P. Artificial neural networks for the detection of odontoid fractures using the Konstanz Information Miner Analytics Platform. Asian Spine J 2024; 18:407-414. [PMID: 38917858 PMCID: PMC11222894 DOI: 10.31616/asj.2023.0259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/30/2023] [Accepted: 10/23/2023] [Indexed: 06/27/2024] Open
Abstract
STUDY DESIGN An experimental study. PURPOSE This study aimed to investigate the potential use of artificial neural networks (ANNs) in the detection of odontoid fractures using the Konstanz Information Miner (KNIME) Analytics Platform that provides a technique for computer-assisted diagnosis using radiographic X-ray imaging. OVERVIEW OF LITERATURE In medical image processing, computer-assisted diagnosis with ANNs from radiographic X-ray imaging is becoming increasingly popular. Odontoid fractures are a common fracture of the axis and account for 10%-15% of all cervical fractures. However, a literature review of computer-assisted diagnosis with ANNs has not been made. METHODS This study analyzed 432 open-mouth (odontoid) radiographic views of cervical spine X-ray images obtained from dataset repositories, which were used in developing ANN models based on the convolutional neural network theory. All the images contained diagnostic information, including 216 radiographic images of individuals with normal odontoid processes and 216 images of patients with acute odontoid fractures. The model classified each image as either showing an odontoid fracture or not. Specifically, 70% of the images were training datasets used for model training, and 30% were used for testing. KNIME's graphic user interface-based programming enabled class label annotation, data preprocessing, model training, and performance evaluation. RESULTS The graphic user interface program by KNIME was used to report all radiographic X-ray imaging features. The ANN model performed 50 epochs of training. The performance indices in detecting odontoid fractures included sensitivity, specificity, F-measure, and prediction error of 100%, 95.4%, 97.77%, and 2.3%, respectively. The model's accuracy accounted for 97% of the area under the receiver operating characteristic curve for the diagnosis of odontoid fractures. CONCLUSIONS The ANN models with the KNIME Analytics Platform were successfully used in the computer-assisted diagnosis of odontoid fractures using radiographic X-ray images. This approach can help radiologists in the screening, detection, and diagnosis of acute odontoid fractures.
Collapse
Affiliation(s)
| | - Sung Tan Cho
- Department of Orthopaedic Surgery, Seoul Seonam Hospital, Seoul, Korea
| | - Vit Kotheeranurak
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok,
Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok,
Thailand
| | - Alvin Pun
- Department of Neurosciences Clinical Institute, Epworth Richmond, Melbourne,
Australia
| | - Khanathip Jitpakdee
- Department of Orthopaedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi,
Thailand
| | - Peem Sarasombath
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai,
Thailand
| |
Collapse
|
4
|
Hamrick FA, Sherrod BA, Cole K, Cox P, Croci DM, Bowers CA, Mazur MD, Dailey AT, Bisson EF. Using Frailty Measures to Predict Functional Outcomes and Mortality After Type II Odontoid Fracture in Elderly Patients: A Retrospective Cohort Study. Global Spine J 2024; 14:1552-1562. [PMID: 36626221 DOI: 10.1177/21925682221149394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Single-center retrospective cohort study. OBJECTIVES Type II odontoid fractures occur disproportionately among elderly populations and cause significant morbidity and mortality. It is a matter of debate whether these injuries are best managed surgically or conservatively. Our goal was to identify how treatment modalities and patient characteristics correlated with functional outcome and mortality. METHODS We identified adult patients (>60 years) with traumatic type II odontoid fractures. We used multivariate regression controlling for patient demographics, Glasgow Coma Scale (GCS) score, Charlson Comorbidity Index (CCI), modified Rankin Scale (mRS) score, modified Frailty Index (mFI-5 and mFI-11), fracture displacement, and conservative vs operative treatment. RESULTS Of the 59 patients (mean age 77.9 years), 24 underwent surgical intervention and 35 underwent conservative management. Operatively managed patients were younger (73.4 vs 80.6 years, P < .001) and had higher degree of fracture displacement (3.5 vs 1.0 mm, P = .002) than conservatively managed patients but no other differences in baseline characteristics. Twenty-four patients (40.7%) died within the study period (median time to death: 376 days). There were no differences between treatment groups in functional outcomes (mRS or Frankel Grade) or mortality (33.3% in operative group vs 45.7%, P = .34). There was a statistically significant correlation between higher presentation mRS score and subsequent mortality on multivariate analysis (OR = 2.06, 95% CI 1.04-4.10, P = .039), whereas surgical intervention, age, GCS score, CCI, mFI-5, mFI-11, sex, and fracture displacement were not significantly correlated. CONCLUSIONS Mortality after type II odontoid fractures in elderly patients is common. mRS score at presentation may help predict mortality more accurately than other patient factors.
Collapse
Affiliation(s)
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Kyril Cole
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Parker Cox
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Davide M Croci
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
5
|
Zhu Y, Qian J, Hu H, Zhou F, Yang H, Shi J. Sequential treatment of concomitant odontoid fracture and lower cervical fracture-dislocation: A case report. Int J Surg Case Rep 2024; 118:109636. [PMID: 38643655 PMCID: PMC11046059 DOI: 10.1016/j.ijscr.2024.109636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/03/2024] [Accepted: 04/17/2024] [Indexed: 04/23/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE To report the sequential treatment of a Type II odontoid fracture combined with a severe lower cervical (C6-7) fracture-dislocation featuring bilateral facet joint interlocking. CASE PRESENTATION A 58-year-old male who had suffered an injury in a car accident, He presented neck pain and extremity paralysis. His neurological function was classified as per the American Spinal Injury Association (ASIA) impairment scale as Grade A, indicating complete deficits below the C6 spinal cord level. A cervical CT scan and magnetic resonance image showed a type II odontoid fracture, C6 slipped anteriorly, C6-7 bilateral facet joint fracture and interlocking, slightly compression change of C7 upper endplate. CLINICAL DISCUSSION Emergency closed reduction using cranial tong traction was success 6 h after the injury. A subsequent CT scan proved the successful reduction of bilateral facet joint dislocations and the odontoid fracture. After careful overall assessment, anterior cervical decompression and fusion (ACDF) was performed at C5-6 and C6-7 segments three days later,while odontoid fracture was treated conservatively. At the 4 months follow-up, a CT scan demonstrated solid bone fusion at C5-6, C6-7 segments, along with successful healing at the odontoid fracture site. However, spinal cord was necrosis at C5-7 segments, and the patient's neurological function had no improvement. CONCLUSION The initial closed reduction could restore the alignment and preliminary stability of cervical spine at sub-axial cervical fracture-dislocation segment as well as displaced odontoid fracture. This timely and effective closed reduction significantly diminished sequential surgical trauma and mitigated associated risks.
Collapse
Affiliation(s)
- Yuanchen Zhu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, China
| | - Jin Qian
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, China
| | - Hanfeng Hu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, China
| | - Feng Zhou
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, China
| | - Huilin Yang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, China
| | - Jinhui Shi
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, China.
| |
Collapse
|
6
|
Mousavi SR, Farrokhi MR, Eghbal K, Motlagh MAS, Jangiaghdam H, Ghaffarpasand F. Posterior-only approach for treatment of irreducible traumatic Atlanto-axial dislocation, secondary to type-II odontoid fracture; report of a missed case, its management and review of literature. Int J Surg Case Rep 2024; 114:109104. [PMID: 38070376 PMCID: PMC10755710 DOI: 10.1016/j.ijscr.2023.109104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 01/01/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Odontoid fracture (OF) is among the most common and challenging cervical spine fractures in regards to the treatment and surgical approach. Atlanto-axial dislocation (AAD) is considered a significant complication after failed non-surgical treatment of OF. Traditionally, it requires anterior odontoidectomy followed by posterior C1-C2 reduction and fusion. In latest studies, Atlanto-axial joint (AAJ) remodeling in a posterior-only approach has got attention. CASE PRESENTATION We herein present a 30-year-old man with missed type-II OF, presenting with irreducible anterior AAD and progressive neurological deficit. Old non-united OF with dorsal callous formation, compressing spinal cord, was detected. The patient underwent correction of the deformity and reduction of the fracture utilizing the posterior-only approach. AAJ remodeling, callous release and C1-C2 fusion was performed in standard prone position, under fluoroscopic guide and intraoperative electrophysiological monitoring. The patient had uneventful surgery and postoperative course and was neurologically intact with appropriate alignment in 6-month follow-up. CLINICAL DISCUSSION The irreducible AAD following type-II OF could be successfully treated with posterior-only approach (C1-C2 fusion). CONCLUSION Type-II OF is considered unstable requiring surgical management. Close follow-up and appropriate patient education is mandatory in non-surgical treatment. Irreducible AAD has been managed with anterior odontoid resection and posterior fusion. Several complications of anterior surgery, makes posterior-only approach a noticeable choice.
