Cervical spine fragility fractures in older people: 5-year experience at a regional spine centre

Superior biomechanical stability of pedicle screws compared to lateral mass screws: recommendations for bicortical positioning and enhancing bone contact in geriatric C1 vertebrae

BACKGROUND

In atlantoaxial instabilities, posterior C1/C2 fusion using lateral mass screws (LMS) or pedicle screws (PS) in a mono- or bicortical position in the atlas is a typical treatment. The bone microstructure and positioning of the screw trajectories appear to be of significant relevance for stability.

PURPOSE

The aim of this study was a comparative analysis of the mechanical durability of screw fixation concerning microstructural characteristics of the trajectories of LMS and PS in mono- and bicortical position.

METHODS

Human C1 from geriatric body donors (n = 28; 50% female, age 80.8 ± 13.9 years) were collected and characterized based on their bone microstructure. Additionally, the mechanical stability of LMS and PS fixation in mono- and bicortical positioning was tested by mechanical loading. High-resolution quantitative computed tomography was used to analyze the bone microstructure of cylinders corresponding to the trajectories of PS and LMS in mono- and bicortical locations in each C1. After instrumentation with both screw types and types of fixation, the mechanical stability was tested by increased cyclic loading in cranio-caudal direction.

RESULTS

Trajectories of PS presented with more bone volume and a higher contact length to cortical bone. Simultaneously, a higher number of cycles and a higher maximum force was needed to loosen PS compared to LMS, while the loose by torque at the experiment end was still greater in PS. Differences between mono- and bicortical positioning of PS and LMS have only been observed in the initial stiffness of screws. When comparing microstructural and mechanical properties, the cortical contact length and bone volume in screw trajectories were strongest associated with a high loose and cycle count.

CONCLUSIONS

This study suggests that mono- and bicortical positioning of PS is similarly efficient in creating a stable basis for screw fixation in the atlas. While PS are superior to LMS, the contact with cortical bone is of major relevance for a stable foundation.

Trends and disparities in the surgical management of spinal fractures in Sweden during 2008-2023

BACKGROUND

Spinal fractures are a group of complex injuries whose management varies according to a number of factors. The aim of this study was to analyze trends in the management of spinal fracture surgery in Sweden from 2008 to 2023 with a focus on disparities based on gender, surgery method, age and geographical location. A secondary aim was to predict future incidence of spinal fracture surgeries.

METHODS

Comprehensive open source data was obtained from the Swedish National Board of Health and Welfare. The data was stratified based on gender, surgery method, age and geographical location per year and analyzed for trends. Future trends were projected using regression modeling. The student's T-test was used to compare means.

RESULTS

The incidence of spinal fracture surgery decreased overall from 2008 to 2023 while maintaining an increased incidence for males compared to females. The highest incidence for osteosynthesis was 2.7 per 100 000 inhabitants in 2008 and 1 in 2023. This trend is projected to be reversed in 2030. Several surgery methods have decreased in usage and are projected to reach close to 0 in 2030. The patient group that underwent spinal fracture surgery had a higher mean age in 2023 compared to 2008. The incidence of spinal fracture surgery varied significantly across Sweden where region Östergötland performed 6.3 surgeries per 100 000 inhabitants and region Örebro performed 1.4.

CONCLUSIONS

We found several trends where males may undergo spinal fractures surgery more commonly than females. Probable influencing factors may be increased life-spans and osteoporosis. This may also explain the observed shift towards older age groups in spinal fracture surgery. The decreased use of several surgery methods may reflect changes in operational techniques, demographics, and more standardized care. Geographical disparities may indicate different local health care protocols and uneven healthcare utilization and access.

TRIAL REGISTRATION

Not applicable.

Long-term outcomes after surgery for subaxial cervical spine injuries in octogenarians, a matched population-based cohort study

PURPOSE

We aimed to investigate surgical outcomes in octogenarians with subaxial cervical spine injuries and determine the predictors of complications and mortality.

METHODS

Eligible for inclusion were all patients surgically treated between 2006 and 2018, with either anterior or posterior fixation for subaxial spine injuries. A cohort of octogenarians was identified and matched 1:1 to a corresponding cohort of younger adults. Primary outcomes were perioperative complications and mortality.

