Type II odontoid fractures in the elderly: early failure of nonsurgical treatment

Using Frailty Measures to Predict Functional Outcomes and Mortality After Type II Odontoid Fracture in Elderly Patients: A Retrospective Cohort Study

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.

Does the Surgical Approach Matter in Treating Odontoid Fractures? A Comparison of Mechanical Complication Rates Between Anterior Versus Posterior Surgical Approaches: A Meta-Analysis and Systematic Review

Objective

Odontoid fractures are treated surgically through the anterior or posterior approach. Each surgical approach has its advantages and disadvantages, so the preferred approach remains debatable. There are few meta-analyses or systemic reviews on the mechanical complications of surgical treatment for odontoid fractures. This meta-analysis aimed to compare the operation-related morbidity, including mechanical complications, and mortality of patients with odontoid fractures, treated via the anterior or posterior approach.

Methods

A systematic search was performed on PubMed/Medline, Embase, and the Cochrane Library for the studies up to October 2023 on the complication rate of the surgical treatment of odontoid fractures, related to the surgical approach. The risk ratios (RR) with the 95% confidence intervals (CIs) were pooled to assess the mechanical complication rates, other complications, revision surgery, and mortality, depending on the surgical approach.

Results

A total of 1,519 studies were retrieved using the search strategy, and 782 patients from 15 articles were included in this meta-analysis. Mechanical complications were significantly more frequent in the anterior surgical group with low heterogeneity. The incidences of fracture nonunion and revision surgery were also higher in the anterior surgery group. However, there was no significant difference in systemic complications and mortality rates between the two groups.

Conclusion

The posterior approach was more advantageous than the anterior approach in terms of mechanical complications, fusion rates, and incidence of revision surgery. However, further studies, should be performed to strengthen these results.

Predicting Mortality Following Odontoid Fracture Fixation in Elderly Patients: CAADS-16 Score

STUDY DESIGN

Retrospective Review of a National Database.

INTRODUCTION

By utilizing a national database, this study aims to quantify the predictors of 30-day mortality after odontoid fixation and guide appropriate management for patients in whom the choice between operative and non-operative management is unclear.

METHODS

The American College of Surgeons National Surgical Quality Improvement Database was queried using Current Procedural Terminology (CPT) codes and International Classification of Disease (ICD) codes to identify patients 60 or older who underwent surgical fixation of an odontoid fracture from 2005 to 2020. Risk factors for mortality significant in univariate and subsequent multivariate analysis were used to develop a scoring system to predict post-operative mortality.

RESULTS

608 patients were identified. Patients were split into a non-mortality 30 days post-op group, and into a mortality 30 days post-op group. The following risk factors were included in the scoring system: functional dependency, disseminated cancer, albumin less than 3.5, WBC count greater than 16 k, anterior surgical approach, and pre-op SIRS. Using a cutoff value of 2, the CAAD-16 score had a sensitivity and specificity of 82% and 81%, respectively. The ASA score, cutoff at 4, showed a sensitivity and specificity of 64% and 75% respectively.

CONCLUSIONS

This sample of 294 patients represents one of the largest samples of odontoid fracture fixation patients available in the literature and comes from a nationally representative database. We structure relevant risk factors into the CAADS-16 score, which has the potential to be a clinically relevant tool to prevent short-term postoperative mortality.

The optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis

PURPOSE

Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the outcome of surgical and conservative treatments in elderly (≥ 65 years), by updating a systematic review published by the authors in 2013.

METHODS

A comprehensive search was conducted in seven databases. Clinical outcome was the primary outcome. Fracture union- and stability were secondary outcomes. Pooled point estimates and their respective 95% confidence intervals (CIs) were derived using the random-effects model. A random-effects multivariable meta-regression model was used to correct for baseline co-variates when sufficiently reported.

RESULTS

Forty-one studies met the inclusion criteria, of which forty were case series and one a cohort study. No clinical differences in outcomes including the Neck Disability Index (NDI, 700 patients), Visual Analogue Scale pain (VAS, 180 patients), and Smiley-Webster Scale (SWS, 231 patients) scores were identified between surgical and conservative treatments. However, fracture union was higher in surgically treated patients (pooled incidence 72.7%, 95% CI 66.1%, 78.5%, 31 studies, 988 patients) than in conservatively treated patients (40.2%, 95% CI 32.0%, 49.0%, 22 studies, 912 patients). This difference remained after correcting for age and fracture type. Fracture stability (41 studies, 1917 patients), although numerically favoring surgery, did not appear to differ between treatment groups.

CONCLUSION

While surgically treated patients showed higher union rates than conservatively treated patients, no clinically relevant differences were observed in NDI, VAS pain, and SWS scores and stability rates. These results need to be further confirmed in well-designed comparative studies with proper adjustment for confounding, such as age, fracture characteristics, and osteoporosis degree.

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Multicenter retrospective cohort study of the association between surgery for odontoid fractures in the elderly and in-hospital outcomes

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.

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

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

Intraoperative Computed Tomography for C1-C2 Stabilization by Goel-Harms: Analysis of Clinical Efficacy and a Novel Classification of Screw Placement Accuracy

BACKGROUND

The introduction of intraoperative computed tomography (iCT) could improve the surgical results of C1-C2 stabilization by Goel-Harms, especially in patients with complex deformities. This study aims to investigate the impact of iCT on the accuracy of C1-C2 screw positioning and to develop a score based on multiparametric analysis of imaging data (Cervical Screw Placement Accuracy score [CSPAs]).

