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Patel N, Rajabian A, George J. Unintended consequences of using collars with occipital extensions in neck support - Snapshot assessment at the largest tertiary spinal referral centre in the UK. Int J Orthop Trauma Nurs 2024; 53:101083. [PMID: 38336571 DOI: 10.1016/j.ijotn.2024.101083] [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: 10/21/2023] [Revised: 01/16/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Upper cervical spine fractures are commonplace in the elderly following low energy trauma. These injuries carry high mortality rates, similar to patients sustaining hip fractures. A key aspect affecting clinical outcome is effective management in the first 12 weeks following injury. This study aims to assess the understanding of healthcare staff that may be required to care for such patients. MATERIALS AND METHODS A survey was carried out over a single day at the UK's largest Spine Specialist referral centre (Salford Royal Foundation Trust, SRFT) assessing the understanding of healthcare staff of the term, 'Collar with occipital extension', by asking staff to identify the safe position of the neck when looking at clinical images of a model in a collar in various different neck positions. The participants demographics were then taken, including profession, grade, spinal/post graduate experience, if English is their first language and their understanding of the term 'Collar with occipital extension'. RESULTS 102 participants were interviewed and the results showed almost half (45.1%) of participants selecting an incorrect hyperextended neck to be a safe position for conservative treatment and only 37.3% selecting the neutral position as satisfactory. The only positive predictors identified for those selective the neutral safe cervical spine alignment was if participants had >5 years of previous spinal experience (p = 0.0006) or if they understood the term 'Collar with occipital extension' to be describing the collar component (p = 0.000013) and not neck position. CONCLUSION Management of spinal injuries are classically poorly managed in non-spinal centres, possibly due to the lack of training and understanding within the spinal speciality. This study shows the importance of clearly communicating with referring hospitals exactly how to conservatively manage patients with high cervical injuries to best improve clinical outcome.
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Affiliation(s)
- N Patel
- Trauma & Orthopaedic Registrar, Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK.
| | - A Rajabian
- Spinal Senior Clinical Fellow, Salford Royal Hospital, Stott Lane, Salford, M8 8HD, UK
| | - J George
- Salford Royal Hospital, Stott Lane, Salford, M8 8HD, UK
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Merali Z, Zhang PF, Jaffe RH, Jaja BNR, Harrington EM, Malhotra AK, Smith CW, He Y, Balas M, Jack AS, Fehlings MG, Wilson JR, Witiw CD. Multicenter retrospective cohort study of the association between surgery for odontoid fractures in the elderly and in-hospital outcomes. Sci Rep 2023; 13:6276. [PMID: 37072405 PMCID: PMC10113203 DOI: 10.1038/s41598-023-33158-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/07/2023] [Indexed: 05/03/2023] Open
Abstract
Odontoid fractures are increasingly prevalent in older adults and associated with high morbidity and mortality. Optimal management remains controversial. Our study aims to investigate the association between surgical management of odontoid fractures and in-hospital mortality in a multi-center geriatric cohort. We identified patients 65 years or older with C2 odontoid fractures from the Trauma Quality Improvement Program database. The primary study outcome was in-hospital mortality. Secondary outcomes were in-hospital complications and hospital length of stay. Generalized estimating equation models were used to compare outcomes between operative and non-operative cohorts. Among the 13,218 eligible patients, 1100 (8.3%) were treated surgically. The risk of in-hospital mortality did not differ between surgical and non-surgical groups, after patient and hospital-level adjustment (OR: 0.94, 95%CI: 0.55-1.60). The risks of major complications and immobility-related complications were higher in the operative cohort (adjusted OR: 2.12, 95%CI: 1.53-2.94; and OR: 2.24, 95%CI: 1.38-3.63, respectively). Patients undergoing surgery had extended in-hospital length of stay compared to the non-operative group (9 days, IQR: 6-12 days vs. 4 days, IQR: 3-7 days). These findings were supported by secondary analyses that considered between-center differences in rates of surgery. Among geriatric patients with odontoid fractures surgical management was associated with similar in-hospital mortality, but higher in-hospital complication rates compared to non-operative management. Surgical management of geriatric patients with odontoid fractures requires careful patient selection and consideration of pre-existing comorbidities.