RESULTS

Fifty-four patients were included in each of the octogenarian and younger groups (median age: 84.0 vs. 38.5). While the risks for surgical complications, including dural tears and wound infections, were similar between groups, the risks of postoperative medical complications, including respiratory or urinary tract infections, were significantly higher among the elderly (p < 0.05). Additionally, there were no differences in operative time (p = 0.625) or estimated blood loss (p = 0.403) between groups. The 30 and 90-day mortality rates were significantly higher among the elderly (p = 0.004 and p < 0.001). These differences were due to comorbidities in the octogenarian cohort as they were revoked when propensity score matching was performed to account for the differences in American Society of Anesthesiology (ASA) grade. Multivariable logistic regression revealed age and ASA score to be independent predictors of complications and the 90-day mortality, respectively.

CONCLUSIONS

Octogenarians with comorbidities were more susceptible to postoperative complications, explaining the increased short-term mortality in this group. However, octogenarians without comorbidities had similar outcomes compared to the younger patients, indicating that overall health, including comorbidities, rather than chronological age should be considered in surgical decision-making.

Understanding the quality-of-life experiences of older or frail adults following a new dens fracture: Nonsurgical management in a hard collar versus early removal of collar

INTRODUCTION

In the United Kingdom, fractures of the cervical dens process in older and/or frail patients are usually managed nonsurgically in a hard collar. However, hard collars can lead to complications and this management approach is now being questioned, with growing interest in maximising patients' short-term quality-of-life. It is vital that patients' perspectives are considered; yet, there is a dearth of literature examining the aspect. To help inform wider decision-making about use of collar/no collar management of dens fractures in older/frail people, we explored older/frail people's experience of the two management approaches and how they affected their perceived quality-of-life.

METHODS

We interviewed older and/or frail adults with a recent dens fracture (aged ≥65 years or with a clinical frailty score of ≥5) or their caregiver. Participants were recruited from both arms of a clinical trial comparing management using a hard collar for 12 weeks (SM) with early removal of the collar (ERC) and were interviewed following randomisation and again, 12-16 weeks later. Data were analysed using a framework approach.

RESULTS

Both participant groups (SM/ERC) reported substantial, negative quality-of-life (QoL) experiences, with the fall itself and lack of access to care services and information being frequent major contributory factors. Many negative experiences cut across both participant groups, including pain, fatigue, diminished autonomy and reduced involvement in personally meaningful activities. However, we identified some subtle, yet discernible, ways in which using SM/ERC reinforced or alleviated (negative) QoL impacts, with the perceived benefits/burdens to using SM/ERC varying between different individuals.

CONCLUSION

Study findings can be used to support informed decision-making about SM/ERC management of dens fractures in older/frail patients.

PATIENT OR PUBLIC CONTRIBUTION

Public and patient involvement contributors were involved in the study design, development of interview topic guides and interpretation of study findings.

Anterior cervical discectomy and fusion with plate versus posterior screw fixation after traumatic subaxial fractures in octogenarians: complications and outcomes with a 2-year follow-up

INTRODUCTION

Surgical intervention for management of spinal instability after traumatic subaxial fractures in octogenarians requires a clear consensus on optimal treatments. This study aimed to provide a guide for more efficient management through comparison and assessment of clinical outcomes and complications of anterior cervical discectomy and fusion with plate (pACDF) and posterior decompression fusion (PDF) instrumentation alone in patients aged 80 years.

METHODS

A single institution retrospective review of electronic medical records was undertaken between September 2005 and December 2021. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Logistic regression was used to identify potential risk factors for ACDF complications.

RESULTS

The rate of comorbidities were similarly high between the pACDF (n=13) and PDF (n=15) groups (pACDF: 8.7 ± 2.4 points vs. 8.5 ± 2.3 points; p=0.555). Patients in the PDF group had significantly longer surgical duration (235 ± 58.4 min vs. 182.5 ± 32.1 min; p<0.001) and significantly higher volumes of intraoperative blood loss (661.5 ± 100.1 mL vs. 487.5 ± 92.1 mL; p<0.001). The in-hospital mortality was 7.7% for the pACDF group and 6.7% for the PDF group. On day 90, the mortality rate increased in both groups from baseline (pACDF: 15.4% vs. PDF: 13.3; p>0.05). Motor scores (MS) improved significantly after surgery in both groups (pACDF: preOP MS: 75.3 ± 11.1 vs. postOP MS: 82.4 ± 10.1; p<0.05; PDF: preOP MS: 80.7 ± 16.7 vs. postOP MS: 89.5 ± 12.1; p<0.05). Statistically significant predictors for postoperative complications included longer operative times (odds ratio 1.2, 95% confidence interval 1.1-2.1; p=0.005) and larger volume of blood loss (odds ratio 1.5, 95% confidence interval 1.2-2.2; p=0.003).