Collapse
Affiliation(s)
- Seyed Reza Mousavi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran; Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Majid Reza Farrokhi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran; Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Keyvan Eghbal
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Hamid Jangiaghdam
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
7
|
Kerschbaum M, Klute L, Henssler L, Rupp M, Alt V, Lang S. 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. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:185-197. [PMID: 37714928 DOI: 10.1007/s00586-023-07919-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/05/2023] [Accepted: 08/23/2023] [Indexed: 09/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- Maximilian Kerschbaum
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Lisa Klute
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Leopold Henssler
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Siegmund Lang
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| |
Collapse
|
8
|
Cloney MB, Texakalidis P, Roumeliotis AG, Thirunavu V, Shlobin NA, Swong K, El Tecle N, Dahdaleh NS. The demographic, clinical, and management differences between traumatic dens fracture patients with and without simultaneous atlas fractures. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:21-29. [PMID: 38644924 PMCID: PMC11029115 DOI: 10.4103/jcvjs.jcvjs_147_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/25/2023] [Indexed: 04/23/2024] Open
Abstract
Introduction Atlas fractures often accompany traumatic dens fractures, but existing literature on the management of simultaneous atlantoaxial fractures is limited. Methods We examined all patients with traumatic dens fractures at our institution between 2008 and 2018. We used multivariable logistic regression and ordinal logistic regression to identify factors independently associated with presentation with a simultaneous atlas fracture, as well myelopathy severity, fracture nonunion, and selection for surgery. Results Two hundred and eighty-two patients with traumatic dens fractures without subaxial fractures were identified, including 65 (22.8%) with simultaneous atlas fractures. The distribution of injury mechanisms differed between groups (χ2 P = 0.0360). On multivariable logistic regression, dens nonunion was positively associated with type II fractures (odds ratio [OR] = 2.00, P = 0.038) and negatively associated with having surgery (OR = 0.52, P = 0.049), but not with having a C1 fracture (P = 0.3673). Worse myelopathy severity on presentation was associated with having a severe injury severity score (OR = 102.3, P < 0.001) and older age (OR = 1.28, P = 0.002), but not with having an atlas fracture (P = 0.2446). Having a simultaneous atlas fracture was associated with older age (OR = 1.29, P = 0.024) and dens fracture angulation (OR = 2.62, P = 0.004). Among patients who underwent surgery, C1/C2 posterior fusion was the most common procedure, and having a simultaneous atlas fracture was associated with selection for occipitocervical fusion (OCF) (OR = 14.35, P = 0.010). Conclusions Among patients with traumatic dens, patients who have simultaneous atlas fractures are a distinct subpopulation with respect to age, mechanism of injury, fracture morphology, and management. Traumatic dens fractures with simultaneous atlas fractures are independently associated with selection for OCF rather than posterior cervical fusion alone.
Collapse
Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pavlos Texakalidis
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anastasios G. Roumeliotis
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vineeth Thirunavu
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kevin Swong
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nader S. Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
9
|
Cloney MB, Thirunavu V, Roumeliotis A, Texakalidis P, Swong K, El Tecle N, Dahdaleh NS. Traumatic Dens Fracture Patients Comprise Distinct Subpopulations Distinguished by Differences in Age, Sex, Injury Mechanism and Severity, and Outcome. World Neurosurg 2023; 178:e128-e134. [PMID: 37423338 DOI: 10.1016/j.wneu.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/30/2023] [Accepted: 07/01/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Dens fractures are an increasingly common injury, yet their epidemiology and its implications remain underexamined. METHODS We retrospectively analyzed all traumatic dens fracture patients managed at our institution over a 10-year period, examining demographic, clinical, and outcomes data. Patient subsets were compared across these parameters. RESULTS Among 303 traumatic dens fracture patients, we observed a bimodal age distribution with a strong goodness of fit centered at age 22.3 ± 5.7 (R = 0.8781) and at 77.7 ± 13.9 (R = 0.9686). A population pyramid demonstrated a bimodal distribution among male patients, but not female patients, which was confirmed with a strong goodness of fit for male patient subpopulations age <35 (R = 0.9791) and age ≥35 (R = 0.8843), but a weaker fit for a second female subpopulation age <35. Both age groups were equally likely to undergo surgery. Patients younger than age 35 were more likely to be male (82.4% vs. 46.9%, odds ratio [OR] = 5.29 [1.54, 17.57], P = 0.0052), have motor vehicle collision as their mechanism of injury (64.7% vs. 14.1%, OR = 11.18 [3.77, 31.77], P < 0.0001), and to have a severe trauma injury severity score (17.6% vs. 2.9%, OR = 7.23 [1.88, 28.88], P = 0.0198). Nevertheless, patients age <35 were less likely to have fracture nonunion at follow (18.2% vs. 53.7%, OR = 0.19 [0.041, 0.76], P = 0.0288). CONCLUSIONS The dens fracture patient population comprises 2 subpopulations, distinguished by differences in age, sex, injury mechanism and severity, and outcome, with male dens fracture patients demonstrating a bimodal age distribution. Young, male patients were more likely to have high-energy injury mechanisms leading to severe trauma, yet were less likely to have fracture nonunion at follow-up.
Collapse
Affiliation(s)
- Michael B Cloney
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA.
| | - Vineeth Thirunavu
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Anastasios Roumeliotis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Pavlos Texakalidis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Kevin Swong
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
10
|
Godlewski B, Dominiak M, Bebenek A. Revision Procedure After Surgery for Atypical Hangman's Fracture Primarily Performed Only from the Posterior Approach - An Attempt to Maintain Head Rotation: Case Report. Int Med Case Rep J 2023; 16:377-383. [PMID: 37366397 PMCID: PMC10290858 DOI: 10.2147/imcrj.s419321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/17/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Hangman's fracture, also known as traumatic spondylolisthesis of the axis, is defined as a bilateral fracture of the C2 pars interarticularis. In 1965, Schneider used this term to describe a pattern of similarities seen in fractures associated with judicial hangings. However, this fracture pattern is only observed in approximately 10% of injuries associated with hangings. Case Report We present a case of an atypical hangman's fracture caused by a headlong dive into a swimming pool and striking the pool's bottom. The patient had undergone surgery at another centre, where posterior C2-C3 stabilisation was performed. Due to the presence of screws in the C1-C2 joint spaces, the patient could not perform rotational movements of the head. Anterior stabilization to prevent C2 dislocation against C3 was also not performed, and appropriate spinal stability was not ensured. Our decision to reoperate was motivated, among other factors, by our intention to restore rotational head movements. The revision surgery was performed from both an anterior and posterior approach. After the surgery, the patient was able to rotate his head while maintaining cervical spine stability. The case presented here represents not only a unique example of an atypical C2 fracture but also highlights a fixation technique that provided the necessary stability for successful fusion. The utilized method restored functional rotational movement of the head, thus preserving the patient's quality of life, which is of paramount importance considering the patient's age. Conclusion The decision-making process regarding the technique for treating hangman's fractures, especially atypical fractures, should account for the patients' quality of life after the operation. The preservation of as much of the physiological range of motion as possible with maintained spinal stability should be the goal of therapy in every case.
Collapse
Affiliation(s)
- Bartosz Godlewski
- Department of Orthopaedics and Traumatology, with Spinal Surgery Ward, Scanmed – St. Raphael Hospital, Cracow, Poland
| | - Maciej Dominiak
- Department of Orthopaedics and Traumatology, with Spinal Surgery Ward, Scanmed – St. Raphael Hospital, Cracow, Poland
| | - Adam Bebenek
- Department of Orthopaedics and Traumatology, with Spinal Surgery Ward, Scanmed – St. Raphael Hospital, Cracow, Poland
| |
Collapse
|
11
|
Salottolo K, Betancourt A, Banton KL, Acuna D, Panchal R, Bar-Or D, Palacio CH. Epidemiology of C2 fractures and determinants of surgical management: analysis of a national registry. Trauma Surg Acute Care Open 2023; 8:e001094. [PMID: 37342819 PMCID: PMC10277549 DOI: 10.1136/tsaco-2023-001094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/26/2023] [Indexed: 06/23/2023] Open
Abstract
Objective Operative management of axis fractures (C2) usually depend on the stability and location of the break and individual patient characteristics. We sought to describe the epidemiology of C2 fractures and hypothesized that determinants for surgery would differ by fracture diagnosis. Methods Patients with C2 fractures were identified from the US National Trauma Data Bank from January 1, 2017, to January 1, 2020. Patients were classified by C2 fracture diagnosis: odontoid type II, odontoid types I and III, and non-odontoid fracture (hangman's fracture or fractures through base of the axis). The primary comparison was C2 fracture surgery versus non-operative management. Multivariate logistic regression was used to identify independent associations with surgery. Decision tree-based models were developed to identify determinants for surgery. Results There were 38 080 patients; 42.7% had an odontoid type II fracture; 16.5% had an odontoid type I/III fracture; and 40.8% had a non-odontoid fracture. All examined patient demographics, clinical characteristics, outcomes, and interventions differed by C2 fracture diagnosis. Overall, 5292 (13.9%) were surgically managed (17.5% odontoid type II, 11.0% odontoid type I/III, and 11.2% non-odontoid; p<0.001). The following covariates increased odds of surgery for all three fracture diagnoses: younger age, treatment at a level I trauma center, fracture displacement, cervical ligament sprain, and cervical subluxation. Determinants of surgery differed by fracture diagnosis: for odontoid type II, age ≤80 years, a displaced fracture, and cervical ligament sprain were determinants; for odontoid type I/III, age ≤85 years, a displaced fracture, and cervical subluxation were determinants; for non-odontoid fractures, cervical subluxation and cervical ligament sprain were the strongest determinants for surgery, by hierarchy. Conclusions This is the largest published study of C2 fractures and current surgical management in the USA. Odontoid fractures, regardless of type, had age and fracture displacement as the strongest determinants for surgical management, whereas associated injuries were determinants of surgery for non-odontoid fractures. Level of evidence III.