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Affiliation(s)
- Zamir Merali
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, M5T1P5, Canada
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
| | - Peng F Zhang
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
| | - Rachael H Jaffe
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, M5T1P8, Canada
| | - Blessing N R Jaja
- St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, M5B1T8, Canada
| | - Erin M Harrington
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
| | - Armaan K Malhotra
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, M5T1P5, Canada
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, M5T1P8, Canada
| | - Christopher W Smith
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
| | - Yingshi He
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
| | - Michael Balas
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
| | - Andrew S Jack
- Division of Neurosurgery, University of Alberta, Edmonton, T6G1Z1, Canada
| | - Michael G Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, M5T1P5, Canada
- Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, M5T2S8, Canada
| | - Jefferson R Wilson
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, M5T1P5, Canada
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, M5T1P8, Canada
| | - Christopher D Witiw
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, M5T1P5, Canada.
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, Toronto, M5B1W8, Canada.
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, M5T1P8, Canada.
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Coleman N, Chan HYH, Gibbons V, Baker JF. Comparison of Hard and Soft Cervical Collars for the Management of Odontoid Peg Fractures in the Elderly. Geriatr Orthop Surg Rehabil 2022; 13:21514593211070263. [PMID: 35320993 PMCID: PMC8935567 DOI: 10.1177/21514593211070263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 11/16/2021] [Accepted: 12/10/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Odontoid peg fractures (OF) are the most common cervical spine fracture in the elderly. This retrospective analysis aimed to compare the outcomes of older patients with OF who had been managed non-operatively with either a hard or soft cervical collar. Materials and Methods We analysed the retrospective data of the clinical and radiographic records of patients 60 years or older who presented over a 10-year period with OF and were treated non-operatively with a cervical collar. Mortality was the primary outcome measure with mechanism of injury, complications, and fracture healing secondary measures. Results 45 patients (hard collar n = 22; soft collar n = 23) were included with comparable demographics for frailty and co-morbidities in each group; age was significantly higher in the soft collar group (80.6 vs 86.4 years; P = .0065). Associated injuries and complications were not significantly different overall, or when Type II fractures were separately analysed (P = .435 associated injuries, P = .121 complications). All-cause mortality was greater in the soft collar group (30-day mortality hard: 0%, soft: 9%; 1-year mortality hard: 18%, soft: 48% P = .035). However, once corrected for age, this proved not to reach significance (P = .333) in any fracture type. Non-union was common (77%) but was not significantly different (hard = 70%; soft = 87%; P = .419). Discussion Consistent with other reports, non-union rates remained substantial regardless of which collar was used. After controlling for age, there was no difference in all-cause mortality between elderly patients treated with a hard or soft cervical collar for odontoid peg fractures. Conclusions Soft collars appear suitable for the treatment of odontoid peg fractures in the elderly without compromising outcome. Larger cohort analyses will help confirm this finding.
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Affiliation(s)
- Nichola Coleman
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Hoi-Ying H Chan
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Veronique Gibbons
- Clinical Effectiveness, Quality and Patient Safety, Waikato Hospital, Hamilton, New Zealand
| | - Joseph F Baker
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand.,Waikato Institute of Surgical Education and Research, Hamilton, New Zealand
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Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations. J Am Acad Orthop Surg 2022; 30:e561-e572. [PMID: 35266921 DOI: 10.5435/jaaos-d-21-00165] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 11/08/2021] [Indexed: 02/01/2023] Open
Abstract
Odontoid fractures represent the most common fractures involving C2 and the most common cervical spine fractures in patients older than 65 years. Despite their increasing frequency, optimal management of these injuries remain a subject to debate. Although types I and III injuries have relatively good healing potential with nonsurgical treatment, type II fractures carry a higher risk for nonunion. In particular, elderly patients are at risk for nonunion or fibrous malunion after nonsurgical treatment; however, increased medical comorbidities and poor bone quality also increase the risks of surgery in this cohort. The high morbidity and mortality associated with these injuries has made it an area of particular interest among spine surgeons. The purpose of this review was to summarize the pathophysiology, evaluation, and diagnosis of these injuries and to review controversies in management and considerations for treatment based on the most recent available literature.
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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.
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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.
