Treatment modality in type II odontoid fractures defines the outcome in elderly patients

Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities

BACKGROUND CONTEXT

Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED).

PURPOSE

This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF).

STUDY DESIGN

This is a retrospective cohort study.

PATIENT SAMPLE

Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded.

OUTCOME MEASURES

The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs.

METHODS

Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs.

RESULTS

A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001).

CONCLUSIONS

This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.

Development of a Novel Risk Stratification Score to Predict 30-Day Mortality in Cervical Trauma Patients: CLAAD Score

STUDY DESIGN

Case control.

OBJECTIVE

Traumatic cervical spine injuries are associated with a substantial risk of mortality. The aim of this study is to develop a novel mortality prediction model for patients with cervical trauma who require operative treatment.

SUMMARY OF BACKGROUND DATA

Patients with cervical spine trauma have a high risk of postoperative complications and mortality. There are few reliable systems that can accurately predict mortality after surgery for cervical spine trauma, and those that do exist are typically not specific to cervical trauma.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients undergoing surgery for cervical spine trauma. Univariate analyses were performed to identify variables associated with mortality. Variables that were found to be significant in the univariate models were compiled into a multivariable model. The final model was compared with the American Society of Anesthesiologists (ASA), a modified Charlson comorbidity index (mCCI), and the 5-factor modified frailty index (mFI-5) in respect to predicting 30-day mortality after cervical trauma. The score was then externally validated using the Nationwide Inpatient Sample (NIS) database.

RESULTS

Fifty-five (6.7%) of 822 patients did not survive 30 days after surgery. The final multivariable logistic regression model consisted of the following variables: circumferential fusion "C." long "L" fusion (more than 4 levels), anemia "A," age over 60 "A," and dialysis "D." The risk of mortality increased with increasing CLAAD score, with mortality rates of 0.9%, 3.1%, 7.4%, 22.7%, and 14.3% for scores of 0, 1, 2, 3, and 4, respectively. The CLAAD model had an AUC of 0.73 for predicting mortality after cervical trauma.

CONCLUSIONS

The CLAAD score is a simple and effective system that can help identify patients at risk of increased mortality within 30 days of cervical trauma.

LEVEL OF EVIDENCE

Level III.

Age-Based Incidence of Dens Fracture Has Unimodal Distribution Rather Than Commonly Claimed Bimodal Distribution

Background

Type-II dens fractures have long been described in the literature as occurring in a bimodal distribution, peaking in young adulthood as well as in older adulthood; however, the origin of this claim is unclear. The primary goal of this study was to examine the incidence of type-II dens fractures and assess for bimodality.

Methods

This is a retrospective cross-sectional review of the National Trauma Data Bank (NTDB) records on traumatic type-II dens fractures between October 2015 and December 2016. Rates were obtained from the NTDB, and the incidence per 100,000 was ascertained by utilizing U.S. Census data from 2016. Subgroupings by gender and Black or White race were also examined.

Results

Dens fractures occur unimodally, peaking around 89 years of age overall, skewed left by high rates in older White adults. The Black subgroup demonstrated trimodality, with the fracture incidence peaking at 25, 62, and 82 years of age. Rates among Black and White patients were similar until age 65, after which dens fractures occurred disproportionately in White patients. Fractures prior to age 75 occurred predominantly in men.

Conclusions

The evidence derived in this study challenges the common belief that type-II dens fractures occur bimodally across the entire population. However, there remains utility in considering younger and older patients as distinct groups for the purposes of management.

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.

Preoperative cervical traction with Gardner-Wells tongs: who profits most?

BACKGROUND

Preoperative traction with the Gardner-Wells tongs (PTGWT) is a valuable option for cervical spine injuries with malalignment. The aim of this study was to analyze the factors related to the treatment success of PTGWT.

METHODS

All consecutive cases with PTGWT due to cervical spine injury with malalignment treated between 01/2010 and 09/2020 were included. Patients' records were reviewed for demographic and clinical characteristics. Treatment success was evaluated upon the angle correction in the sagittal plane using the computed tomography scans before and after the treatment.