METHODS

Twenty-one patients were retrospectively evaluated. The data obtained with the use of an iCT were compared with the incidence of cases of malpositioning in the literature. Multiparametric imaging criteria were developed: the 82 screw positions were evaluated using the CSPA criteria and 2 additional variables. The CSPAs was obtained from the aggregation of the CSPAs criteria: optimal (CSPAs ≥8), suboptimal (CSPAs = 6-7), malpositioned (CSPAs ≤5).

RESULTS

The average incidence of malpositioning in C1-C2 arthrodesis decreased from 13% without iCT to 1.2% with the aid of iCT, considering a monoparametric value. The CSPAs analysis shows a greater discretion and higher number of well-defined categories of the accuracy of C1-C2 screw position: optimal, 80.3%; suboptimal, 17.1%; and malposition, 2.6%. A correlation was observed between the accuracy of the positioning of both right and left screws in C2. Furthermore, the anatomic site of C2 screws was found to be a predictor of cortical invasion.

CONCLUSIONS

The results suggest that the introduction of the iCT is associated with a consistent improvement of the accuracy in the positioning of the screws. A multiparametric score (CSPAs) could improve the assessment of screw placement.

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

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Volume-outcome relationship in halo vest utilization for C2 fractures

BACKGROUND CONTEXT

The prevalence of C2 fractures has increased in recent years. The treatment of these fractures include halo-vest immobilization (HVI), rigid cervical collar, or spinal fusion. There is controversy regarding the management of these fractures with different institutions having their own protocols based on individualized experience. The volume-outcome relationship of HVI use for C2 fractures has not been studied. Evaluation of such relationships are important as they suggest that patients may benefit from referral to and treatment at high-volume institutions.

PURPOSE

To evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State.

STUDY DESIGN

Retrospective analysis of a statewide database.

PATIENT SAMPLE

We queried the New York Statewide Planning and Research Cooperative System database for the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 805.02 (closed fracture of second cervical vertebra) and procedure code 029.4 (insertion or replacement of skull tongs or halo traction device) to identify all patients who received HVI for a fracture of the second cervical vertebra between the years 2001 and 2014. Those who had isolated C2 fractures were selected.

OUTCOME MEASURES

Outcomes of interest included resource utilization characteristics (hospitalization charges and length of stay), perioperative complications, comorbidities, 30-day mortality, any readmission, and any future cervical fusion surgery.

METHODS

The 2001 to 2014 Statewide Planning and Research Cooperative System database was used to identify patients with C2 fractures who received HVI. Our key independent variable was institution volume modeled as high- (>25 halos/year), medium-, (10-25 halos/year), or low-volume (<10 halos/year) based on the total number of HVI procedures reported by hospitals during the study period. We compared outcomes with respect to hospital volume. We also compared patients by age groups: <40, 40 to 60, 60 to 80, and >80. Multivariate logistic regressions were performed for the binary variables any complication and any readmission while controlling for covariates hospital volume, age, sex, race, insurance status, and Elixhauser comorbidity mean. Statistical significance was set at a value of p<.05 for all analyses.

RESULTS

In all, 625 patients with C2 fractures managed with HVI were included. Most patients were male (53%) and Caucasian (76%) with a mean age of 57. Patients at high-volume hospitals were younger (52 vs. 59 and 60 for medium- and low-volume, respectively; p<.01) and had fewer future readmissions (40% vs. 54% and 84% for medium- and low-volume, respectively; p<.01). On multivariable analysis, those with private insurance and worker's compensation had lower likelihood of future readmission compared to Medicaid patients. Patients >80 had higher rates of major in-hospital complications (52% vs. 40%, 18%, and 19% for groups 60-79, 40-59, and <40, respectively; p<.01), mortality (14% vs. 5%, 1%, and 1% for groups 60-79, 40-59, and <40, respectively; p<.01), and readmissions after the initial HVI (62% vs. 50%, 54%, and 37% for groups 60-79, 40-59, and <40, respectively; p<.01). The annual rate of HVI use for C2 fractures decreased significantly from 2001 to 2014 (0.32 to 0.06 HVI procedures per 100,000 people; p<.01) with the rate of decline being less pronounced in high-volume institutions (70% decrease vs. 85% and 90% for medium- and low-volume, respectively).

CONCLUSIONS

Halo vest utilization for C2 fractures in New York State has been declining over the past decade, with the decline being less pronounced in high-volume hospitals. Our hospital volume analysis suggests that HVI use in high-volume institutions is associated with a lower rate of future readmissions. This finding suggests that patients with C2 fractures may benefit from treatment at high-volume institutions. Further research to help improve referral of appropriate patients and increase access to such institutions is warranted.

Miniplate-Augmented Interlaminar Fusion in C1-C2 Screwing

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Type II odontoid fracture in elderly patients treated conservatively: is fracture healing the goal?

PURPOSE

Analysis of functional outcome of elderly patients with type II odontoid fractures treated conservatively in relation to their radiological outcome.