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Hamilton P, Lawrence P, Eisenring CV. Treatment of type II odontoid fracture in the elderly. J Surg Case Rep 2020; 2020:rjaa235. [PMID: 32874537 PMCID: PMC7449561 DOI: 10.1093/jscr/rjaa235] [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] [Received: 05/13/2020] [Accepted: 06/16/2020] [Indexed: 11/18/2022] Open
Abstract
Odontoid fractures constitute the commonest cervical spinal fracture in the elderly. There are varied management approaches with paucity of robust evidence to guide decision-making. We review the case of a 92-years-old man with traumatic Grauer type II B odontoid fracture treated with anterior cannulated screw fixation. Postoperatively, he was noted to have dysphagia due to a zenker’s diverticulum. Further history revealed repair of a zenker’s diverticulum ~40 years prior. Cervical spine images and video fluoroscopy demonstrated a recurrent zenker’s diverticulum. After re-excision of the recurrent zenker’s diverticulum his dysphagia resolved. This unique case describes dysphagia due to recurrent zenker’s diverticulum presenting after anterior cannulated screw fixation for type II B odontoid fracture. The dysphagia was diagnosed and treated in close collaboration with speech and language therapists and otorhinolaryngologist. This underscores the importance of holistic approach to the elderly patient with odontoid fractures.
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Affiliation(s)
- Preci Hamilton
- Division of Neurosurgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, University Hospital of the West Indies, University of the West Indies, Kingston, Jamaica
| | - Peyton Lawrence
- Division of Neurosurgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, University Hospital of the West Indies, University of the West Indies, Kingston, Jamaica
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Huang PJ, Lin JH, Chiang YH. Miniplate-Augmented Interlaminar Fusion in C1-C2 Screwing. World Neurosurg 2020; 138:e634-e641. [PMID: 32173550 DOI: 10.1016/j.wneu.2020.03.023] [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: 10/25/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The interlaminar fusion combination involving C1-C2 screwing fixation is one of the most effective techniques for atlantoaxial dislocation or subluxation, and the bone graft is usually stabilized by wiring constructs. However, some adverse events were reported during the insertion of sublaminar wiring, such as accidentally damaging the spinal cord or dura. Thus we used the miniplate to stabilize the harvest bone graft on the C1-C2 laminar, which led to a shorter operation time and prevented spinal canal violation. This study investigated the safety and efficacy of the novel surgical technique, namely miniplate-augmented interlaminar fusion. METHODS We retrospectively reviewed 43 patients who underwent posterior atlantoaxial fusion with the miniplate-augmented iliac crest autograft at our institute. Complications related to surgery were recorded and calculated. After operation, patients were followed up through routine radiography to examine whether the fusion of the atlantoaxial segment was achieved. Success of fusion was defined as follows: 1) the presence of bone bridging between the bone graft and both the atlas and axis; and 2) the absence of movement of the atlantoaxial spinous process on flexion-extension radiography, which meant that the variation of length measured in 2 views, respectively, was <1 mm. The first time when radiography showed successful fusion after surgery was termed as fusion time and was recorded individually. In addition, overall fusion rates and mean fusion times were analyzed. RESULTS Of 43 patients, long-term follow-up data were available for 31 patients, whereas the remaining 12 patients had dropped out (mean follow-up duration, 24.91 months; range, 6-72 months). Among 31 patients, 22 (70.96%) were women and 9 (29.03%) were men. The mean age was 63.33 years. Regarding the etiology, atlantoaxial dislocations or subluxations were caused due to degeneration, rheumatoid arthritis, odontoid fracture, trauma, and os odontoideum in 14 (45%), 3 (10%), 5 (16%), 8 (26%), and 1 (3%) patient(s), respectively. Successful fusion was achieved in 30 (96.77%) patients, with a mean fusion time of 6.23 months, whereas only 1 (3.23%) patient did not meet the fusion criteria. No complications related to the miniplate occurred. We noted vertebral artery rupture not requiring blood transfusion in 1 patient, aspiration pneumonia in 1 patient, urinary tract infection in 1 patient, anemia requiring transfusion in 1 patient, and leg dysesthesia in 1 patient. No neurologic deficit was found. CONCLUSIONS Miniplate-augmented interlaminar fusion with C1-C2 screwing resulted in excellent fusion rates with a considerably low probability of complications. Hence this novel technique for bone graft fixation with atlantoaxial screwing has a good efficacy and safety and can serve as an alternative for bone graft fixation during C1-C2 fusion.