RESULTS

Of 20 patients in the final analysis (median age: 77.5 years; 12 females [60%]), 14 individuals were treated for the type-II odontoid fracture, and six cases presented with subluxation fractures between C3 and C7. After PTGWT and subsequent intraoperative reposition, there was an improvement of the median deviation angle from initial 32° to 5.5°. PTGWT resulted in a significant improvement of the median deviation angle for the odontoid (17°, P<0.0001), but not for the subluxation (4°, P=0.10) fractures. The time interval between trauma and PTGWT was associated with the treatment success of subluxation (P=0.051) but not of odontoid (P=0.87) fractures. Older individuals aged ≥51 years showed better reposition results with PTGWT (17° vs. 7.5°, P=0.02). There were no PTGWT-related complications in the cohort.

CONCLUSIONS

PTGWT is an effective and safe treatment for cervical spine injuries with malalignment. The patients with odontoid fractures might particularly profit from the PTGWT. Treatment delay seems more relevant for PTGWT success in subluxation than in odontoid fractures.

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.

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.

Odontoid fracture type and angulation affect nonunion risk, but comminution and displacement do not: A propensity score matched analysis of fracture morphology

OBJECTIVE

Odontoid fractures disproportionately affect older patients who have high surgical risk, but also high rates of fracture nonunion. To guide surgical decision-making, we quantified the effect of fracture morphology on nonunion among nonoperatively managed, traumatic, isolated odontoid fractures.

METHODS

We examined all patients with isolated odontoid fractures treated nonoperatively at our institution between 2010 and 2019. Multivariable regression and propensity score matching were used to quantify the effect of fracture type, angulation, comminution, and displacement on bony healing by 26 weeks from injury.

RESULTS

303 consecutive traumatic odontoid fracture patients were identified, of whom 163 (53.8 %) had isolated fractures that were managed nonoperatively. Selection for nonoperative management was more likely with older age (OR=1.31 [1.09, 1.58], p = 0.004), and less likely with higher fracture angle (OR=0.70 [0.55, 0.89], p = 0.004), or higher presenting Nurick scores (OR=0.77 [0.62, 0.94], p = 0.011). Factors associated with nonunion at 26 weeks were fracture angle (OR=5.11 [1.43, 18.26], p = 0.012) and Anderson-D'Alonzo Type II morphology (OR=5.79 [1.88, 17.83], p = 0.002). Propensity score matching to assess the effect of type II fracture, fracture angulation> 10^o, displacement≥ 3 mm, and comminution all yielded balanced models (Rubin's B<25.0, 0.5 <Rubin's R<2.0). By 26 weeks, controlling for confounders, 77.3 % of type I or III fractures healed, compared to 38.3 % of type II fractures (p = 0.001). 56.3 % of non-angulated fractures healed compared to 12.5 % of fractures angled> 10^o (p = 0.015), and there was an 18.2 % lower rate of bony healing for each 10^o increase in fracture angle. Fracture displacement≥ 3 mm and comminution had no significant effect.

CONCLUSION

Type II fracture morphology and fracture angle > 10^o significantly increase nonunion among nonoperatively managed isolated traumatic odontoid fractures, but fracture comminution and displacement ≥ 3 mm do not.

Comparison of anterior and posterior approaches in Treating odontoid fractures: a meta-analysis and systematic review

Background

Odontoid fractures account for 15%-20% of cervical injuries. Although the operation methods vary in different types, the superiority of overall outcomes of the anterior approach (AA) and posterior approach (PA) in treating odontoid fractures still remains controversial. Thus, a meta-analysis was performed comparing AA and PA for these fractures.

Methods

The relevant studies were searched in PubMed/MEDLINE, Cochrane Library, EMBASE, China Biological Medicine (CBM), and Wanfang Database from the onset of conception to June 2022. Prospective or retrospective comparative studies on AA and PA for odontoid fractures were screened, referring to fusion rates (primary outcomes), complications, and postoperative mortality rates. A meta-analysis of the primary outcomes and a systematic review of other outcomes were performed; the procedure was conducted with Review Manager 5.3.

Results

Twelve articles comrising 452 patients were included, and all publications were retrospective cohort studies. The average postoperative fusion rate was 77.5 ± 17.9% and 91.4 ± 13.5% in AA and PA, respectively, with statistical significance [OR = 0.42 (0.22, 0.80), P = 0.009]. Subgroup analysis showed a difference in fusion rates between AA and PA in the elderly group [OR = 0.16 (0.05, 0.49), P = 0.001]. Five articles referred to postoperative mortality, and the mortality rates of AA (5.0%) and PA (2.3%) showed no statistical difference (P = 0.148). Nine studies referred to complications, with a rate of 9.7%. The incidence of complications in AA and PA groups was comparable (P = 0.338), and the incidence of nonfusion and complications was irrelevant. The prevalent cause of death was myocardial infarction. The time and segmental movement retention of AA were possibly superior to those of PA.