CONCLUSIONS

Both pACDF and PDF can be considered safe treatment strategies for octogenarians with a poor baseline profile and subaxial fractures as they lead to patients substantial neurological improvements, and they are accompanied with low morbidity and mortality rates. Operation duration and intraoperative blood loss should be minimized to increase the degree of neurological recovery in octogenarian patients.

Management of C2 odontoid peg fragility fractures - A UK survey of spinal surgeons

PURPOSE

Patients sustaining fragility fractures of the C2 odontoid peg have 30-day mortality rates as high as 10% rising up to 34.1% at 1 year. Substantial controversy exists regarding optimal management of these fractures and there is a lack of national guidance to inform best practice. The aim of this study was to determine current practice in the management of these fractures throughout the United Kingdom.

METHODS

A UK wide, cross sectional survey was conducted, asking 10 questions regarding the initial management, imaging and follow-up of an elderly patient with a type 2 fragility odontoid peg fracture. This was publicised through the British Orthopaedic Association website and sent to all members of the Society of British Neurological Surgeons (SBNS) via email.

RESULTS

107 Responses were received. 56% from orthopaedic consultants, 29% from neurosurgical consultants and 15% from senior spine fellows. 86% (92) of respondents choose treatment with a cervical orthosis, with 84% (77) of these opting for a semi rigid Aspen or Philadelphia collar compared to 16% (15) opting for a soft cervical collar. Three (3%) opted for operative intervention with a further three (3%) choosing Halo fixation. Nine respondents (8%) opted for no orthosis and treatment with analgesia alone. Length of immobilisation in cervical orthosis ranged from 6 to 12 weeks. Initial follow-up ranged from 1 week to 6 weeks, with 6% (6) discharged without follow up. There was also marked variation in the use of follow-up imaging with 17% (18) using plain radiographs, 62% (66) requesting lateral flexion / extension radiographs, 10% (11) using CT and 11% (12) not performing any imaging at final follow up. In 60% (64) of cases respondents did not change subsequent management as a result of imaging.

CONCLUSION

Type-2 fragility peg fractures have high morbidity and mortality. There is marked variation in the treatment modalities used, follow-up regime and use of imaging throughout the UK. Given the rapidly increasing incidence of these injuries and the associated mortality this should be a high priority field for further research. Further large scale studies are urgently required to inform best practice and standardise management of these injuries.

Traumatic spinal cord injury caused by low falls and high falls: a comparative study

BACKGROUND

Quite a few traumatic spinal cord injuries (TSCI) were caused by falls. However, the comparison of different causes of TSCI or the epidemiological characteristics of TSCI caused by falls of different heights are rare. This study investigated the epidemiological characteristics of TSCI caused by falls and conducted a comparison between low falls and high falls.

METHOD

Data from cases with TSCI admitted to China Rehabilitation Research Center from 2010 to 2019 were collected, including age, gender, occupation, cause, neurological level, and severity of the injury in admission, combined injuries, complications, and rehabilitation length of stay. Mann-Whitney U and chi-square (χ2) tests were used to assess the differences between two groups at a statistical significance level of 0.05.

RESULT

A total of 1858 TSCI cases were included and 41.7% were caused by falls, 11.4% by low falls and 30.3% by high falls, respectively. Patients with fall-induced TSCI were older and had a shorter rehabilitation length of stay than those with non-fall-induced TSCI. Patients with high fall-induced TSCI were younger and more likely to suffer from paraplegia, severer injuries, and combined injuries, and had longer time from injury to rehabilitation and rehabilitation length of stay, compared with patients with low fall-induced TSCI.

CONCLUSION

Falls is the leading causes of TSCI and high fall is becoming more common. Attention not only should be paid to high falls for the severe injury and longer hospitalization, but also low falls due to the higher neurological level of the injury and the aging of population in China.