METHODS

A total of 50 geriatric patients with type II odontoid fractures were treated with Aspen/Vista collars. On admission, each patient was assessed assigning ASA score, modified Rankin Scale (mRS-pre) and Charlson Comorbidity Index (CCI). From 12-15 months after treatment, functional evaluations were performed employing a second modified Rankin Scale (mRS-post) together with Neck Disability Index (NDI) and Smiley-Webster pain scale (SWPS). Radiological outcome was evaluated through dynamic cervical spine X-rays at 3 months and cervical spine CT scans 6 months after treatment. Three different conditions were identified: stable union, stable non-union and unstable non-union. Surgery was preferred whenever a fracture gap > 2 mm, an antero-posterior displacement > 5 mm, an odontoid angulation > 11° or neurological deficits occurred.

RESULTS

Among the 50 patients, 24 reached a stable union, while 26 a stable non-union. Comparing the two groups, no differences in ASA (p = 0.60), CCI (p = 0.85) and mRS-pre (p = 0.14) were noted. Similarly, no differences in mRS-post (p = 0.96), SWPS (p = 0.85) and NDI (p = 0.51) were observed between patients who reached an osseous fusion and those with a stable fibrous non-union. No effects of age, sex, ASA, mRS-pre, fracture dislocation and radiological outcome were discovered on functional outcome. At logistic regression analysis, female sex and high values of CCI emerged associated with worse NDI.

CONCLUSIONS

In geriatric type II odontoid fractures, pre-injury clinical status and comorbidities overcome imaging in determining post-treatment level of function. Hard collar immobilization led to a favourable functional outcome with mRS-post, NDI and SWPS values diffusely encouraging whatever a bony union or a fibrous non-union was obtained. These slides can be retrieved under Electronic Supplementary Material.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN/SETTING

Systematic review and meta-analysis were performed.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

A Cohort Study of the Natural History of Odontoid Pseudoarthrosis Managed Nonoperatively in Elderly Patients

OBJECTIVE

Although the primary goal of treatment of type II odontoid fracture is bony union, some advocate continued nonsurgical management of minimally symptomatic older patients who have fibrous union or minimal fracture motion. The risk of this strategy is unknown. We reviewed our long-term outcomes after dens nonunion to define the natural history of Type II odontoid fractures in elderly patients managed nonoperatively.

METHODS

A retrospective chart review of 50 consecutive adults aged 65 or older with Type II odontoid fracture initially managed nonsurgically from 1998 to 2012 at a single tertiary care institution was conducted. Particular attention was paid to patients who had orthosis removal despite absent bony fusion. Patients were contacted prospectively by telephone and followed until death, surgical intervention, or last known contact.

RESULTS

Fifty patients initially were managed nonsurgically; of these, 21 (42.0%) proceeded to bony fusion, 3 (6%) underwent delayed surgery for persistent instability, and 26 (52%) had orthosis removal despite the lack of solid arthrodesis on imaging. The last group had a median follow-up of 25 months (range 4-158 months), with 20 of 26 (76.9%) followed until death. Of these patients, 1 patient developed progressive quadriplegia and dysphagia 11 months after initial injury. Compared with patients with spontaneous union, patients with nonunion had shorter life expectancy, despite no significant differences between the groups with respect to age, sex, injury mechanism, radiographic variables, or follow-up duration.

CONCLUSIONS

Orthosis removal despite fracture nonunion may be reasonable in elderly patients with Type II dens fractures.

Management of Odontoid Fractures in the Elderly: A Review of the Literature and an Evidence-Based Treatment Algorithm

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.

[Management and outcome of type II fractures of the odontoid process]

BACKGROUND

The most effective treatment of type II dens fractures according to Anderson and D'Alonzo remains controversial as there is no guidance on the choice of conservative or surgical therapy and if the anterior or the posterior approach is more advantageous. In 1993 Eysel and Roosen showed that the consolidation rate of type II odontoid fractures mostly depends on the morphology of the fracture and established a classification with corresponding treatment recommendations.

OBJECTIVE

The investigation aimed at clarifying the outcome of type II dens fractures treated according to the recommendations of Eysel and Roosen.

MATERIAL AND METHODS

Data of dens fractures from 72 patients were analyzed and categorized according to the Eysel and Roosen classification. Furthermore, the treatment was analyzed and the outcome was evaluated retrospectively using radiographs acquired during follow-up.

RESULTS

The mean age of the 72 patients was 70.7 years. Of the patients 19.4% suffered from type A, 75% from type B and 5.6% from type C fractures according to Eysel and Roosen. Out of the 72 patients 45 were assessed by computed tomography (CT) scan during follow-up. According to the recommendations of the authors 34 of the 41 patients with type A or type B fractures underwent anterior screw fixation of the dens and 3 out of the 4 patients with a type C fracture underwent a dorsal C1 and C2 fusion. After a mean follow-up of 7 months non-union was observed in 15.6% of the patients whereby 6 of the these patients were treated by surgery and 1 patient was managed conservatively. All of the patients who developed a non-union had a type B fracture.

CONCLUSION

The simple clinical applicability together with the low rate of non-union development shows that the Eysel and Roosen classification appears to be a suitable guide for clinical use when deciding on the appropriate treatment regimen.