Conclusion

AA may be superior in regard to operation time and motion retention. There was no difference in complications and mortality rates between the two approaches. The posterior approach would be preferred in consideration of the fusion rate.

A Predictive Model to Identify Treatment-related Risk Factors for Odontoid Fracture Nonunion Using Machine Learning

STUDY DESIGN

Multicenter retrospective analysis of routinely collected data.

OBJECTIVE

The underlying aim of this study was to identify potential treatment-related risk factors for odontoid fracture nonunion while accounting for known patient- and injury-related risk factors.

SUMMARY OF BACKGROUND DATA

Type II and III odontoid fractures represent the most common cervical spine fracture in elderly patients and are associated with a relatively high nonunion rate. The management of odontoid fractures is controversial and treatment strategies range from conservative treatment to extensive surgical stabilization and fusion.

METHODS

A total of 415 individuals who sustained odontoid fracture and were treated in either of four tertiary referral centers in Austria and Germany were included in the study. We included the following potential contributing factors for fracture nonunion in cross-validated extreme gradient boosted (XGBoost) and binary logistic regression models: age, gender, fracture displacement, mechanism of injury (high vs. low energy), fracture classification (Anderson II vs. III), presence of comorbidities (Charlson comorbidity index), and treatment (conservative, anterior screw fixation with one or two screws, posterior C1/C2 spondylodesis, cervico-occipital C0-C4 fusion).

RESULTS

In our cohort, 187 (45%) had radiologically confirmed odontoid nonunion six months postinjury. The odds for nonunion increase significantly with age, and are lower in type III compared to type II fractures. Also, odds for nonunion are significantly lower in posterior C1/C2 spondylodesis, and C0-C4 fusion compared to conservative treatment. Importantly, odds are not statistically significantly lower in the group treated with anterior screw fixation compared to conservative treatment. The factors gender, fracture displacement, mechanism of injury, and the presence of comorbidities did not produce significant odds.

CONCLUSION

Higher age, type II fractures, and conservative treatment are the main risk factors for odontoid nonunion. Anterior screw fixation did not differ significantly from conservative treatment in terms of fracture union.

LEVEL OF EVIDENCE

3.

Classifications of Odontoid Process Fractures: A Systematic Review and Proposal of a New Simplified Classification System Based on Embryology

Odontoid fractures are the most common cervical spine fractures in the elderly. Although many classification systems have been developed for them, the ambiguity in various definitions can potentially lead to misunderstandings. This paper aims to review the terminologies and current classification systems of odontoid fractures and propose a new, simplified anatomical classification. Given the descriptive variability of odontoid fractures in current classifications, we systematically reviewed the literature using PRISMA guidelines querying the National Library of Medicine PubMed database. The initial literature search yielded 175 publications. A total of seven reports met the inclusion criteria and were ultimately included for a full review. The classification systems previously used to categorize fractures of the odontoid process often need to be more transparent, imprecise, and incongruous. To simplify them, a new embryologically accurate system is proposed. A new embryological and anatomically-based system, combining the former systems' specific attributes, allows a more straightforward and adaptable classification of odontoid fractures.

Mortality related to and functional outcomes of upper cervical spine fractures in the elderly

BACKGROUND

Although the mortality related to hip fracture and osteoporotic vertebral fracture have been reported, few studies have examined the mortality related to atlas and/or axis fractures. The aim of this study was to assess the association between mortality and atlas and/or axis fractures retrospectively and to elucidate the efficacy of surgical treatment.

METHODS

A total of 33 elderly patients who were treated for atlas and/or axis fractures at our institution between January 2012 and December 2018 were included in this study. These patients were divided into two groups: surgical treatment and conservative treatment. Fracture types, comorbidities, neurological status, treatment types, and walking ability at follow-up were reviewed. Mortality was assessed using medical records or via phone interviews.

RESULTS

The mean age at injury was 79.9 ± 8.0 years, and the mean follow-up period was 2.3 years. The overall mortality rates at 1 and 5 years were 21.4% and 48.4%, respectively. During the observation period, 12 (36%) patients died. Twenty-two patients were treated conservatively (14 were treated with a cervical collar, 8 were treated with a halo vest). Surgical procedures included occipital-cervical fixation, osteosynthesis of C2 fractures, C1-2 fixation, and C1-4 fixation using a posterior approach. Surgical treatment correlated with better survival rates. There was no significant difference between the two groups in terms of ambulatory ability and functional recovery.