Collapse
Affiliation(s)
| | | | | | - David Acuna
- Trauma Services, Wesley Medical Center, Wichita, Kansas, USA
| | - Ripul Panchal
- Neurosurgery, American Neurospine Institute, PLLC, Plano, Texas, USA
- Neurosurgery, Medical City Plano, Plano, Texas, USA
| | - David Bar-Or
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
| | - Carlos H Palacio
- Trauma Services, South Texas Health System McAllen, McAllen, TX, USA
| |
Collapse
|
12
|
Osterhoff G, Scholz M, Disch AC, Katscher S, Spiegl UJA, Schnake KJ, Scheyerer MJ. Geriatric Odontoid Fractures: Treatment Algorithms of the German Society for Orthopaedics and Trauma Based on Expert Consensus and a Systematic Review. Global Spine J 2023; 13:13S-21S. [PMID: 37084350 PMCID: PMC10177304 DOI: 10.1177/21925682231157316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Systematic review/expert consensus. OBJECTIVES Fractures of the axis represent the most frequent injury of the spine in elderly patients. Both, operative and non-operative treatment are associated with a high rate of complications and mortality. The aim of this article was to summarize the current literature on the management of odontoid fractures in geriatric patients and to weigh it based on an expert consensus process. METHODS In a joint consensus process, members of the Spine Section of the German Orthopaedic and Trauma Society (DGOU) aimed to formulate recommendations for the diagnostic workup and treatment of odontoid fractures in geriatric patients. Based on the previously published recommendations, this article is an updated version with incorporating a systematic review of the recent literature. RESULTS Based on the new data available, the recommendations established in the initial consensus process were adapted. CONCLUSIONS Computed tomography represents the diagnostic standard for patients with suspected injuries of the upper cervical spine. Anderson/D'Alonzo odontoid fractures type 1, non-displaced type 2, and type 3 can be treated conservatively. Even non-unions do not necessarily result in poor clinical outcome. In Anderson/D'Alonzo type 2 fractures, surgical therapy offers the advantage of relatively safe osseous healing with no increased complication rate even in elderly patients and can thus be recommended. In very high aged patients, however, a case-by-case decision should be made. When surgical stabilization of osteoporotic odontoid fractures is indicated, posterior techniques are biomechanically advantageous and can be considered the standard.
Collapse
Affiliation(s)
- Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Matti Scholz
- ATOS Orthopaedic Clinic Braunfels, Braunfels, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center (UCSC), University Center for Orthopaedics, Traumatology & Plastic Surgery, University Hospital Carl Gustav Carus at the TU Dresden, Germany
| | - Sebastian Katscher
- Interdisciplinary Center for Spine and Neurotrauma, Sana Klinikum Borna, Borna, Germany
| | - Ulrich J A Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Waldkrankenhaus Erlangen, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Max J Scheyerer
- Department of Orthopaedics and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Koln, Germany
| |
Collapse
|
13
|
Berkay F, Minhas A, Lyons JG, Fonte E, Foster N. Epidemiology of C2 fractures in the United States: A National Electronic Injury Surveillance System database study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:187-193. [PMID: 37448502 PMCID: PMC10336903 DOI: 10.4103/jcvjs.jcvjs_37_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/15/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction C2 fractures are one of the most common traumatic injuries of the cervical spine, with high rates of morbidity and mortality. Current literature on the incidence of C2 fractures is limited to populations outside of the United States (US), prior to 2014, or specific age cohorts. The purpose of this study is to report the incidence rate (IR) of C2 fractures and associated patient demographics in the US between 2002 and 2021 using the National Electronic Injury Surveillance System (NEISS) database. Methods This study analyzed the NEISS database to identify cases of C2 fractures presenting to US Emergency Departments (EDs) from 2002 to 2021. Annual and overall numbers of fractures, IR, and patient demographics were analyzed. IR is expressed as the number of fractures per 100,000 person-years at risk (PYR). Patients were split into three different age groups for comparison (children and young adults, 0-64 years; older adults, 65-79 years; elderly individuals, 80 + years). Results A national estimate of n = 72,764 patients (95% confidence interval [CI] = 54,371-91,156) presented to US EDs with a C2 fracture (IR was 1.17/PYR; 95% CI = 0.87-1.46), and elderly individuals had the highest IR overall (IR = 15.9; P < 0.05). The IR of C2 fractures between 2002 and 2021, reported as average annual percent change (AAPC), increased significantly, regardless of age or sex (AAPC = 10.9; 95% CI = 6.3-15.6; P < 0.0001). Conclusion C2 fractures occur at higher rates than previous years, with especially high IR in elderly individuals. Emphasis of public health efforts toward osteoporosis and coordination difficulties in elderly individuals would likely significantly reduce the overall IR of these injuries.
Collapse
Affiliation(s)
- Fehmi Berkay
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Arjun Minhas
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Joseph G. Lyons
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Elizabeth Fonte
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Norah Foster
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
- Department of Orthopaedic Surgery, Miami Valley Hospital, Dayton, OH, USA
| |
Collapse
|
14
|
Koepke LG, von Kroge S, Heuer A, Kammal AL, Ondruschka B, Rolvien T, Viezens L. Analysis of Three-Dimensional Bone Microarchitecture of the Axis Exposes Pronounced Regional Heterogeneity Associated with Clinical Fracture Patterns. Calcif Tissue Int 2023; 112:563-572. [PMID: 36826480 PMCID: PMC10106346 DOI: 10.1007/s00223-023-01070-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
The odontoid process (dens) of the second cervical vertebra (axis) is prone to fracture. While the importance of its skeletal integrity has been previously noted, representative three-dimensional microarchitecture analyses in humans are not available. This study aimed to determine the bone microarchitecture of the axis using high-resolution quantitative computed tomography (HR-pQCT) and to derive clinical implications for the occurrence and treatment of axis fractures. For initial clinical reference, the apparent density of the axis was determined based on clinical computed tomography (CT) images in patients without and with fractures of the axis. Subsequently, 28 human axes (female 50%) obtained at autopsy were analyzed by HR-pQCT. Analyses were performed in three different regions corresponding to zones I (tip of dens), II (base of dens), and III (corpus axis) of the Anderson and D'Alonzo classification. Lower apparent densities based on clinical CT data were detected in zone II and III compared to zone I in both the group without and with fracture. In the autopsy specimens, cortical thickness and bone volume fraction decreased continuously from zone I to zone III. Trabecular and cortical tissue mineral density was lowest in zone III, with no differences between zones I and II. In conclusion, our clinical and high-resolution ex vivo imaging data highlight a marked regional heterogeneity of bone microarchitecture, with poor cortical and trabecular properties near the dens base. These results may partly explain why zones II and III are at high risk of fracture and osteosynthesis failure.
Collapse
Affiliation(s)
- Leon-Gordian Koepke
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Heuer
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Lena Kammal
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Viezens
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
15
|
Simion G, Eckardt N, Senft C, Schwarz F. Bone density of the axis (C2) measured using Hounsfield units of computed tomography. J Orthop Surg Res 2023; 18:93. [PMID: 36765379 PMCID: PMC9921026 DOI: 10.1186/s13018-023-03560-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION The assessment of bone density is of great importance nowadays due to the increasing age of patients. Especially in regard to the surgical stabilization of the spine, the assessment of bone density is important for therapeutic decision making. The aim of this work was to record trabecular bone density values using Hounsfield units of the second cervical vertebra. MATERIAL AND METHODS The study is a monocentric retrospective data analysis of 198 patients who received contrast-enhanced polytrauma computed tomography in a period of two years at a maximum care hospital. Hounsfield units were measured in three different regions within the C2: dens, transition area between dens and vertebral body and vertebral body. The measured Hounsfield units were converted into bone density values using a validated formula. RESULTS A total of 198 patients were included. The median bone density varied in different regions of all measured C2 vertebrae: in the dens axis, C2 transition area between dens and vertebral body, and in the vertebral body bone densities were 302.79 mg/cm3, 160.08 mg/cm3, and 240.31 mg/cm3, respectively. The transition area from dens axis to corpus had statistically significant lower bone density values compared to the other regions (p < 0.001). There was a decrease in bone density values after age 50 years in both men and women (p < 0.001). CONCLUSIONS The transitional area from dens axis to corpus showed statistically significant lower bone density values compared to the adjacent regions (p < 0.001). This area seems to be a predilection site for fractures of the 2nd cervical vertebra, which is why special attention should be paid here in radiological diagnostics after a trauma.