Early Morbidity and Mortality in 50 Very Elderly Patients After Posterior Atlantoaxial Fusion for Traumatic Odontoid Fractures

BACKGROUND

Traumatic odontoid fractures (tOFs) in the very elderly are associated with high morbidity and mortality. The best treatment strategy (conservative vs. surgery) is still unclear.

METHODS

Between April 2008 and April 2014, fifty (17 male, 33 female) patients (mean age 87.2 ± 4.4 years; range: 80-99) were included in this retrospective cohort study. All patients underwent posterior fusion surgery for tOF. Early outcome, morbidity and mortality, length of hospital and intensive care unit (ICU) stay, comorbidities, and perioperative complications were assessed.

RESULTS

The mean age-adjusted Charlson Comorbidity Index (CCI) was 5.8 ± 3.9 (range: 0-13), and the mean American Society of Anesthesiologists score was 3 ± 0.5 (range: 2-4). Surgery was delayed in 48% of patients. Thirty percent of patients had preoperative complications (72.4% severe), of which a leading cause was dysphagia with subsequent pneumonia, and 18% required preoperative assessment or improvement of health status. Surgery-related complications were experienced in 14% with no neurovascular lesion. Postoperative medical complications occurred in 52% of patients (67.3% severe). Major complications were mostly respiratory/pulmonary (66.7%), of which postoperative pneumonia (36.4%) was leading. Twenty-four percent of patients were ICU monitored. Mean length of ICU stay was 9 ± 6.6 days (1-20). Mean length of hospital stay was 15 ± 8.6 days (4-56). There was no in-hospital mortality, and 30-day mortality was 6%.

CONCLUSIONS

Posterior fusion for tOF in patients 80 years or older seems to be a feasible treatment option in these high-risk patients. Despite a high incidence of severe comorbidities and perioperative complications, outcome was satisfactory.

LEVEL OF EVIDENCE

Our research was a retrospective cohort study, Level III.

Reliability of treating asymptomatic traumatic type II dens fractures in patients over age 80: A retrospective series

Background:

Management of type II odontoid fractures in elderly remains controversial to whether surgical treatment is favored over conservative one. This is a study of geriatric patients with asymptomatic type II dens fractures who after sustaining a fall were initially evaluated at community hospitals. They were placed in a rigid collar and were followed up in a spine clinic.

Purpose:

To assess the reliability of treating very old patients with type II dens fracture conservatively and whether surgical intervention if needed would affect the clinical outcome.

Study Design:

Retrospective study with the literature review.

Patient Sample:

Consecutive patients above 80 years of age, who sustained a clinically asymptomatic type II dens fracture and were observed after a conservative treatment plan, was initiated.

Outcome Measures:

Outcome measures included self-reported worsening neck pain, neurological function, and radiographic measures over the follow-up period.

Materials and Methods:

A retrospective clinical analysis of 5 active geriatric patients with type II asymptomatic dens fracture. After evaluating them, treatment options were discussed with patients and their family members. The decision was to continue to follow them with a rigid collar very closely since they were reluctant to undergo any surgical procedure.

Results:

Patients were followed for an average of 29 months. They were observed for any worsening neck pain, neurological deficit, or deterioration of fracture on follow-up imaging studies. At last follow-up, 2 of 5 patients continued to be asymptomatic, the 3^rd died of unrelated causes while 2 others required surgeries at least 1-year post injury.

Conclusions:

Treatment of type II dens fractures in the elderly is controversial. Independent elderly patients who are asymptomatic at presentation may be safe to be followed up very closely with a neck brace and serial X-ray. Converting to surgical treatment can be done safely when needed without affecting the overall clinical out.

Longer-Term Outcomes of Geriatric Odontoid Fracture Nonunion

INTRODUCTION

Longer-term outcomes of patients with geriatric type II odontoid fracture nonunion remain unclear.

METHODS

Thirty-four consecutive geriatric patients (>70 years old) with minimally displaced (<50% displacement) type II odontoid fractures were treated 24 hours a day for 12 weeks with rigid collar immobilization between the years 2003 and 2011. Radiographic and medical record reviews were performed on all 34 patients. Additionally, 7 patients were available for clinical longer-term follow-up (>4 years).

RESULTS

In all, 30 (88%) of the 34 patients had nonunion after 12 weeks of treatment, 2 (6%) patients had union, and 2 (6%) patients died during the first 12 weeks. Twenty-one of the 30 patients with nonunion had a displaced or mobile nonunion (70%), and 4 (12%) patients were lost to follow-up. At longer-term follow-up, 23 (68%) patients had died. The average time death occurred was 3.8 years with a range of 0.17 years to 9.42 years postinjury. Twenty of the 23 deaths were attributed to medical comorbidities not related to the patient's odontoid nonunion. We were unable to determine the cause of death in 3 patients. None of the patients who died had identifiable clinical myelopathy prior to their death on chart review. Of the 7 patients who were alive, all were determined to have odontoid nonunion, of which 5 (70%) were mobile odontoid nonunion. Visual Analog Scale (VAS) and Neck Disability Index (NDI) scores were low (VAS averaged 0.57 and NDI averaged 6.9%) and treatment satisfaction was high (averaged 9.7 of 10). Scores for pain and function did not differ significantly when compared to age-matched controls (P = .08, t test).