CONCLUSION

Upper cervical spine fractures appear to have a worse prognosis compared to hip and osteoporotic vertebral fractures. This study indicates the efficacy of surgical treatment for upper cervical spine fractures in the elderly for improving survival prognosis.

Case report: Minimally invasive modification of the Goel-Harms atlantoaxial fusion utilizing percutaneous screws and intra-articular cage is feasible and results in decreased blood loss

Treatment of atlantoaxial pathology is often associated with significant morbidity and mortality. While surgical techniques for fixation are well established, approaches that minimize blood loss and muscle dissection are advantageous for expediting recovering and minimizing surgical risk. We present a 34-year-old female who presented with a Type III odontoid fracture requiring surgical fixation. She underwent a C1-2 fusion employing a novel minimally invasive modification of the Goel-Harms atlantoaxial fusion using percutaneous screws and intra-articular cage.

Biomechanical comparison of a C1 posterior arch clamp with C1 lateral mass screws in constructs for C1-C2 fusion

The aim of this experimental study was to assess the biomechanical performance of a novel C1 posterior arch (C1PA) clamp compared with C1 lateral mass (C1LM) screws in constructs used to treat atlantoaxial instability. These constructs had either C2 pedicle (C2P) screws or C2 translaminar (C2TL) screws. Eight fresh-frozen human cadaveric ligamentous spine specimens (C0-C3) were tested under six conditions: the intact state, the destabilized state after a simulated odontoid fracture, and when instrumented with four constructs (C1LM-C2P, C1LM-C2TL, C1PA-C2P, C1PA-C2TL). Each specimen was tested in a spinal loading simulator that separately applied axial rotation, flexion-extension and lateral bending. In each test condition, displacement controlled angular motion was applied in both directions at a speed of 2 deg/s until a resulting moment of 1.5 Nm was achieved. The measured ranges of motion (ROM) of the C1-C2 segments were compared for each test condition using nonparametric Friedman tests. The destabilized state had significantly more C1-C2 motion (p < 0.05) than the intact state in all cases, and all constructs greatly reduced this motion. C2 pedicle screw constructs that used the C1PA clamp had significantly less C1-C2 motion (p < 0.05) than those with C1LM screws in flexion-extension as well as axial rotation and no statistically significant difference was detected in lateral bending. C2 translaminar screw constructs that used the C1PA clamp had significantly less C1-C2 motion (p < 0.05) than those with C1LM screws in flexion-extension and no statistically significant difference was detected in axial rotation or in lateral bending. Data from the current study suggested that constructs using the novel C1PA clamp would provide as good, or improved, biomechanical stability to the C1-C2 segment compared with constructs using C1LM screws.

Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome

Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75 years) with Type II odontoid fracture managed conservatively during the last 10 years. All patients underwent CT scan on admission and at 3 months; if indicated, selected patient had CT scan at 6 and 12 months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6 weeks, 3, 6, 12, and 24 months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12 months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83 years. Patients were followed up for a minimum of 24 months: 247 (95%) showed an excellent functional outcome within 6 weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12 weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Experience in surgical treatment of type Ⅱ odontoid fractures: A report of two cases and review of the literature

Two cases of type Ⅱ odontoid fractures were reported to share our experience in surgery treatment of such cases. A 33-year-old woman with comminuted type Ⅱ odontoid fracture and a 42-year-old man with fracture end hardened type Ⅱ odontoid fracture received surgical treatment in our hospital. Though imaging examination suggested that these two patients were suitable for anterior screw fixation, we encountered difficulties during the operation. The two patients eventually underwent posterior C1-C2 fusion surgery and recovered well. According to the experience of these two cases, we found that the fracture line angle and the degree of comminution are two important factors affecting surgical decision-making. Although anterior screw fixation is the ideal choice for type Ⅱ odontoid fractures with anterior superior to posterior inferior fracture line, it may not be the best choice for comminuted or fracture end hardened type Ⅱ odontoid fractures.

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.

Postoperative intracranial migration of a C2 odontoid screw: A case report and literature review

Background:

Intracranial migration of odontoid screws is a rare but serious complication of anterior odontoid screw fixation not often reported in literature by neurosurgeons. Here, we describe the second case in literature of intracranial migration of an odontoid screw.