Collapse
Affiliation(s)
- George Simion
- grid.9613.d0000 0001 1939 2794Department of Neurosurgery, Jena University Hospital – Friedrich Schiller University Jena, Jena, Germany
| | - Niklas Eckardt
- grid.9613.d0000 0001 1939 2794Department for Radiology, Jena University Hospital – Friedrich Schiller University Jena, Jena, Germany
| | - Christian Senft
- grid.9613.d0000 0001 1939 2794Department of Neurosurgery, Jena University Hospital – Friedrich Schiller University Jena, Jena, Germany
| | - Falko Schwarz
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany.
| |
Collapse
|
16
|
Vaccaro AR, Lambrechts MJ, Karamian BA, Canseco JA, Oner C, Benneker LM, Bransford R, Kandziora F, Shanmuganathan R, El-Sharkawi M, Kanna R, Joaquim A, Schnake K, Kepler CK, Schroeder GD. Global Validation of the AO Spine Upper Cervical Injury Classification. Spine (Phila Pa 1976) 2022; 47:1541-1548. [PMID: 35877555 PMCID: PMC9612701 DOI: 10.1097/brs.0000000000004429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/17/2022] [Accepted: 06/02/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Global cross-sectional survey. OBJECTIVE To determine the classification accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on an international group of AO Spine members. SUMMARY OF BACKGROUND DATA Previous upper cervical spine injury classifications have primarily been descriptive without incorporating a hierarchical injury progression within the classification system. Further, upper cervical spine injury classifications have focused on distinct anatomical segments within the upper cervical spine. The AO Spine Upper Cervical Injury Classification System incorporates all injuries of the upper cervical spine into a single classification system focused on a hierarchical progression from isolated bony injuries (type A) to fracture dislocations (type C). METHODS A total of 275 AO Spine members participated in a validation aimed at classifying 25 upper cervical spine injuries through computed tomography scans according to the AO Spine Upper Cervical Classification System. The validation occurred on two separate occasions, three weeks apart. Descriptive statistics for percent agreement with the gold-standard were calculated and the Pearson χ 2 test evaluated significance between validation groups. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS The accuracy of AO Spine members to appropriately classify upper cervical spine injuries was 79.7% on assessment 1 (AS1) and 78.7% on assessment 2 (AS2). The overall intraobserver reproducibility was substantial (κ=0.70), while the overall interobserver reliability for AS1 and AS2 was substantial (κ=0.63 and κ=0.61, respectively). Injury location had higher interobserver reliability (AS1: κ = 0.85 and AS2: κ=0.83) than the injury type (AS1: κ=0.59 and AS2: 0.57) on both assessments. CONCLUSION The global validation of the AO Spine Upper Cervical Injury Classification System demonstrated substantial interobserver agreement and intraobserver reproducibility. These results support the universal applicability of the AO Spine Upper Cervical Injury Classification System. LEVEL OF EVIDENCE 4.
Collapse
Affiliation(s)
| | | | | | - Jose A. Canseco
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, the Netherlands
| | | | - Richard Bransford
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | | | | | | | - Rishi Kanna
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Andrei Joaquim
- Department of Neurology, Neurosurgery Division, State University of Campinas, Campinas, Sao Paulo, Brazil
| | - Klaus Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | | | | | | |
Collapse
|
17
|
Florman JE, Gerstl JVE, Kilgallon JL, Riesenburger RI. Fibrous Nonunion of Odontoid Fractures: Is It Safe To Accept Nonoperative Management? A Systematic Review. World Neurosurg 2022; 164:298-304. [PMID: 35659587 DOI: 10.1016/j.wneu.2022.05.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Nonoperative management of odontoid fractures can result in solid fusion, unstable nonunion, and fibrous nonunion. Odontoid fractures with fibrous nonunion will not demonstrate dynamic instability on imaging studies. However, the safety of accepting this outcome has been debated. We have provided, to the best of our knowledge, the first systematic review of the existing literature to explore the safety of allowing fibrous nonunion as an acceptable outcome for odontoid fractures. METHODS The PubMed and Embase databases were searched in January 2022. The outcomes were extracted and categorized according to the mortality, neurologic sequelae, pain, neck disability index, and satisfaction. RESULTS Of a total of 700 abstracts screened, the full text of 79 reports was assessed, with 13 studies included. Of the included patients, 141 had had a fibrous nonunion, all described in observational studies. The follow-up ranged from 0.6 to 5.8 years. None of the 141 patients had experienced a neurologic event. One patient had died of trauma-related issues; however, causality was not reported. Most of the studies had reported good to excellent pain scores. Most of the neck disabilities reported had ranged from mild to moderate in severity. However, 1 study of 5 patients had reported severe disability. All the patients reported good or excellent satisfaction. CONCLUSIONS The evidence we found supports that it is safe to forgo surgery for carefully selected patients with nonunited odontoid fractures when near-anatomic alignment is present, dynamic instability is lacking on imaging studies, the neurologic examination findings are normal, and the risk of neck injury is low. Further study is needed to define the full natural history of fibrous nonunion of odontoid fractures.
Collapse
Affiliation(s)
- Jeffrey E Florman
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA.
| | - Jakob V E Gerstl
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John L Kilgallon
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
18
|
Honda A, Michihata N, Iizuka Y, Mieda T, Takasawa E, Ishiwata S, Matsui H, Fushimi K, Yasunaga H, Chikuda H. Clinical features and early post-operative complications of isolated C2 odontoid fractures: a retrospective analysis using a national inpatient database in Japan. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3631-3638. [PMID: 33959795 DOI: 10.1007/s00586-021-06862-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 04/27/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To examine the clinical features and post-treatment complications in patients with isolated C2 odontoid fractures. METHODS We extracted data for all patients who were admitted with C2 odontoid fractures from the Japanese Diagnosis Procedure Combination database between July 2010 and March 2017. We then compared the post-treatment complications during hospitalization according to treatment types: conservative treatment (with or without use of halo-vest) and surgery (anterior or posterior spinal fixation). RESULTS A total of 3167 patients (1533 men, 1634 women; mean age, 70 years) with isolated C2 odontoid fractures were identified, including 1124 patients (35%) aged ≥ 80 years. Among the total patients, 2476 (78%) received conservative treatment (with halo-vest, 728; without halo-vest, 1748). The remaining 691 patients (22%) underwent surgery (anterior surgery, 129; posterior surgery, 556; combined surgery, 6). There were no differences between the conservative treatment and surgery groups in baseline characteristics and preexisting comorbid conditions except for age (71 vs. 69 years, p = 0.042). In-hospital death occurred in 136 patients (4.3%). There was no significant difference in in-hospital mortality between the two groups (overall, conservative treatment 4.6% vs. surgery 3.0%, p = 0.066; age ≥ 80 years, conservative treatment 7.2% vs. surgery 5.4%, p = 0.34). Use of halo-vest was not associated with increased mortality (with halo-vest 3.7% vs. without halo-vest 5.0%, p = 0.15). CONCLUSION The great majority of isolated odontoid fractures occurred in elderly patients. Conservative treatment and surgery had similarly low in-hospital mortality. Use of halo-vest was not associated with an increase in mortality.