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Affiliation(s)
- Po-Jen Huang
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan
| | - Jiann-Her Lin
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan; Department of Surgery, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
| | - Yung-Hsiao Chiang
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan; Department of Surgery, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
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Association Between Frailty Status and Odontoid Fractures After Traumatic Falls: Investigation of Varying Injury Mechanisms Among 70 Elderly Odontoid Fracture Patients. J Orthop Trauma 2019; 33:e484-e488. [PMID: 31365449 DOI: 10.1097/bot.0000000000001597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine significant associations between patient frailty status and odontoid fractures across common traumatic mechanisms of injuries (MOIs) in the elderly. DESIGN Retrospective review. SETTING Single, academic-affiliated hospital with full surgical services. PATIENTS/PARTICIPANTS Patients 65 years or older with traumatic odontoid fractures were included. INTERVENTION Nonoperative management (soft/hard collar, halo, traction tongs, and Minerva) and/or operative fixation. MAIN OUTCOME MEASUREMENTS Modified frailty index (mFI), MOI, concurrent injuries, inpatient length of stay (LOS), reoperation, and mortality rates. RESULTS Seventy patients were included (80.6 ± 8.5 years, 60% F, 88% European, 10% Maori/Pacific, 1.4% Asian, Charlson Comorbidity Index 5.3 ± 2.2, mFI 0.21 ± 0.15). The most common MOIs were falls (74.3%), high-speed motor vehicle accidents (MVAs) (17.1%), low-speed MVAs (5.7%), and pedestrian versus car (2.9%). Patients with traumatic falls exhibited significantly higher mFI scores (0.25) compared with low-speed MVAs (0.16), high-speed MVAs (0.08), and pedestrian versus car (0.01) (P = 0.003). Twenty-seven patients with odontoid fractures were frail, 33 were prefrail, and 10 were robust. Ninety-two percent of frail patients had a traumatic fall as their MOI, as opposed to 73% of prefrail and 30% of robust patients (P < 0.001). Prefrail and frail patients were 4.3 times more likely than robust patients to present with odontoid fractures through traumatic fall [odds ratio (OR): 4.33 (1.47-12.75), P = 0.008], and frailty increased likelihood of reoperation [OR: 4.2 (1.2-14.75), P = 0.025] and extended LOS [OR: 5.71 (1.05-10.37), P = 0.017]. Frail patients had the highest 30-day (P = 0.017) and 1-year mortality (P < 0.001) compared with other groups. CONCLUSION Patients with traumatic odontoid fractures from falls were significantly more frail in comparison with any other MOIs, with worse short- and long-term outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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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.
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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
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Smith JS, Shaffrey CI, Kim HJ, Passias P, Protopsaltis T, Lafage R, Mundis GM, Klineberg E, Lafage V, Schwab FJ, Scheer JK, Miller E, Kelly M, Hamilton DK, Gupta M, Deviren V, Hostin R, Albert T, Riew KD, Hart R, Burton D, Bess S, Ames CP. Prospective Multicenter Assessment of All-Cause Mortality Following Surgery for Adult Cervical Deformity. Neurosurgery 2019; 83:1277-1285. [PMID: 29351637 DOI: 10.1093/neuros/nyx605] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 11/30/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Surgical treatments for adult cervical spinal deformity (ACSD) are often complex and have high complication rates. OBJECTIVE To assess all-cause mortality following ACSD surgery. METHODS ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Clinical and surgical parameters and all-cause mortality were assessed. RESULTS Of 123 ACSD patients, 120 (98%) had complete baseline data (mean age, 60.6 yr). The mean number of comorbidities per patient was 1.80, and 80% had at least 1 comorbidity. Surgical approaches included anterior only (15.8%), posterior only (50.0%), and combined anterior/posterior (34.2%). The mean number of vertebral levels fused was 