Case Description:

A 64-year-old neurologically intact patient with a type II odontoid fracture secondary to trauma underwent anterior odontoid screw fixation without any intraoperative complications. He tolerated the procedure well, and postoperative imaging demonstrated near anatomic correction of the fracture with satisfactory placement of the lag screw. Unfortunately, the patient was subsequently lost to follow up and he presented 7 months later for a routine outpatient computed tomography (CT) of the cervical spine, which demonstrated upward migration of the screw into the intracranial cavity abutting the medulla, with CT angiography of the neck also confirming the screw lying between the two vertebral arteries. Magnetic resonance imaging of the cervical spine also demonstrated the odontoid screw lying within close proximity to the ventral cervicomedullary junction, marginating the left vertebral artery. Subsequently, the patient was managed with removal of the odontoid screw and posterior cervical arthrodesis and instrumented fusion.

Conclusion:

Our case demonstrates the rare but serious complication of intracranial odontoid screw migration, which we bring to the attention of the neurosurgical community. The recognition of risk factors for this complication and optimized management of this rare occurrence is important for surgeons to recognize.

Functional Outcome of Elderly Patients Treated for Odontoid Fracture: A Multicenter Study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

Analysis of impact of conservative and surgical treatments on functional outcome of geriatric odontoid fractures.

SUMMARY OF BACKGROUND DATA

Treatment of odontoid fractures in aged population is still debatable.

METHODS

One hundred fourty-seven consecutive odontoid fractures in elderly patients were classified according to Anderson-D'Alonzo and Roy-Camille classifications. Philadelphia type collar was always positioned and kept as a treatment whenever acceptable. Halo-vest, anterior screw fixation, C1-C2 posterior arthrodesis, and occipito-cervical fixation were the other treatments adopted. Conservative or surgical treatment strategy was more significantly influenced by antero-posterior displacement (< or >5 mm) and by surgeon decision. On admission ASA, modified Rankin scale (mRS-pre) and Charlson Comorbidity Index (CCI) were assessed. Modified Rankin scale (mRS-post), Neck Disability Index (NDI), and Smiley Webster Pain Scale (SWPS) were administered 12 to 15 months after treatment to estimate functional outcome in terms of general disability, neck-related disability, and ability to return to work/former activity. Risk of treatment crossover was calculated considering factors affecting outcome. Fracture healing process in terms of fusion-stability, no fusion-stability, no fusion-no stability was evaluated at 12 months through a cervical computed tomography (CT) scan. Dynamic cervical spine x-rays were obtained whether necessary. No fusion-stability was considered an adequate treatment goal in our geriatric population. Chi square/Fisher exact test and logistic regression were performed for statistical anal.

RESULTS

Overall 67 patients were treated conservatively whereas 80 underwent surgery. Collar was adopted in 45 patients, while anterior odontoid fixation and C1-C2 posterior arthrodesis were preferred for 30 patients each. 79.8% of patients showed good outcomes according to NDI. No significant differences were observed between patients of 65 to 79 years and more than or equal to 80 years (P = 0.81). CCI greatly correlated with mRS-post, with higher indexes in 68.8% of cases characterized by good outcomes (P = 0.05). mRS-pre correlated with NDI (P < 0.000001) and mRS-post (P = 0.04). CCI, mRS-pre, and surgery were associated with worse NDI, while both C1-C2 posterior arthrodesis and occipito-cervical stabilization were associated with worse mRS-post, respectively in 40% and 30% of cases. Younger patients had a higher risk of treatment crossover.

CONCLUSION

mRS-pre and CCI provided two independent predictive values respectively for functional outcome and post-treatment disability. Compared with conservative immobilizations, surgery revealed no advantages in the elderly in terms of functional outcome.

LEVEL OF EVIDENCE

3.

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.

Morbidity and mortality in cervical spine injuries in the elderly

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN/SETTING

Systematic review and meta-analysis were performed.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Type II Fractures in Older Adults: Can They Be Treated Conservatively?: A Single-Center Experience and Review of the Literature

BACKGROUND

Odontoid fractures are the most common acute cervical spinal fractures in the geriatric population. Their rate is increasing along with the rising age of the elderly population. Whereas conservative management with external immobilization is reported as the treatment of choice for type I and III odontoid fractures, there are no clear indications concerning the best treatment for type II fractures. In younger patients surgical management is considered the best choice, but in older adults the rate of good outcomes worsens and operative risk because of comorbidities increases.