Collapse
Affiliation(s)
- Akira Honda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan. .,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan
| | - Tokue Mieda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan
| | - Sho Ishiwata
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 45-5-1 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan
| |
Collapse
|
19
|
Catalino MP, Kessler BA, Pate V, Cutshaw D, Stürmer T, Bhowmick DA. Gender Disparities in Surgical Treatment of Axis Fractures in Older Adults. Global Spine J 2021; 11:71-75. [PMID: 32875842 PMCID: PMC7734274 DOI: 10.1177/2192568219890573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Gender appears to play in important role in surgical outcomes following acute cervical spine trauma, with current literature suggesting males have a significantly higher mortality following spine surgery. However, no well-adjusted population-based studies of gender disparities in incidence and outcomes of spine surgery following acute traumatic axis injuries exist to our knowledge. We hypothesized that females would receive surgery less often than males, but males would have a higher 1-year mortality following isolated traumatic axis fractures. METHODS We performed a retrospective cohort study using Medicare claims data that identified US citizens aged 65 and older with ICD-9 (International Classification of Diseases, Ninth Revision) code diagnosis corresponding to isolated acute traumatic axis fracture between 2007 and 2014. Our primary outcome was defined as cumulative incidence of surgical treatment, and our secondary outcome was 1-year mortality. Propensity weighted analysis was performed to balance covariates between genders. Our institutional review board approved the study (IRB #16-0533). RESULTS There was no difference in incidence of surgery between males and females following acute isolated traumatic axis fractures (7.4 and 7.5 per 100 fractures, respectively). Males had significantly higher 1-year weighted mortality overall (41.7 and 28.9 per 100 fractures, respectively, P < .001). CONCLUSION Our well-adjusted data suggest there was no significant gender disparity in incidence of surgical treatment over the study period. The data also support previous observations that males have worse outcomes in comparison to females in the setting of axis fractures and spinal trauma regardless of surgical intervention.
Collapse
Affiliation(s)
| | - Brice A. Kessler
- University of North Carolina, Chapel Hill, NC, USA,Brice A. Kessler, University of North Carolina School of Medicine, Department of Neurosurgery, 170 Manning Drive, Campus Box 7060, Chapel Hill, NC 27599, USA.
| | | | - Drew Cutshaw
- University of North Carolina, Chapel Hill, NC, USA
| | - Til Stürmer
- University of North Carolina, Chapel Hill, NC, USA
| | | |
Collapse
|
20
|
Agunbiade S, Belton PJ, Mesfin FB. Spinal Cord Transection in a Type II Odontoid Fracture From a Ground-Level Fall. Cureus 2020; 12:e12342. [PMID: 33520537 PMCID: PMC7837629 DOI: 10.7759/cureus.12342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Odontoid fractures typically occur as a result of trauma: high-velocity injuries like motor vehicle accidents in young people and falls for the elderly. Odontoid fractures are the most common cervical spine fractures in patients over 65, with type II being the most common. However, spinal cord transections are rare with these types of injuries, especially without significant fracture displacement, translation or evidence of ligamentous disruption on post-injury imaging. We report a case of a patient who sustained a spinal cord transection secondary to an acute type II odontoid fracture from a ground-level fall, without computed tomography radiographic evidence of cord disruption or impingement.
Collapse
|
21
|
Bakhsh A, Alzahrani A, Aljuzair AH, Ahmed U, Eldawoody H. Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management. Int J Spine Surg 2020; 14:908-915. [PMID: 33560250 PMCID: PMC7872410 DOI: 10.14444/7139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures. METHODS All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures. RESULTS Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation. CONCLUSIONS The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.
Collapse
Affiliation(s)
- Ahmed Bakhsh
- Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Kingdom of Saudi Arabia
| | | | | | | | - Hany Eldawoody
- Department of Neurosurgery, Mansoura Faculty of Medicine, Mansoura University, Egypt, and Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
22
|
McIlroy S, Lam J, Khan MF, Mirza AB, Philip JA, Grahovac G, Bell D. Conservative Management of Type II Odontoid Fractures in Older People: A Retrospective Observational Comparison of Osseous Union Versus Nonunion. Neurosurgery 2020; 87:E648-E654. [PMID: 32570274 DOI: 10.1093/neuros/nyaa256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Type II odontoid fractures are a common cervical fracture in older people. Lower osseous-union rates are reported in those treated conservatively compared to surgically; however, the clinical relevance of a nonunion is unknown. OBJECTIVE To compare pain, disability, and quality of life in older people following conservative management of type II odontoid fractures demonstrating osseous-union and nonunion. METHODS Electronic records were searched from 2008 to 2018 for adults ≥65 yr with type II odontoid fracture, managed in a semi-rigid collar. Clinical and demographic data were retrieved from electronic patient notes. Surviving patients were invited to complete questionnaires to assess pain, disability, and quality of life. Ethical approval was granted. RESULTS A total of 125 patients were identified: 36 (29%) demonstrated osseous-union, 89 (71%) had nonunion, of which 33 (40%) had radiological instability. Mean age at fracture was 84 yr (osseous-union 83 yr; nonunion 84 yr). A total of 53 had deceased (41 nonunion). Median length of survival was 77 mo for osseous-union vs 50 mo for nonunion; P = .02. No patient developed myelopathy during the follow-up period. Questionnaire response rate was 39 (58%). There were no statistically significant differences between the groups in terms of pain, disability, or quality of life (P > .05). Both groups reported mild disability and pain but low quality of life. CONCLUSION Management with a semi-rigid collar in older people with type II odontoid fracture is associated with low levels of pain and disability without statistically significant differences between those demonstrating osseous-union or stable or unstable nonunions. Conservative management appears to be a safe treatment for older people with type II fractures.
Collapse
Affiliation(s)
- Suzanne McIlroy
- Physiotherapy Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jordan Lam
- University College London, London, United Kingdom
| | - Muhammad Faheem Khan
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Asfand Baig Mirza
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jerry Ajayi Philip
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gordan Grahovac
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - David Bell
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
23
|
Abstract
STUDY DESIGN Review article. OBJECTIVE A review and update of the treatment of Hangman's fractures including the indications for both nonoperative and operative treatment of typical and atypical fractures. SUMMARY OF BACKGROUND DATA Hangman's fractures are the second most common fracture pattern of the C2 vertebrae following odontoid fractures. Many of the stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIa and III fractures require surgical stabilization. METHODS A review of the literature. RESULTS The clinical and radiographic outcomes of the treatment of Hangman's fractures lend a good overall prognosis when the correct diagnosis is made. The nonoperative treatment of stable type I and II fractures with external immobilization leads to excellent long-term outcomes as does the operative treatment of the unstable type IIa and III fractures. CONCLUSIONS Hangman's fractures can be classified as stable (type I and most II) or unstable (type IIa and III) and the optimal treatment depends upon this distinction. Stable injuries do well with rigid immobilization and rarely require operative intervention. In contrast, unstable injuries do poorly if treated nonoperatively but do well with surgical intervention. When treating atypical Hangman's variants, great vigilance and close clinical observation is paramount if nonoperative treatment is indicated given the potential for neurological compression in this fracture pattern. Properly identifying and treating these injuries represents an opportunity for the spine surgeon to optimize patient outcomes.
Collapse
|
24
|
Rizvi SAM, Helseth E, Rønning P, Mirzamohammadi J, Harr ME, Brommeland T, Aarhus M, Høstmælingen CT, Ølstørn H, Rydning PNF, Mejlænder-Evjensvold M, Utheim NC, Linnerud H. Odontoid fractures: impact of age and comorbidities on surgical decision making. BMC Surg 2020; 20:236. [PMID: 33054819 PMCID: PMC7556921 DOI: 10.1186/s12893-020-00893-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Surgical fixation is recommended for type II and III odontoid fractures (OFx) with major translation of the odontoid fragment, regardless of the patient’s age, and for all type II OFx in patients aged ≥50 years. The level of compliance with this recommendation is unknown, and our hypothesis is that open surgical fixation is less frequently performed than recommended. We suspect that this discrepancy might be due to the older age and comorbidities among patients with OFx. Methods We present a prospective observational cohort study of all patients in the southeastern Norwegian population (3.0 million) diagnosed with a traumatic OFx in the period from 2015 to 2018. Results Three hundred thirty-six patients with an OFx were diagnosed, resulting in an overall incidence of 2.8/100000 persons/year. The median age of the patients was 80 years, and 45% were females. According to the Anderson and D’Alonzo classification, the OFx were type II in 199 patients (59%) and type III in 137 patients (41%). The primary fracture treatment was rigid collar alone in 79% of patients and open surgical fixation in 21%. In the multivariate analysis, the following parameters were significantly associated with surgery as the primary treatment: independent living, less serious comorbidities prior to the injury, type II OFx and major sagittal translation of the odontoid fragment. Conversion from external immobilization alone to subsequent open surgical fixation was performed in 10% of patients. Significant differences the in conversion rate were not observed between patients with type II and III fractures. The level of compliance with the treatment recommendations for OFx was low. The main deviation was the underuse of primary surgical fixation for type II OFx. The most common reasons listed for choosing primary external immobilization instead of primary surgical fixation were an older age and comorbidities. Conclusion Major comorbidities and an older age appear to be significant factors contributing to physicians’ decision to refrain from the surgical fixation of OFx. Hence, comorbidities and age should be considered for inclusion in the decision tree for the choice of treatment for OFx in future guidelines.