CONCLUSION

Rates of odontoid nonunion are high in patients with geriatric odontoid fractures that are treated with continuous rigid collar for 12 weeks. The majority of patients with nonunion appear to achieve high functional outcomes. In this study, mortality did not appear to be related to adverse neurologic events after treatment.

Conservative versus surgical treatment for type II odontoid fractures in the elderly: Grading the evidence through a meta-analysis

BACKGROUND

Odontoid fractures are common C-spine fractures in the elderly. However, the optimal treatment of odontoid fractures in the elderly is, still subject to controversy.

HYPOTHESIS

Surgical treatment has several advantages on conservative treatment, such as reduced mortality and lower incidence of non-union. This meta-analysis was performed to identify the efficacy of conservative treatment compared with surgical treatment and provides recommendations for using these procedures to treat type II odontoid fractures in the elderly.

MATERIALS AND METHODS

A systematic search of all studies published was conducted using the PubMed, EMBASE, OVID, ScienceDirect and Cochrane CENTRAL databases. The randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) that compared conservative treatment with surgical treatment and provided data on clinical effects were identified. The included trials were screened out strictly based on the criterion of inclusion and exclusion. The quality of included trials was evaluated. RevMan 5.1 was used for data analysis.

RESULTS

Twelve studies involving 730 patients met the inclusion criteria. There were 441 patients with conservative treatment and 289 with surgical treatment. The results of meta-analysis indicated that no difference with regard to the mortality was noted (P > 0.05) between the two procedures. However, there was statistically significant difference with respect to the non-union numbers (P < 0.05) between the two procedures.

DISCUSSION

Conservative treatment and surgical treatment are both effective procedures for treating type II odontoid fractures in the elderly. Compared with surgical treatment, there is no significant difference in mortality; With respect to non-union numbers, conservative treatment numbers are higher than surgical treatment. Due to the poor quality of the evidence currently available, high quality RCTs are required. Level of evidence Level II: low-powered prospective randomized trial meta-analysis.

National trends of incidence, treatment, and hospital charges of isolated C-2 fractures in three different age groups

OBJECT

Incidence of C-2 fracture is increasing in elderly patients. Patient age also influences decision making in the management of these fractures. There are very limited data on the national trends of incidence, treatment interventions, and resource utilization in patients in different age groups with isolated C-2 fractures. The aim of this study is to investigate the incidence, treatment, complications, length of stay, and hospital charges of isolated C-2 fracture in patients in 3 different age groups by using the Nationwide Inpatient Sample (NIS) database. methods The data were obtained from NIS from 2002 to 2011. Data on patients with closed fractures of C-2 without spinal cord injury were extracted using ICD-9-CM diagnosis code 805.02. Patients with isolated C-2 fractures were identified by excluding patients with other associated injuries. The cohort was divided into 3 age groups: < 65 years, 65–80 years, and > 80 years. Incidence, treatment characteristics, inpatient/postoperative complications, and hospital charges (mean and total annual charges) were compared between the 3 age groups.

RESULTS

A total of 10,336 patients with isolated C-2 fractures were identified. The majority of the patients were in the very elderly age group (> 80 years; 42.3%) followed by 29.7% in the 65- to 80-year age group and 28% in < 65-year age group. From 2002 to 2011, the incidence of hospitalization significantly increased in the 65- to 80-year and > 80-year age groups (p < 0.001). However, the incidence did not change substantially in the < 65-year age group (p = 0.287). Overall, 21% of the patients were treated surgically, and 12.2% of the patients underwent nonoperative interventions (halo and spinal traction). The rate of nonoperative interventions significantly decreased over time in all age groups (p < 0.001). Regardless of treatment given, patients in older age groups had a greater risk of inpatient/postoperative complications, nonroutine discharges, and longer hospitalization. The mean hospital charges were significantly higher in older age groups (p < 0.001).

CONCLUSIONS

The incidence of hospitalization for isolated C-2 fractures is progressively increasing in older age groups. Simultaneously, there has been a steadily decreasing trend in the preference for nonoperative interventions. Due to more complicated hospital stay, longer hospitalizations, and higher rates of nonroutine discharges, the patients in older age groups seem to have a higher propensity for greater health care resource utilization.

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

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

Neurologic injury because of trauma after type II odontoid nonunion

BACKGROUND CONTEXT

Treatment of Type II odontoid fractures remains controversial, whereas nonoperative treatment is well accepted for isolated Type III odontoid fractures. Little is known about long-term sequelae of nonoperative management or risk of recurrent injury after nonsurgical treatment. We hypothesize that a substantial proportion of odontoid fractures assumed to be acute are actually chronic injuries and have a high rate of late displacement resulting in neurologic injury.

PURPOSE

To identify patients presenting with previously unrecognized odontoid fracture nonunions and to document the incidence of new neurologic injury after secondary trauma in this population.

STUDY DESIGN

Retrospective case series.

PATIENT SAMPLE

One hundred thirty-three patients with Type II odontoid fractures presenting to a Level I trauma center.

OUTCOME MEASURES

Computed tomography (CT) and magnetic resonance imaging (MRI) scans, American Spinal Injury Association Motor Score (AMS), and neurologic examination.