METHODS

We report our retrospective single-center experience with conservative treatment of type II odontoid fractures in an elderly population, focusing on both radiologic and functional outcomes to compare our results with the recent literature.

RESULTS

Among the 21 selected subjects with a minimum follow-up of 18 months, 19 (90.5%) showed a satisfactory clinical outcome, with an adequate bony healing in 10 cases and nonsymptomatic pseudarthrosis in 9 patients. All these patients were satisfied with the conservative results and could stop use of the collar. Two patients (9.5%) did not show any improvement and had to keep the collar indefinitely.

CONCLUSIONS

Our study was limited because it was a retrospective review, with a limited number of patients. Nevertheless, the clinical and radiologic outcomes of our patients differ from the results of other studies, suggesting that conservative management of these fractures in this population does not necessarily lead to a bad clinical outcome or delayed surgery.

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.

Predisposing Factors of Fracture Nonunion After Posterior C1 Lateral Mass Screws Combined with C2 Pedicle/Laminar Screw Fixation for Type II Odontoid Fracture

INTRODUCTION

The aim of this study was to explore the predisposing factors for fracture nonunion after a lateral screw was combined with C2 pedicle/laminar screw for a type II odontoid fracture and hopefully provide references in decision making and surgical planning for spinal surgeons.

METHODS

This is a retrospective study. By retrieving the medical records from January 2010 to July 2015 in our hospital, 117 type II odontoid fracture patients were reviewed. According to the occurrence of fracture union at the final follow-up, patients were divided into 2 groups: union and nonunion. To investigate the predisposing factors for fracture nonunion, 3 categorized factors were analyzed statistically: patient characteristics-age, sex, body mass index, preoperative Japanese Orthopaedic Association (JOA) scores, duration, comorbidity, and complicated injuries; surgical variables-surgery time, blood loss, C2 fixation manner, vertebral artery injury, bone source for fusion between the posterior arch of C1 and the laminae and spinous process of C2; radiographic parameters-preoperative and immediate postoperative data of C_0-2 curvature, C_2-7 curvature, C_2-7 sagittal vertical axis, C7 slope, fracture classification, congenital hypoplastic vertebral artery, and the separation and displacement of the odontoid fracture. Other variables including JOA and visual analog scale scores for neck pain, neck stiffness, and patient satisfaction at final follow-up were recorded and compared between the 2 groups.

RESULTS

Postoperative fracture nonunion was detected in 76 of 117 patients (65%) at final follow-up. There was no statistically significant difference between the 2 groups in patient characteristics of sex, body mass index, JOA score, comorbidity, and complicated injuries. The mean age at operation was younger in the union group than in the nonunion group, and the mean duration was shorter in the union group than in the nonunion group. There was no difference in surgical variables of surgery time, blood loss, C2 fixation manner, vertebral artery injury, bone source for fusion between the posterior arch of C1 and the laminae and spinous process of C2. There was no difference in radiographic parameters of fracture classification, congenital hypoplastic vertebral artery, preoperative and immediate postoperative C_0-2 curvature, C_2-7 curvature, C_2-7 SVA, and C7 slope. No difference was found in preoperative and immediate postoperative displacement of the odontoid fracture or immediate postoperative separation of the odontoid fracture, while the preoperative separation of the odontoid fracture was shorter in the union group than in the nonunion group. The logistic regression analysis revealed that advanced age (>45 years), long duration (>2 months), and preoperative separation of the odontoid fracture (>4 mm) were independently associated with the postoperative fracture nonunion. There were no differences between the 2 groups in JOA, neck pain, neck stiffness, and patient satisfaction at final follow-up.

CONCLUSIONS

Advanced age, long duration, and preoperative separation of odontoid fracture >4 mm are predisposing factors for fracture nonunion after posterior C1 lateral screw combined with C2 pedicle/laminar screw fixation for type II odontoid fracture. Our findings did not demonstrate any evidence of lower functional outcome and patients satisfaction for those patients who had odontoid nonunion.

Anterior retropharyngeal plate screw fixation with bilateral anterior transarticular screws for odontoid fractures ... a new comprehensive technique

INTRODUCTION

A certain group of odontoid fractures (Anderson and D' Alonzo Type-2) are usually offered surgical treatment. Common surgical option is an anterior odontoid screw. Some of the fractures are not suitable for anterior odontoid screw (anterior oblique, displaced distal fragments and those with atlantoaxial instability) and these are usually offered posterior transarticular screws (Magerl's) or posterior atlantoaxial screw rod/plate fixation (Goel-Harms technique). Posterior surgery involves atlantoaxial fixation with an indirect attempt to reduce and fuse the fracture . Posterior surgery has a risk of injury to the vertebral arteries, hemorrhage from the paravertebral venous plexus and the C2 root ganglion.