Collapse
Affiliation(s)
- Syed Ali Mujtaba Rizvi
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | - Eirik Helseth
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | - Pål Rønning
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | - Jalal Mirzamohammadi
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | - Marianne Efskind Harr
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | - Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | | | - Håvard Ølstørn
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | | | | | - Nils Christian Utheim
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway
| | - Hege Linnerud
- Department of Neurosurgery, Oslo University Hospital, Mailbox 4956, 0424, Oslo, Norway.
| |
Collapse
|
25
|
AlEissa SI, Alhandi AA, Bugis AA, Alsalamah RK, Alsheddi A, Almubarak AK, AlAssiri SS, Konbaz FM. The incidence of odontoid fractures following trauma in a major trauma center, a retrospective study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:71-74. [PMID: 32904973 PMCID: PMC7462132 DOI: 10.4103/jcvjs.jcvjs_28_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/31/2020] [Indexed: 11/10/2022] Open
Abstract
Background: Cervical spine injury is the most common vertebral injury after major trauma, 20% of all cervical fractures happen to be odontoid fractures. In young adults, odontoid fracture usually happens as a result of high-energy trauma after a motor vehicle accident (MVA). MVA in Riyadh represents 38.4% of all trauma cases, in which the head-and-neck are the most injured body parts. This research aims to provide information about the incidence of odontoid process fracture post-MVA in Riyadh, Saudi Arabia. Methods: The design of this study was retrospective. A single level one trauma center database (trauma registry) was used to identify odontoid fractures post-MVA. All trauma cases from 2008 to the most recent were included, a total of 17,047 patients, to identify cervical spine fractures and further identify odontoid fracture incidence. The patients' radiographs were reviewed retrospectively, and odontoid fractures were classified by a board-certified spine surgeon. A descriptive analysis was carried out to report basic data distribution. Pearson's correlation was carried out to assess associations. Results: A total number of cervical spine fracture was 1195 patients (6.6% of the total sample). The incidence of odontoid fractures during the entire study period from 2008 to 2018 was 42 of 480 patients with C2 cervical trauma, constituting 8.75% C2 fractures, and 3.5% of cervical spine fractures. The mean age was 41.75 ± 18 years. There were three patients (onemale, two females) with type I odontoid fracture, 26 (all males) with type II, and 13 (11 males, 2 females) with type III. Most patients were managed conservatively (83.33%), whereas 16.67% underwent surgical management. Conclusion: The incidence of posttraumatic odontoid fractures is low, given the younger population of this study. This does not predict future incidence rates with the continued improvement of road traffic laws and awareness in the population.
Collapse
Affiliation(s)
- Sami Ibrahim AlEissa
- Department of Surgery, Division of Orthopedics, King Abdulaziz Medical City, National Guard Health Affaires, Riyadh, Saudi Arabia.,Collage of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali Abdullah Alhandi
- Department of Surgery, Division of Orthopedics, King Abdulaziz Medical City, National Guard Health Affaires, Riyadh, Saudi Arabia
| | | | - Raghad Khalid Alsalamah
- Collage of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulellah Alsheddi
- Department of Surgery, Division of Orthopedics, King Abdulaziz Medical City, National Guard Health Affaires, Riyadh, Saudi Arabia
| | - Abdulaziz Khalid Almubarak
- Collage of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Suhail Saad AlAssiri
- Department of Surgery, Division of Orthopedics, King Abdulaziz Medical City, National Guard Health Affaires, Riyadh, Saudi Arabia
| | - Faisal MohammedSaleh Konbaz
- Department of Surgery, Division of Orthopedics, King Abdulaziz Medical City, National Guard Health Affaires, Riyadh, Saudi Arabia
| |
Collapse
|
26
|
Grabel ZJ, Lunati MP, Segal DN, Kukowski NR, Yoon ST, Jain A. Thoracolumbar spinal fractures associated with ground level falls in the elderly: An analysis of 254,486 emergency department visits. J Clin Orthop Trauma 2020; 11:916-920. [PMID: 32879581 PMCID: PMC7452325 DOI: 10.1016/j.jcot.2020.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/04/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022] Open
Abstract
STUDY DESIGN retrospective. OBJECTIVES To investigate the epidemiology of elderly (age ≥65 years) patients who presented to the emergency department (ED) in the United States with thoracolumbar (TL) fractures after ground level falls. METHODS Using the National Emergency Department Sample database, we queried all ED visits in the United States from 2009 through 2012 of elderly patients who presented after ground level falls. We identified patients who sustained TL fractures with and without neurological injury. Resulting data was used to analyze the fracture prevalence, ED and patient characteristics, associated injuries, treatment patterns, inpatient mortality, and hospital charges. RESULTS Of the 6,654,526 ED visits in the elderly for ground level falls, 254,486 (3.8%) were associated with a diagnosis of TL fracture. 39% patients had multiple injuries, and upper extremity fractures were the most common associated injuries. Overall, 55.6% were admitted to the hospital. Of those, 77.7% were treated non-operatively, 20.4% were treated with cement augmentation alone, 1.5% were treated with spinal fusion surgery, and 0.4% were treated with spinal decompression alone. The overall rate of inpatient mortality was 2.14%. CONCLUSIONS This investigation evaluated the epidemiology of elderly patients who presented to the ED in the United States with TL fractures after ground level falls. The study demonstrated a rather high incidence of TL fractures in this patient cohort. As a result, it is important for ED physicians and orthopaedic surgeons to be highly suspicious of TL fractures in elderly patients who sustain low energy trauma. With the continued aging of the population and rising health care costs, future effort ought to focus on fall prevention and increased surveillance for TL injuries in the elderly.
Collapse
Affiliation(s)
- Zachary J. Grabel
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329, USA
| | - Matthew P. Lunati
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329, USA
| | - Dale N. Segal
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329, USA
| | - Nathan R. Kukowski
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329, USA
| | - S. Tim Yoon
- Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline St, Baltimore, MD, 21287, USA
| |
Collapse
|
27
|
Epidemiology and Imaging Classification of Pediatric Cervical Spine Injuries: 12-Year Experience at a Level 1 Trauma Center. AJR Am J Roentgenol 2020; 214:1359-1368. [DOI: 10.2214/ajr.19.22095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
28
|
Gembruch O, Ahmadipour Y, Lemonas E, Müller O. The Anterior Transarticular Fixation of C1/C2 in the Elderly With Dens Fractures. Int J Spine Surg 2020; 14:162-169. [PMID: 32355621 DOI: 10.14444/7031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Anterior transarticular screw fixation (ATSF) of C1/C2 can be used for the treatment of unstable dens fractures. Here, we evaluated the feasibility of an anterior C1/C2 fixation in elderly patients with unstable dens fractures. Furthermore, we tried to analyze safe entry zones for ATSF surgery. Methods A consecutive cohort of 13 patients with unstable dens fractures were treated with ATSF of C1/C2 between January 2015 and October 2016. If necessary, an additional screw was placed into the odontoid process. The placement was radiographically analyzed using the 3D Arcadis Orbic (Siemens, Erlangen, Germany). Additionally, computed tomography scans of the cervical spine from 50 trauma patients were analyzed to evaluate safe entry zones for anterior odontoid screw fixation and for ATSF. Results ATSF was performed in 13 cases (7 female, 6 male; mean age 81.80 years). One screw had to be corrected intraoperatively due to initial malplacement. Neurological deficits or an injury of the vertebral artery were not observed. All patients suffered from swallowing difficulties during the postoperative course, without lesions of the esophagus or the trachea. In 4 patients (30.8%), an additional posterior fixation was offered to the patients due to progressive loosening of the screws.The anatomical-radiographic analyzes revealed a significantly shallower angle of trajectory for anterior odontoid screw fixation (24.9° ± 5.85°) than for ATSF (39.1° ± 6.44° (left); 40.5° ± 6.79° (right) P = 0.02). Conclusions The ATSF of C1/C2 might be a valuable option in the treatment of instable C1/C2 fractures, especially in the elderly or in patients with short necks and/or high body mass index due to the steeper trajectory compared with odontoid screw placement. Yet available screws seem to be of inferior resistance compared with the biomechanical properties of a dorsal fixation. Further studies should focus on screws with better mechanical properties and probably additional cement augmentation. Level of Evidence 4.