8.0 (standard deviation [SD] = 4.5), and 23.3% had a 3-column osteotomy. Death was reported for 11 (9.2%) patients at a mean of 1.1 yr (SD = 0.76 yr; range = 7 d to 2 yr). Mean follow-up for living patients was 1.2 yr (SD = 0.64 yr). Causes of death included myocardial infarction (n = 2), pneumonia/cardiopulmonary failure (n = 2), sepsis (n = 1), obstructive sleep apnea/narcotics (n = 1), subsequently diagnosed amyotrophic lateral sclerosis (n = 1), burn injury related to home supplemental oxygen (n = 1), and unknown (n = 3). Deceased patients did not significantly differ from alive patients based on demographic, clinical, or surgical parameters assessed, except for a higher major complication rate (excluding mortality; 63.6% vs 22.0%, P = .006). CONCLUSION All-cause mortality at a mean of 1.2 yr following surgery for ACSD was 9.2% in this prospective multicenter series. Causes of death were reflective of the overall high level of comorbidities. These findings may prove useful for treatment decision making and patient counseling in the context of the substantial impact of ACSD.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin K Scheer
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Emily Miller
- Stanford Physical Medicine and Rehabilitation, Redwood City, California
| | - Michael Kelly
- Department of Orthopedic Surgery, Washington University, St Louis, Missouri
| | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, Missouri
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Todd Albert
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - K Daniel Riew
- Department of Orthopaedic Surgery, Columbia University, New York City, New York
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Doug Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Shay Bess
- Presbyterian St Lukes Medical Center, Denver, Colorado
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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11
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Chan HYH, Segreto FA, Horn SR, Bortz C, Choy GG, Passias PG, Deverall HH, Baker JF. C2 Fractures in the Elderly: Single-Center Evaluation of Risk Factors for Mortality. Asian Spine J 2019; 13:746-752. [PMID: 31079430 PMCID: PMC6773992 DOI: 10.31616/asj.2018.0300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/31/2019] [Indexed: 12/13/2022] Open
Abstract
Study Design Retrospective cohort study. Purpose The aim of this study was to identify features associated with increased mortality risk in traumatic C2 fractures in the elderly, including measures of comorbidity and frailty. Overview of Literature C2 fractures in the elderly are of increasing relevance in the setting of an aging global population and have a high mortality rate. Previous analyzes of risk factors for mortality have not included the measures of comorbidity and/or frailty, and no local data have been reported to date. Methods This study comprises a retrospective review of 70 patients of age >65 years at Waikato Hospital, New Zealand with traumatic C2 fractures identified on computed tomography between 2010 and 2016. Demographic details, medical history, laboratory results on admission, mechanism of injury, and neurological status on presentation were recorded. Medical comorbidities were also detailed allowing calculation of the Charlson Comorbidity Index (CCI) and the modified Frailty Index (mFI). Results The most common mechanism of injury was a fall from standing height (n=52, 74.3%). Mortality rates were 14.3% (n=10) at day 30, and 35.7% (n=25) at 1 year. Bivariate analysis showed that both CCI and mFI correlated with 1-year mortality rates. Reduced albumin and hemoglobin levels were also associated with 30-day and 1-year mortality rates. Forward stepwise logistic regression models determined CCI and low hemoglobin as predictors of mortality within 30 days, whereas CCI, low albumin, increased age, and female gender predicted mortality at 1 year. Conclusions The CCI was a useful tool for predicting mortality at 1 year in the patient cohort. Other variables, including common laboratory markers, can also be used for risk stratification, to initiate timely multidisciplinary management, and prognostic counseling for patients and family members.