METHODS

A direct anterior submandibular retropharyangeal approach with open reduction and fixation (ORIF) using a customized variable screw placement (VSP) plate was used to realign and fix the fracture fragments in compression mode under direct vision. Twenty patients of type-II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior variable screw position (VSP) plate and screw fixation and eight amongst them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws.

RESULTS

All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow-up has been for 3 years.

CONCLUSION

Anterior retropharyangeal approach allows direct fracture fragment realignment under vision with an opportunity to fix in compression mode using the VSP plate, which ensures early fusion across the type-II odontoid fracture. Any associated instability can be treated by additional bilateral anterior transarticular screws. The approach is simple and safe without any risk to the vertebral arteries and biomechanically appealing.

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

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

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

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

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

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

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

Biomechanical Assessment of Stabilization of Simulated Type II Odontoid Fracture with Case Study

STUDY DESIGN

Researchers created a proper type II dens fracture (DF) and quantified a novel current posterior fixation technique with spacers at C1-C2. A clinical case study supplements this biomechanical analysis.

PURPOSE

Researchers explored their hypothesis that spacers combined with posterior instrumentation (PI) reduce range of motion significantly, possibly leading to better fusion outcomes.

OVERVIEW OF LITERATURE

Literature shows that the atlantoaxial joint is unique in allowing segmental rotary motion, enabling head turning. With no intervertebral discs at these joints, multiple ligaments bind the axis to the skull base and to the atlas; an intact odontoid (dens) enhances stability. The most common traumatic injury at these strong ligaments is a type II odontoid fracture.

METHODS

Each of seven specimens (C0-C3) was tested on a custom-built six-degrees-of-freedom spine simulator with constructs of intact state, type II DF, C1-C2 PI, PI with joint capsulotomy (PIJC), PI with spacers (PIS) at C1-C2, and spacers alone (SA). A bending moment of 2.0 Nm (1.5°/sec) was applied in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). One-way analysis of variance with repeated measures was performed.

RESULTS

DF increased motion to 320%, 429%, and 120% versus intact (FE, LB, and AR, respectively). PI significantly reduced motion to 41%, 21%, and 8%. PIJC showed negligible changes from PI. PIS reduced motion to 16%, 14%, and 3%. SA decreased motion to 64%, 24%, and 54%. Reduced motion facilitated solid fusion in an 89-year-old female patient within 1 year.

CONCLUSIONS

Type II odontoid fractures can lead to acute or chronic instability. Current fixation techniques use C1-C2 PI or an anterior dens screw. Addition of spacers alongside PI led to increased biomechanical rigidity over intact motion and may offer an alternative to established surgical fixation techniques.

Passage of an Anterior Odontoid Screw through Gastrointestinal Tract

Purpose. Anterior screw fixation has become a popular surgical treatment method for instable odontoid fractures. Screw loosening and migration are a rare, severe complication following anterior odontoid fixation, which can lead to esophagus perforation and requires revision operation. Methods. We report a case of screw loosening and migration after anterior odontoid fixation, which perforated the esophagus and was excreted without complications in a 78-year-old male patient. Results. A ventral dislocated anterior screw perforated through the esophagus after eight years after implantation and was excreted through the gastrointestinal (GI) tract. At a 6-month follow-up after the event the patient was asymptomatic. Conclusion. Extrusion via the GI tract is not safe enough to be considered as a treatment option for loosened screws. Some improvements could be implemented to prevent such an incident. Furthermore, this case is a fine example that recent preoperative imaging is mandatory before revision surgery for screw loosening.

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

Aims

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

Patients and Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of associated injuries in conjunction with fracture of the axis vertebra on inpatient outcomes and postoperative complications: a Nationwide Inpatient Sample analysis from 2002 to 2011

BACKGROUND CONTEXT

There are limited data available on the impact of associated spinal (other spinal injuries [OSIs]) and extra-spinal injuries (ESIs) occurring in conjunction with fractures of the axis vertebra (C2) on clinical outcomes.

PURPOSE

This study aimed to compare outcomes in patients with isolated C2 fractures versus patients with associated injuries in conjunction with C2 fractures.

STUDY DESIGN/SETTING

A retrospective cohort study.