METHODS

All patients presenting after traumatic injury to a Level I trauma center from May 2005 to May 2010 with a Type II odontoid fracture on CT scan were included. Patients aged less than 18 years and those with pathologic fractures were excluded. Fractures were classified as chronic or acute based on CT evidence of chronic injury/nonunion including fracture resorption, sclerosis, and cyst formation. Magnetic resonance imaging was then examined for evidence of fracture acuity (increased signal in C2 on T2 images). Patients without evidence of acute fracture on MRI were considered to have chronic injuries. Computed tomography and MRI scans were interpreted independently by two reviewers. Chart review was performed to document demographics, AMS, and new-onset neurologic deficit associated with secondary injury.

RESULTS

One hundred thirty-three patients presented with Type II odontoid fractures and no known history of cervical fracture with an average age of 79 years. Based on CT criteria, 31/133 (23%) fractures were chronic injuries. Nine additional fractures appeared acute on CT but were determined to be chronic by MRI findings. The overall number of chronic fractures was therefore 40 (30%). Interobserver reliability analysis for classification of fractures as chronic demonstrated κ=0.65 representing substantial agreement. Of the 40 chronic fractures, 7 patients (17.5%) had new-onset neurologic deficits after secondary injury including 4 motor deficits, 2 sensory deficits, and 1 combined deficit. Although the chronic injury group as a whole had similar AMS to the acute injury group (89 vs. 84, p=.27), the seven patients with new-onset neurologic deficit had an average AMS of 52.4.

CONCLUSIONS

A substantial proportion of patients presenting after cervical trauma with Type II odontoid fractures have evidence of nonacute injury. Of these patients, 17% presented with a new neurologic deficit caused by an "acute-on-chronic" injury.

Systematic review on surgical and nonsurgical treatment of type II odontoid fractures in the elderly

Odontoid fractures type II according to Anderson and d'Alonzo are not uncommon in the elderly patients. Still, due to the paucity of evidence the published treatment guidelines are far from equivocal. This systematic review focuses on the published results of type II odontoid fracture treatment in the elderly with regard to survival, nonunion, and complications. After a systematic literature research 38 publications were included. A cumulative analysis of 1284 published cases found greater survival if elderly patients with odontoid fractures type II received surgical treatment (RR = 0.64). With regard to nonunion in 669 published cases primary posterior fusion had the best fusion results. The systematic literature review came to the following conclusions. (1) Surgical stabilisation of odontoid fractures type II improves survival in patients between 65 and 85 years of age compared to nonsurgical treatment. (2) Posterior atlantoaxial fusion for odontoid fractures type II in the elderly has the greatest bony union rate. (3) Odontoid nonunion is not associated with worse clinical or functional results in the elderly. (4) The complication rate of nonsurgical treatment is similar to the complication rate of surgical treatment of odontoid fractures type II in the elderly.

Understanding post-hospital morbidity associated with immobilisation of cervical spine fractures in older people using geriatric medicine assessment techniques: A pilot study

INTRODUCTION

There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people.

AIMS

To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures.

PATIENTS AND METHODS

We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence.

RESULTS

Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation.

CONCLUSIONS

Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

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

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Elderly patients are at increased risk for mortality undergoing surgical repair of dens fractures

OBJECTIVE

Dens fractures are common cervical injuries in advanced aged patients. The presented study was undertaken to analyze the clinical results and risks of surgically treated patients with dens fractures over 70 years.

METHODS

Data of 28 patients (17 female, 11 male) over 70 years treated from September 2004 to October 2009 were recorded. Clinical and radiological parameters were obtained including type of fracture, associated cervical and/or other injuries, comorbidities, symptoms, neurological condition, surgical strategy, postoperative course and complications.

RESULTS

89% were in a good neurological condition before surgery (ASIA E or D). In most cases, surgery was performed at an early stage after trauma (21 patients within 5 days). Ventral screw fixation was the preferred surgical strategy (64%). A slight worsening of neurological functions immediately after operation was only seen in one patient. Five patients died in the early and 2 in the late postoperative course which means a treatment mortality of 25%. Among the surviving patients two had general medical complications.

CONCLUSION

Type II dens fractures are a common fracture of elderly patients. Our results are good concerning the neurological functions. Surgical and general medical complications were acceptable. However, the study also underlines that mortality rate is high and therefore treatment options should be well-considered in this high risk group.

The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up

STUDY DESIGN

Retrospective, multicenter cohort study.

OBJECTIVE

Assess for differences in short- and long-term mortality between operative and nonoperative treatment for elderly patients with type II odontoid fractures.

SUMMARY OF BACKGROUND DATA

There is controversy regarding whether operative or nonoperative management is the best treatment for elderly patients with type II odontoid fractures.

METHODS

This is a retrospective study of consecutive patients aged 65 years or older with type II odontoid fracture from 3 level I trauma centers from 2003-2009. Demographics, comorbidities, and treatment were abstracted from medical records. Mortality outcomes were obtained from medical records and a public database. Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated.