Collapse
Affiliation(s)
- Oliver Gembruch
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Elias Lemonas
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
29
|
Catalino MP, Pate V, Stürmer T, Bhowmick DA. Comparative Propensity-Weighted Mortality After Isolated Acute Traumatic Axis Fractures in Older Adults. Geriatr Orthop Surg Rehabil 2020; 11:2151459320911867. [PMID: 32284902 PMCID: PMC7133078 DOI: 10.1177/2151459320911867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/27/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In older patients with axis fractures, the survival benefit from surgery is unclear due to high baseline mortality. Comparative effectiveness research can provide evidence from population level cohorts. Propensity weighting is the preferred methodology for reducing bias when analyzing national administrative cohort data for these purposes but has not yet been utilized for this important surgical conundrum. We estimate the effect of surgery on mortality after isolated acute traumatic axis fracture in older adults. MATERIALS AND METHODS We used a retrospective population-based cohort of Medicare patients and generated a propensity score-weighted nonsurgical cohort and compared mortality with and without surgery. This balanced the comorbid conditions of the treatment groups. Incident fractures were defined using a predetermined algorithm based on enrollment, code timing, and billing location. The primary outcome was adjusted all-cause 1-year mortality. RESULTS From 12 372 beneficiaries with 1-year continuous enrollment and a coded axis fracture, 2676 patients met final inclusion/exclusion criteria. Estimated incidence was 16.5 per 100 000 person-years overall in 2014 (95% confidence interval [CI]: 15.0-18.0) and was stable from 2008 through 2014. Patients with axis fracture had a mean age of 82.8 years, 30.2% were male, and 91.9% were Caucasian. Mortality was 3.8 times higher (CI 3.6-4.1) compared with the general population of older US adults. Propensity-weighted mortality at 1 year for nonsurgical patients was 26.7 of 100 (CI: 24.5-29.0). Mortality for surgical patients was significantly lower (19.7/100; CI 14.5-25.0). Risk difference was 7.0 fewer surgical deaths per 100 patients (CI: 1.3-12.7). Surgical patients aged 65 to 74 years had the largest difference in mortality with 11.2 fewer deaths per 100 (CI: 1.1-21.3). DISCUSSION Patients with axis fractures are predominantly older Caucasian women and have a higher mortality rate than the general population. Propensity-weighted mortality at 1-year was lower in the surgical patients with the largest risk difference occurring in patients 65 to 74 years old. CONCLUSIONS Surgery may provide an independent survival benefit in patients aged 65 to 75 years, and the mortality difference diminishes thereafter.
Collapse
Affiliation(s)
| | - Virginia Pate
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
| | - Til Stürmer
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
| | | |
Collapse
|
30
|
Osterhoff G, Schnake K, Scheyerer MJ, Ullrich BW, Hartmann F, Franck A, Koepp H, Reinhold M, Schmeiser G, Sprengel K, Zimmermann V, Siekmann H, Badke A, Gebhard H, Täubel KC, Grüninger S, Verheyden AP, Schleicher P, Spiegl UJA. Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:647-656. [PMID: 31634954 DOI: 10.1055/a-0989-2791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature. METHODS In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients. RESULTS For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.
Collapse
Affiliation(s)
- Georg Osterhoff
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
| | - Klaus Schnake
- Zentrum für Wirbelsäulen- und Skoliosetherapie, Schön Klinik Nürnberg/Fürth, Fürth
| | - Max J Scheyerer
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln
| | - Bernhard W Ullrich
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost GgmbH Halle/Saale
| | - Frank Hartmann
- Zentrum für Unfallchirurgie und Orthopädie, Ev. Stift St. Martin, Gemeinschaftsklinikum Mittelrhein, Koblenz
| | - Alexander Franck
- Klinik für Orthopädie und Unfallchirurgie, Regiomed Klinikum Coburg
| | - Holger Koepp
- Wirbelsäulenzentrum, St. Josefs-Hospital, Wiesbaden
| | - Maximilian Reinhold
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Südstadt Rostock
| | | | - Kai Sprengel
- Klinik für Traumatologie, UniversitätsSpital Zürich, Schweiz
| | - Volker Zimmermann
- Abt. Unfallchirurgie und Orthopädische Chirurgie, Klinikum Traunstein
| | - Holger Siekmann
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle
| | - Andreas Badke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Unfallklinik Tübingen
| | | | - Kai C Täubel
- Orthopädisch-Unfallchirurgisches Zentrum, ALB FILS KLINIKEN, Standort Klinik am Eichert, Göppingen
| | - Sebastian Grüninger
- Universitätsklinik für Orthopädie und Unfallchirurgie, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg
| | - Akhil P Verheyden
- Klinik für Unfall-, Orthopädische und Wirbelsäulenchirurgie, Ortenau Klinikum Lahr-Ettenheim
| | | | - Ulrich J A Spiegl
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
| | | |
Collapse
|
31
|
Abstract
Odontoid fractures represent one of the most common and controversial injury types affecting the cervical spine, being associated with a high incidence of nonunion, morbidity, and mortality. These complications are especially common and important in elderly patients, for which ideal treatment options are still under debate. Stable fractures in young patients maybe treated conservatively, with immobilization. Although halo-vest has been widely used for their conservative management, studies have shown high rates of complications in the elderly, and therefore current evidence suggests that the conservative management of these fractures should be carried out with a hard cervical collar or cervicothoracic orthosis. Elderly patients with stable fractures have been reported to have better clinical results with surgical treatment. For these and for all patients with unstable fractures, several surgical techniques have been proposed. Anterior odontoid fixation can be used in reducible fractures with ideal fracture patterns, with older patients requiring fixation with 2 screws. In other cases, C1-C2 posterior fixation maybe needed with the best surgical option depending on the reducibility of the fracture and vertebral artery anatomy. In this paper, current evidence on the management of odontoid fractures is discussed, and an algorithm for treatment is proposed.
Collapse
|
32
|
Characteristics and Management of Emergency Department Patients Presenting with C2 Cervical Spine Fractures. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4301051. [PMID: 31223616 PMCID: PMC6541942 DOI: 10.1155/2019/4301051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/12/2019] [Accepted: 04/28/2019] [Indexed: 11/17/2022]
Abstract
Background C2 cervical fractures account for approximately 18% of cervical spine injuries. Few studies have examined patients presenting to an emergency department (ED) with this injury relative to demographics, injury mechanism, and hospital course. Objectives To compare multiple variables of ED patients presenting with these types of injuries. Methods In this retrospective cohort study, data were obtained from the Trauma Registry of an academic trauma referral center from January 1, 2011, to December 31, 2015. Patients who presented with a C2 fracture were identified. Information regarding the patient's gender, age, mechanism of injury, associated injuries, if a procedure was required, disposition, and mortality was extracted. Comparative analyses were conducted between cases over or under age 60. Results Between January 1, 2011, to December 31, 2015, a total of 139 patients with C2 fractures were identified. Most patients were 60 years or older (79%). Of those, 62% were female, and falls were the most common mechanism (78%). Of those under 60, 50% were female and motor vehicle crashes (MVCs) were the most common mechanism (71%). Odontoid fractures comprised 84% of C2 fractures. Only 6% had an associated spinal cord injury. Less than one-third of patients required operative intervention for their spinal injuries, and intervention was more common in older patients. Following admission, 19% of patients required placement into a nursing home or skilled nursing facility. Conclusions C2 fractures are more common in older adults and usually resulted from falls. Odontoid fractures are most common. Most C2 fractures do not result in neurologic injury, and only a third were treated surgically. However, several patients were unable to return to their homes following their injury.
Collapse
|
33
|
Donnally CJ, Trapana EJ, Barnhill SW, Bondar KJ, Rivera S, Sheu JI, Wang MY. The Most Influential Publications in Odontoid Fracture Management. World Neurosurg 2019; 123:41-48. [DOI: 10.1016/j.wneu.2018.11.205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 10/27/2022]
|
34
|
Gembruch O, Lemonas E, Ahmadipour Y, Sure U, El Hindy N, Dodel R, Müller O. Treatment of Odontoid Type II Fractures in Octogenarians: Balancing Two Different Treatment Strategies. Neurospine 2019; 16:360-367. [PMID: 31154696 PMCID: PMC6603819 DOI: 10.14245/ns.1836250.125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/31/2018] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Oliver Gembruch
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Elias Lemonas
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nicolai El Hindy
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Department of Spine Surgery, Katholisches Klinikum Lünen/Werne GmbH, St. Christophorus-Krankenhaus, Werne, Germany
| | - Richard Dodel
- Department of Geriatric Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Geriatric Center Haus Berge, Contilia Group, Essen, Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
35
|
Rehousek P, Jenner E, Holton J, Czyz M, Capek L, Henys P, Kulvajtova M, Krbec M, Skala-Rosenbaum J. Biomechanical comparison of cemented versus non-cemented anterior screw fixation in type II odontoid fractures in the elderly: a cadaveric study. Spine J 2018; 18:1888-1895. [PMID: 29783086 DOI: 10.1016/j.spinee.2018.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/21/2018] [Accepted: 05/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Odontoid process fractures are the most common injuries of the cervical spine in the elderly. Anterior screw stabilization of type II odontoid process fractures improves survival and function in these patients but may be complicated by failure of fixation. PURPOSE The present study aimed to determine whether cement augmentation of a standard anterior screw provides biomechanically superior fixation of type II odontoid fractures in comparison with a non-cemented standard screw. STUDY DESIGN Twenty human cadaveric C2 vertebrae from elderly donors (mean age 83 years) were obtained. METHODS Anderson and D'Alonzo type IIa odontoid fracture was created by transverse osteotomy, and fluoroscopy-guided anterior screw fixation was performed. The specimens were divided into two matched groups. The cemented group (n=10) had radiopaque high viscosity polymethylmethacrylate cement injected via Jamshidi needle into the base of the odontoid process. The other group was not augmented. A V-shaped punch was used for loading the odontoid in an anteroposterior direction until failure. The failure state was defined as screw cutout or 5% force decrease. Mean failure load and bending stiffness were calculated. RESULTS The mean failure load for the cemented group was 352±12 N compared with 168±23 N for the non-cemented group (p<.001). The mean initial stiffness of the non-cemented group was 153±19 N/mm compared with 195±29 N/mm for the cemented group (p<.001) CONCLUSIONS: Cement augmentation of an anterior standard screw fixation of type II odontoid process fractures in elderly patients significantly increased load to failure under anteroposterior load in comparison with non-augmented fixation. This may be a valuable technique to reduce failure of fixation.