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Affiliation(s)
- Hoi-Ying H Chan
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Frank A Segreto
- Department of Orthopaedic and Neurological Surgery, NYU Langone Medical Centre-Orthopaedic Hospital, New York, NY, USA
| | - Samantha R Horn
- Department of Orthopaedic and Neurological Surgery, NYU Langone Medical Centre-Orthopaedic Hospital, New York, NY, USA
| | - Cole Bortz
- Department of Orthopaedic and Neurological Surgery, NYU Langone Medical Centre-Orthopaedic Hospital, New York, NY, USA
| | - Godwin G Choy
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Peter G Passias
- Department of Orthopaedic and Neurological Surgery, NYU Langone Medical Centre-Orthopaedic Hospital, New York, NY, USA
| | - Hamish H Deverall
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Joseph F Baker
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
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12
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Natella L, Bronsard N, Allia J, Hekayem L, Euller-Ziegler L, De Peretti F, Breuil V. A Case Series Study of Odontoid Fracture in the Elderly: A Severe Fracture Occurring Most Frequently in Osteoporotic Subjects. JBMR Plus 2019; 3:e10076. [PMID: 31044178 PMCID: PMC6478580 DOI: 10.1002/jbm4.10076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/23/2018] [Accepted: 08/07/2018] [Indexed: 11/27/2022] Open
Abstract
The WHO definition of osteoporosis excludes cervical fractures. Recent studies suggest that atraumatic odontoid fractures (OF) may be favored by osteoporosis but global bone status for osteoporosis diagnosis has not been described. We present a case series of patients >65 years old hospitalized for low‐energy OF who had an evaluation of their bone status within 3 months after fracture, including clinical risk factors of osteoporosis, bone mineral density (BMD), vertebral fracture assessment (VFA) by dual X‐ray absorptiometry, and laboratory tests. Osteoporosis was defined as a T‐score ≤ −2.5 on at least one site, or a bone fragility fracture associated with a T‐score ≤ −1 at one site. Thirty‐three patients were hospitalized for OF, 30 of them as a consequence of a low‐energy impact: 20 women and 10 men (mean age: 85 years). Eight patients died before bone evaluation, four refused, and six were lost to follow‐up. Twelve patients were included: 11 women and one man (mean age: 83.8 years). Ten out of twelve patients fulfilled diagnostic criteria of osteoporosis, including eight with previous osteoporotic fractures (six severe fractures). Eight fulfilled specific treatment of osteoporosis criteria, but only two were treated. The mean follow‐up period was 12.2 ± 4.1 months. Prior to OF occurrence, all lived at home and were independent; at the time of discharge, six went to a nursing home. At 3 months of follow‐up (n = 10), one was dead and nine lived at home. At 12 months (n = 9), two were dead and seven lived at home. This study provides for the first time a classical evaluation of osteoporotic status for low‐energy OF in the elderly and shows that it occurs in osteoporotic subjects. These preliminary results require larger‐scale studies to determine whether OF could be considered as a severe osteoporotic fracture. © 2018 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Lauren Natella
- Rheumatology Universite Cote d'Azur Centre Hospitalier Universitaire (CHU) de Nice Nice France
| | - Nicolas Bronsard
- Orthopaedic Trauma and Spine Surgery Universite Cote d'Azur Institut Universitaire de l'Appareil Locomoteur et du Sport Nice France
| | - Jeremy Allia
- Orthopaedic Trauma and Spine Surgery Universite Cote d'Azur Institut Universitaire de l'Appareil Locomoteur et du Sport Nice France
| | - Laurent Hekayem
- Orthopaedic Trauma and Spine Surgery Universite Cote d'Azur Institut Universitaire de l'Appareil Locomoteur et du Sport Nice France
| | - Liana Euller-Ziegler
- Rheumatology Universite Cote d'Azur Centre Hospitalier Universitaire (CHU) de Nice Nice France
| | - Fernand De Peretti
- Orthopaedic Trauma and Spine Surgery Universite Cote d'Azur Institut Universitaire de l'Appareil Locomoteur et du Sport Nice France
| | - Véronique Breuil
- Rheumatology Universite Cote d'Azur Centre Hospitalier Universitaire (CHU) de Nice Nice France.,Commission for Atomic Energy and Alternative Energies (CEA)/Directorate of Basic Research (DRF)/Biosciences and Biotechnologies Institute of Aix-Marseille (BIAM) Unités Mixtes de Recherche (UMR) E4320 Transporters Imaging and Radiotherapy in Oncology (TIRO)-Mécanismes biologiques des Altérations du Tissu Osseux (MATOs) Nice France
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13
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Shafafy R, Valsamis EM, Luck J, Dimock R, Rampersad S, Kieffer W, Morassi GL, Elsayed S. Predictors of mortality in the elderly patient with a fracture of the odontoid process. Bone Joint J 2019; 101-B:253-259. [DOI: 10.1302/0301-620x.101b3.bjj-2018-1004.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients. Patients and Methods We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100). Results Overall mortality was 14.6% at 30 days and 34.1% at one year. Univariate analysis revealed head injury and the NHFS to be significant predictors of mortality at 30 days and one year. Multivariate analysis showed that head injury is an independent predictor of mortality at 30 days and at one year. The NHFS was an independent predictor of mortality at one year. The presence of other spinal injuries was an independent predictor at 30 days. Following survival analysis, an NHFS score greater than 5 stratified patients into a significantly higher risk group at both 30 days and one year. Conclusion The NHFS may be used to identify high-risk patients with a fracture of the OP. Head injury increases the risk of mortality in patients with a fracture of the OP. This may help to guide multidisciplinary management and to inform patients. This paper provides evidence to suggest that frailty rather than age alone may be important as a predictor of mortality in elderly patients with a fracture of the odontoid process. Cite this article: Bone Joint J 2019;101-B:253–259.