RESULTS

A total of 322 patients were included (mean age, 81.8 yr; range, 65.0-101.5 yr). Compared with patients treated nonoperatively (n = 157), patients treated operatively (n = 165) were slightly younger (80.4 vs. 83.2 yr, P = 0.0014), had a longer hospital (15.0 vs. 7.4 d, P < 0.001) and intensive care unit (1.5 vs. 1.1 d, P = 0.008) stay, and were more likely to receive a feeding tube (18% vs. 5%, P = 0.0003). Operative and nonoperative treatment groups had similar sex distribution (P = 0.94) and Charlson comorbidity index (P = 0.11). Within 30 days of presentation, 14% of patients died, and at maximal follow-up (average = 2.05 yr; range = 0 d-7.02 yr), 44% had died. On multivariate analysis, nonoperative treatment was associated with higher 30-day mortality (HR = 3.00, 95% CI = 1.51-5.94, P = 0.0017), after adjusting for age (HR = 1.10, 95% CI = 1.05-1.14; P < 0.0001), male sex (P = 0.69), and Charlson comorbidity index (P = 0.16). At maximal follow-up, there was a trend toward higher mortality associated with nonoperative treatment (HR = 1.35, 95% CI = 0.97-1.89, P = 0.079), after adjusting for age (HR = 1.07, 95% CI = 1.05-1.10; P < 0.0001), male sex (HR = 1.55, 95% CI = 1.10-2.16; P = 0.012), and Charlson comorbidity index (HR = 1.28, 95% CI = 1.16-1.40; P < 0.0001).

CONCLUSION

Surgical treatment of type II odontoid fracture in this elderly population did not negatively impact survival, even after adjusting for age, sex, and comorbidities. The data suggest a significant 30-day survival advantage and a trend toward improved longer-term survival for operatively treated over nonoperatively treated patients.

LEVEL OF EVIDENCE

4.

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

STUDY DESIGN

Systematic methodological review.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Functional outcomes, morbidity, mortality, and fracture healing in 58 consecutive patients with geriatric odontoid fracture treated with cervical collar or posterior fusion

Controversy exists as to the most effective management option for elderly patients with type II odontoid fractures. The purpose of this study is to evaluate outcomes associated with rigid cervical collar and posterior fusion surgery. Patients with ≥ 50% odontoid displacement were treated with posterior fusion surgery including C1-2 (PSF group, n = 25, average age = 80 years). Patients with < 50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (collar group, n = 33, average age = 83 years). These inhomogeneous groups were followed for an average of 14 months. Fracture healing rates were higher in the operative group (28% versus 6%). Neck Disability Index scores were slightly lower in the nonoperative group (13 versus 18.3, p = 0.23). Analogue pain scores were also slightly lower in the nonoperative group (1.3 versus 1.9, p = 0.26). The mortality rate was 12.5% in the collar group and 20% in the operative group. Complications were higher in the operative group (24% versus 6%). Rates of type II odontoid facture healing and stability appear to be higher in geriatric patients treated with posterior fusion surgery. Fracture healing and stability did not correlate with improved outcomes with respect to levels of pain, function, and satisfaction. Mortality and complication rates are lower in those patients with lesser-displaced fractures who are treated with a cervical collar and early mobilization.

The optimal treatment of type II and III odontoid fractures in the elderly: a systematic review

PURPOSE

Odontoid fractures are the most common cervical spine fractures in the elderly. As the population ages, their incidence is expected to increase progressively. The optimal treatment of this condition is still the subject of controversy. The objective of this review is to summarize and compare the outcome of surgical and conservative interventions in the elderly (≥ 65 years).

METHODS

A comprehensive search was conducted in nine databases of medical literature, supplemented by reference and citation tracking. Clinical status was considered the primary outcome. Fracture union and stability rates were considered secondary outcomes.

RESULTS

A total of nineteen studies met the inclusion criteria. All studies were performed retrospectively and were of limited quality. There was insufficient data, especially from direct comparisons, to determine the difference in clinical outcome between surgical and conservative interventions. Osseous union was achieved in 66-85 % of surgically treated patients and in 28-44 % of conservatively treated patients. Fracture stability was achieved in 82-97 % of surgically patients and in 53-79 % of conservatively treated patients.

CONCLUSIONS

There was insufficient data to determine a potential difference in clinical outcome between different treatment groups. Surgically treated patients showed higher osseous union rates compared to conservatively treated patients, possibly because of different selection mechanisms. The majority of patients appears to achieve fracture stability regardless of the applied treatment. A prospective trial with appropriate sample size is needed to identify the optimal treatment of odontoid fractures in the elderly and predictors for the success of either one of the available treatments.

Morbidity and mortality of C2 fractures in the elderly: surgery and conservative treatment

BACKGROUND

Closed C2 fractures commonly occur after falls or other trauma in the elderly and are associated with significant morbidity and mortality. Controversy exists as to best treatment practices for these patients.

OBJECTIVE

To compare outcomes for elderly patients with closed C2 fractures by treatment modality.

METHODS

We retrospectively reviewed 28 surgically and 28 nonsurgically treated cases of closed C2 fractures without spinal cord injury in patients aged 65 years of age or older treated at Stanford Hospital between January 2000 and July 2010. Comorbidities, fracture characteristics, and treatment details were recorded; primary outcomes were 30-day mortality and complication rates; secondary outcomes were length of hospital stay and long-term survival.

RESULTS

Surgically treated patients tended to have more severe fractures with larger displacement. Charlson comorbidity scores were similar in both groups. Thirty-day mortality was 3.6% in the surgical group and 7.1% in the nonsurgical group, and the 30-day complication rates were 17.9% and 25.0%, respectively; these differences were not statistically significant. Surgical patients had significantly longer lengths of hospital stay than nonsurgical patients (11.8 days vs 4.4 days). Long-term median survival was not significantly different between groups.