PATIENT SAMPLE

A total of 30,472 adult patients with C2 fractures (International Classification of Diseases, Ninth Revision, Clinical Modification code 805.02) registered in the Nationwide Inpatient Sample (NIS) database (2002-2011) comprised the patient sample.

OUTCOME MEASURES

Inpatient mortality, unfavorable discharge, prolonged length of stay (LOS) and high-end hospital charges in the non-operative and operative cohorts, and postoperative complications (deep venous thrombosis [DVT]; acute renal failure [ARF]; respiratory complications and wound infections) for the operative cohort were the outcome measures.

METHODS

Patients were stratified into four categories based on injury type: (1) isolated C2 fracture (n=10,135; 33.3%); (2) C2 fracture+OSI (8.7%); (3) C2 fracture+ESI (37.2%); and (4) C2 fracture+OSI+ESI (20.8%). Multivariable logistic regression fitted with generalized estimating equations using the sandwich variance-covariance matrix estimator to account for clustering of similar outcomes within hospitals was used to examine the association of primary endpoints for each of the associated injury categories with reference to isolated C2 fractures.

RESULTS

Mean age of the cohort was 66.27±21.67 years and 52% were female. Of the cohort, 52% underwent surgical intervention for C2 fracture. In a pooled regression analysis involving the operative cohort, the risks for inpatient mortality (odds ratio [OR]: 3.77; 95% confidence interval [CI]: 3.02-4.70; p<.001), unfavorable discharge (OR: 1.83; 95% CI: 1.66-2.01; p<.001), prolonged LOS (OR: 1.33; 95% CI: 1.18-1.50; p<.001), high hospital charges (OR: 1.49; 95% CI: 1.31-2.69; p<.001), DVT (OR: 2.08; 95% CI: 1.61-2.68; p<.001), and ARF (OR: 1.46; 95% CI: 1.16-1.83; p=.001) were significantly higher in patients with additional injuries when compared with patients with C2 fractures alone. Likewise, increased chances of inpatient mortality (OR: 1.40; 95% CI: 1.21-1.62; p<.001), unfavorable discharge (OR: 1.24; 95% CI: 1.15-1.34; p<.001) and high hospital charges (OR: 1.31; 95% CI: 1.21-1.43; p<.001) were observed in a pooled analysis of patients with concomitant associated injuries in the non-operative cohort.

CONCLUSIONS

Associated injuries occurring concomitantly with C2 fractures adversely influence postoperative outcomes. In comparison to isolated C2 fractures, patients with associated injuries tend to have a greater propensity for higher health-care resource use because of more complicated and longer hospital inpatient stay.

Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation in Cadavers-Cadavers versus Patients, the Effect of Repeated Intubations, and the Effect of Type II Odontoid Fracture on C1-C2 Motion

BACKGROUND

The aims of this study are to characterize (1) the cadaver intubation biomechanics, including the effect of repeated intubations, and (2) the relation between intubation force and the motion of an injured cervical segment.

METHODS

Fourteen cadavers were serially intubated using force-sensing Macintosh and Airtraq laryngoscopes in random order, with simultaneous cervical spine motion recorded with lateral fluoroscopy. Motion of the C1-C2 segment was measured in the intact and injured state (type II odontoid fracture). Injured C1-C2 motion was proportionately corrected for changes in intubation forces that occurred with repeated intubations.

RESULTS

Cadaver intubation biomechanics were comparable with those of patients in all parameters other than C2-C5 extension. In cadavers, intubation force (set 2/set 1 force ratio = 0.61; 95% CI, 0.46 to 0.81; P = 0.002) and Oc-C5 extension (set 2 - set 1 difference = -6.1 degrees; 95% CI, -11.4 to -0.9; P = 0.025) decreased with repeated intubations. In cadavers, C1-C2 extension did not differ (1) between intact and injured states; or (2) in the injured state, between laryngoscopes (with and without force correction). With force correction, in the injured state, C1-C2 subluxation was greater with the Airtraq (mean difference 2.8 mm; 95% CI, 0.7 to 4.9 mm; P = 0.004).

CONCLUSIONS

With limitations, cadavers may be clinically relevant models of intubation biomechanics and cervical spine motion. In the setting of a type II odontoid fracture, C1-C2 motion during intubation with either the Macintosh or the Airtraq does not appear to greatly exceed physiologic values or to have a high likelihood of hyperextension or direct cord compression.

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.

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.