Collapse
Affiliation(s)
- Petr Rehousek
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK; Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia.
| | - Edward Jenner
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK
| | - James Holton
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK
| | - Marcin Czyz
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK
| | - Lukas Capek
- Technical University of Liberec, Studentska 1402/2, 461 17 Liberec, Czechia
| | - Petr Henys
- Technical University of Liberec, Studentska 1402/2, 461 17 Liberec, Czechia
| | - Marketa Kulvajtova
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia
| | - Martin Krbec
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia
| | - Jiri Skala-Rosenbaum
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia
| |
Collapse
|
36
|
Robinson AL, Olerud C, Robinson Y. Surgical treatment improves survival of elderly with axis fracture-a national population-based multiregistry cohort study. Spine J 2018; 18:1853-1860. [PMID: 29649609 DOI: 10.1016/j.spinee.2018.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/27/2018] [Accepted: 03/26/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Fractures of the axis (C2) are the most common cervical spinal injuries in the elderly population. Several authors have reported improved survival among elderly patients with C2 fractures when treated surgically. PURPOSE We aimed to analyze whether surgery improves survival of elderly with C2 fractures. STUDY DESIGN/SETTING An observational population-based longitudinal multi-registry study was carried out. PATIENT SAMPLE Swedish Patient Registry 1997 to 2014 and Swedish Cause of Death Registry 1997 to 2014 served as source of patient sample. OUTCOME MEASURES Survival after C2 fracture according to non-surgical and surgical treatment was the outcome measure. METHODS We included all patients treated for the primary diagnosis of C2 fracture (10th revision of the International Statistical Classification of Diseases and Related Health Problems or ICD-10: S12.1) at an age ≥70 years and receiving treatment at a health-care facility. Non-surgical treatment comprises cervical collar or halo-vest treatment. Surgical treatment was identified in the Swedish patient registry extract using the Swedish classification of procedural codes. Survival was determined using the Kaplan-Meier method. Comorbidity was determined using the Charlson Comorbidity Index. RESULTS Of the included 3,375 elderly patients with C2 fractures (43% men, aged 83±7 years), 22% were treated surgically. Surgical treatment was assigned based on age, gender, and year of treatment. The 1-year survival of 2,618 non-surgically treated patients was 72% (n=1,856), and 81% (n=614) for the 757 surgically treated (p<.001, relative risk reduction=11%). Adjusted for age, gender, comorbidity, and year of injury, surgically treated patients had greater survival than non-surgically treated patients (hazard ratio=0.88, 95% confidence interval: 0.79-0.97). Among those above 88 years of age (95% confidence interval: 85-92), surgical treatment lost its effect on survival. CONCLUSIONS Despite the frailty of elderly patients, the morbidity of cervical external immobilization with a rigid collar seemingly weighs greater than surgical morbidity, even in octogenarians. For those above 88 years of age, non-surgical treatment should be primarily attempted.
Collapse
Affiliation(s)
- Anna-Lena Robinson
- Stockholm Spine Center, Löwenströmska Sjukhuset, 194 89 Upplands-Väsby, Sweden; Department of Surgical Sciences, Uppsala University Hospital, 751 85 Uppsala, Sweden.
| | - Claes Olerud
- Department of Surgical Sciences, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Yohan Robinson
- Department of Surgical Sciences, Uppsala University Hospital, 751 85 Uppsala, Sweden; Department of Research and Development, Swedish Armed Forces Centre for Defence Medicine, Box 5155, 425 05 Västra Frölunda, Sweden
| |
Collapse
|
37
|
Robinson AL, Schmeiser G, Robinson Y, Olerud C. Surgical vs. non-surgical management of displaced type-2 odontoid fractures in patients aged 75 years and older: study protocol for a randomised controlled trial. Trials 2018; 19:452. [PMID: 30134944 PMCID: PMC6106890 DOI: 10.1186/s13063-018-2690-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 05/16/2018] [Indexed: 11/25/2022] Open
Abstract
Background Displaced odontoid fractures in the elderly are treated non-surgically with a cervical collar or surgically with C1–C2 fusion. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon. Methods The Uppsala Study on Odontoid Fracture Treatment (USOFT) is a multicentre, open-label, randomised controlled superiority trial evaluating the clinical superiority of the surgical treatment of type-2 odontoid fractures, with a 1-year Neck Disability Index (NDI) as the primary endpoint. Fifty consecutive patients aged ≥ 75 years, with displaced type-2 odontoid fracture, are randomised to non-surgical or surgical treatment. Excluded are patients with an American Society of Anaesthesiologists (ASA) score ≥ 4, dementia nursing care or anatomical cervical anomalies. The minimal clinically important difference of the NDI is 3.5 points. A minimum of 16 patients are needed in each group to test the superiority with 80% power. By considering a 1-year mortality forecast of 29%, up to 25 participants are recruited in each group. The non-surgical group is fitted with a rigid cervical collar for 12 weeks. The surgical group is treated with a posterior C1–C2 fusion. All participants are monitored with regard to the NDI, EuroQol score (EQ-5D), socio-demographics and computed tomography (CT) at the time of injury, at 6 weeks, 3 months and 12 months. At 12 months, a dynamic radiographical investigation of upper cervical stability is performed. The secondary endpoints are: EQ-5D score, activities of daily living (ADL), bony union, upper cervical stability and mortality. Discussion USOFT is the first randomised controlled trial comparing non-surgical and surgical management of type-2 odontoid fractures in the elderly. Using the NDI and EQ-5D as endpoints, future value-based decisions may consider quality-adjusted life years gained. Major limitations are (1) the allocation bias of the open-label study design, (2) that only higher training levels of all core specialties of spine surgery are included in the surgical treatment arm and (3) that only one type of surgical stabilisation is investigated (posterior C1–C2 fusion), while other methods are not included in this study. Trial registration ClinicalTrials.gov, NCT02789774. Registered retrospectively on 25 August 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2690-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Anna-Lena Robinson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden. .,Stockholm Spine Center, Stockholm, Sweden. .,Stockholm Spine Center, Löwenströmska Hospital, 194 89, Stockholm, Upplands Väsby, Sweden.
| | - Gregor Schmeiser
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.,Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | - Yohan Robinson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.,Dept. of Research and Development, Armed Forces Centre for Defence Medicine, Västra Frölunda, Gothenburg, Sweden
| | - Claes Olerud
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|
38
|
|
39
|
Robinson AL, Olerud C, Robinson Y. Epidemiology of C2 Fractures in the 21st Century: A National Registry Cohort Study of 6,370 Patients from 1997 to 2014. Adv Orthop 2017; 2017:6516893. [PMID: 29181200 PMCID: PMC5664209 DOI: 10.1155/2017/6516893] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/31/2017] [Accepted: 09/14/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE C2 fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. This study aims to investigate the incidence and treatment trend of C2 fractures in Sweden. METHODS Patients with the principal and secondary diagnosis of fracture of the second vertebrae (ICD-10: S12.1) between 1997 and 2014 were identified in the Swedish National Patient Registry (NPR). RESULTS Between 1997 and 2014, 6,370 patients with a C2 fracture (51% male; age: 72 ± 18) were identified in the NPR. The incidence of C2 fractures increased from 3 to 6 per 100,000 (r = 0.94; p < 0.01), mainly due to an increase of incidence in the geriatric subgroup (≥70 years). The percentage of surgically treated patients decreased from 1997 to 2014 (r = -0.80; p < 0.01). Younger age, male gender, spinal cord injury, and earlier year of admission were associated with surgical treatment assignment. DISCUSSION This study documents a rising incidence of C2 fractures in the elderly during the last two decades in Sweden. Greater awareness of fractures, improved diagnostics, coding, and a higher activity level of the patients are plausible causes. The declining trend of surgical treatment warrants further study.
Collapse
Affiliation(s)
- Anna-Lena Robinson
- Stockholm Spine Center, Upplands Väsby, Sweden
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Claes Olerud
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Yohan Robinson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|