CONCLUSION

The 30-day mortality and complication rates in surgically and nonsurgically treated patients were comparable. Elderly patients faced relatively high morbidity and mortality regardless of treatment modality; thus, age alone does not appear to be a contraindication to surgical fixation of C2 fractures.

[Odontoid fracture: Long-term subarachnoid hemorrhage after anterior screw fixation. Case report and literature review]

Odontoid fractures have been classified by Anderson and D'Alonzo into three main categories. The most unstable injuries, type II fractures involve the base of the odontoid peg at the junction with the C2 body. Due to the proximity of vital neural structures, fracture of the odontoid process may result in instability and fatal neurological damage. Treatment aims to re-establish stability of the atlanto-axial complex by restoring the odontoid process. This may be achieved by conservative or surgical treatment. Anterior screw fixation of the odontoid peg is an interresting alternative surgical option but this technique has a significant complication rate. However, vascular injury is very rare with three case reported in the literature: one case of an intracranial vertebral artery (VA) injury, one case of a cervical internal carotid artery (ICA) injury and one case of anterior pseudoaneurysm of the spinal artery branch. We report a new case of long term vascular injury after screw fixation revealed by a subarachnoid hemorrhage. We discuss the incidence, the mechanisms of injury and the conditions necessary for the occurrence of this complication.

Impact of age, injury severity score, and medical comorbidities on early complications after fusion and halo-vest immobilization for C2 fractures in older adults: a propensity score matched retrospective cohort study

STUDY DESIGN

Propensity score matched retrospective cohort study.

OBJECTIVE

To report early complication rates and associated risk factors in patients with C2 fractures who underwent fusion or halo immobilization.

SUMMARY OF BACKGROUND DATA

There is limited data on the impact of age, injury severity score, and medical comorbidities on overall complication rates from surgical fixation versus halo-vest immobilization of C2 fractures.

METHODS

The Nationwide Inpatient Sample database from 2002 to 2008 was queried to identify cohorts of adult patients (age ≥ 18 years) with C2 fractures without spinal cord injury who were treated with either fusion or halo-vest immobilization. Complication rates, hospital length of stay, and costs were compared in a propensity score matched sample. Multivariate analysis was used to identify predictors of in-hospital complications.

RESULTS

A total of 3758 patients (1627 fusion and 2131 halo) were identified. Fusion was associated with greater overall complication rates (20.2% vs. 10.1%, P < 0.0001), increased length of stay (8.9 d vs. 6.4 d, P < 0.0001), higher charges ($80,000 vs. $41,000, P < 0.0001), but a lower rate of nonroutine discharge (52.6% vs. 62.6%, P < 0.0001). There was no difference in mortality between the fusion group (2.75%) and the halo group (3.33%). Age, injury score, and comorbidity increased complication rates by a similar degree (odds ratio) in both cohorts. Patients aged 80 years and older were 3.5 times more likely to have a complication than those younger than 60 years.

CONCLUSION

Fusion patients had greater overall complication rates, increased length of stay, and greater resource utilization but were discharged home in a greater proportion. Both fusion and halo were associated with significant (more than 3-fold) increase in complication rates in elderly patients aged 80 years or older. Given the similar mortality rate between the fusion group and the halo group and the higher cost and complication rate in the fusion group, our study supports the use of halo-vest immobilization in patients where operative therapy is contraindicated.

Rigid cervical collar treatment for geriatric type II odontoid fractures

PURPOSE

To evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars.

METHODS

Thirty-four patients with <50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (Average age = 84 years). Outcome scores were compared with a group of 40 age-matched control subjects (Average age 79.3).

RESULTS

At average 14.9-month follow-up, only 6% demonstrated radiographic evidence of fracture healing and 70% had mobile odontoid nonunion. NDI scores indicated only mild disability, pain scores were low, and neither differed significantly from age-matched controls. Mobile odontoid nonunion was not associated with higher levels of disability or neck pain. Mortality rate was 11.8%. Treatment complications occurred in 6% of patients.

CONCLUSIONS

Odontoid nonunion and instability are high in geriatric patients treated with a rigid cervical collar. Fracture healing and stability did not correlate with improved outcomes. Outcomes did not differ significantly from age-matched cohorts.

Anterior screw fixation of type IIB odontoid fractures in octogenarians

PURPOSE

Type IIB odontoid fractures (OF) in elderly patients are life-threatening conditions. Optimal treatment of these fractures is still controversial. The aim of this study was to assess the clinical and radiological outcome of surgically treated type IIB OF by anterior screw fixation in octogenarians.

METHODS

Eleven octogenarians with type IIB OF were operated using anterior screw fixation. Follow-up assessment included operative mortality and morbidity rates, long-term functional outcome and fracture union and stability.

RESULTS

There was neither operative mortality nor morbidity. Five patients had excellent clinical outcome, two good outcome, one fair and three poor. Two patients died of unrelated causes 2 months after surgery. Radiographs showed stable bone union in four patients and stable fibrous union in five patients.

CONCLUSIONS

Given the results in this short series, we suggest that anterior screw fixation of Type IIB OF may be offered as primary treatment in octogenarians.