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Affiliation(s)
- R. Shafafy
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital NHS Foundation Trust, Brighton, UK
| | - E. M. Valsamis
- Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - J. Luck
- Department of Trauma and Orthopaedics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - R. Dimock
- Department of Trauma and Orthopaedics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - S. Rampersad
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - W. Kieffer
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Camberley, UK
| | - G. L. Morassi
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - S. Elsayed
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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14
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Squarza S, Uggetti CL, Politi MA, Pescatori LC, Bisogno R, Campi A, Reganati P, Cariati M. C1-C2 fractures in asymptomatic elderly patients with minor head trauma: evaluation with a dedicated head CT protocol. Radiol Bras 2019; 52:17-23. [PMID: 30804611 PMCID: PMC6383526 DOI: 10.1590/0100-3984.2017.0154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/19/2017] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To evaluate the frequency and types of upper cervical spine injuries in asymptomatic elderly patients undergoing computed tomography (CT) for the investigation of minor head trauma. MATERIALS AND METHODS This was a prospective study of 2613 asymptomatic elderly patients with minor head trauma seen between January 2015 and December 2016. We adopted a dedicated head CT protocol that included the C1-C2 region. RESULTS Of the 2613 patients analyzed, 33 (1.26%) had upper cervical spine injuries, corresponding to 8.37% of the 394 patients with trauma-related findings. Of those 33 patients, 6 had C1 fractures and 27 had C2 fractures. The use of 16- and 128-slice scanners increased the CT dose by 25.0% and 23.7%, respectively. CONCLUSION Inclusion of the C1-C2 region in head CT scans allowed us to identify upper cervical spine injuries in 1.26% of asymptomatic elderly patients with minor head trauma. The protocol evaluated helps detect potentially life-threatening injuries and could be adopted for routine use in elderly individuals with minor head trauma.
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Affiliation(s)
- Silvia Squarza
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria
Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | - Carla Luisa Uggetti
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria
Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | | | | | | | - Adriana Campi
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria
Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | - Paolo Reganati
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria
Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | - Maurizio Cariati
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria
Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
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15
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Sheikh HQ, Athanassacopoulos M, Doshi AB, Breakwell L, Cole A, Rex Michael AL, Chiverton N. Early mortality and morbidity following a type II odontoid fracture in the elderly. Surgeon 2018; 16:297-301. [DOI: 10.1016/j.surge.2018.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/13/2018] [Accepted: 03/06/2018] [Indexed: 11/28/2022]
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16
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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.
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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
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17
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Affiliation(s)
- Theodore J Choma
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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18
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Iyer S, Hurlbert RJ, Albert TJ. Management of Odontoid Fractures in the Elderly: A Review of the Literature and an Evidence-Based Treatment Algorithm. Neurosurgery 2017; 82:419-430. [DOI: 10.1093/neuros/nyx546] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 10/01/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature. We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly population must be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunion with close follow-up is an acceptable outcome. If operative management is chosen, a posterior approach is should be chosen when fracture- or patient-related factors make an anterior approach challenging. The high levels of morbidity and mortality associated with odontoid fractures should encourage all providers to pursue medical co-management and optimization of bone health following diagnosis.
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Affiliation(s)
- Sravisht Iyer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - R John Hurlbert
- Spine Program, Department of Surgery, University of Arizona—College of Medicine, Tuscon, Arizona
| | - Todd J Albert
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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