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

doi:10.1016/S0020-1383(15)70007-0

Injury

Volume 46, Supplement 1, January 2015, Pages S24-S27

https://doi.org/10.1016/S0020-1383(15)70007-0 Get rights and content

Abstract

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.

Introduction

Fractures of the upper cervical spine in elderly patients are rising globally mainly due to the increased life expectancy noted in this patient population. These injuries are secondary to low energy trauma and the underlying bone is characterised by osteopenia and degenerative changes [1]. The risk of neurological deficit is high including the likelihood of fatality in a very fragile patient. Involvement of the upper cervical spine has been reported to be around 69% of all fractures of the cervical spine in elderly, in contrast to 36% in young adults [2]. Among these injuries, odontoid fractures are the most common ones. They represent over 50% of the injuries listed in patients over 80 years old [3]. Unfortunately, it is a commonly missed injury because most patients are asymptomatic. Furthermore, radiologic diagnosis is also difficult as the upper cervical spine in the elderly is always modified due to degenerative arthritis involving the anterior and posterior segment of the vertebra. In addition, fixed deformities are not uncommon. Consequently, radiologic landmarks used for screening are missing and positive diagnosis of trauma of the upper cervical spine in the elderly may lead to misdiagnosis. To avoid under diagnosis, upper cervical spine fracture must be systematically excluded in every elderly patient suffering from head injury, and for this reason some authors recommend the acquisition of routine CT-scan of the C1 and C2 vertebra [1, 3].

Once diagnosis is made, therapeutic options in the elderly are still controversial [3, 4, 5]. Three main types of treatment are used in daily orthopaedic practice: rigid cervical collar immobilisation (CC) without fracture reduction, Halo-vest (HV) and equivalent management with progressive fracture reduction, and surgical treatment (ST) which includes aggressive approach based on the fracture type [6]. The aim of the study was to review the literature in order to evaluate the morbidity and mortality rates of each treatment protocol in elderly patients suffering from upper cervical spine fracture.

Section snippets

Materials and methods

A systematic review of the international literature was conducted using PubMed. Inclusion criteria were articles published either in French or in English between 1995 and 2011 and evaluating the morbidity-mortality rates of the three treatment protocols in elderly patients over 65 years of age. Only papers where complete clinical data were available were included. The PubMed research was made using the keywords: ‘fracture, cervical spine, elderly’. Studies were pre-selected depending on their

Results

Fourteen [2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16] articles were selected in total, according to the criteria described. Six of them [6, 7, 8, 9, 10, 11] focused their content on the type of fracture and management of the upper cervical spine, and eight articles [2, 3, 4, 12, 13, 14, 15, 16] evaluated specifically the odontoid fracture out of which four [2, 5, 11, 16] reported only on fractures Type II according to the Anderson-Alonzo classification [16].

Only four articles [5, 14, 17, 18

Discussion

The occurrence of an upper cervical spine fracture in an elderly patient is associated with a high rate of morbidity and mortality. Treatment options must include well defined indications for intervention and the existing evidence acquired from previous studies.

Van Middendrop et al. [22] in a meta-analysis including 1,550 elderly patients suffering from a cervical spine fracture identified a medium term mortality rate of 45.2% for upper cervical spine fractures. During initial hospitalization,

Conclusion

It appears that there is a lack of consensus for the management of upper cervical spine injuries in the elderly. Surgeons facing this issue must take into account different criteria such as patient's medical co-morbidities, previous autonomy, and life expectancy in order to choose the most appropriate treatment modality. The three treatment options that have been used in patients include rigid cervical collar (CC) application, halo-vest (HV) and surgical treatment (ST) [6].

Although treatment by

Conflict of Interest Statement

The authors declare there are no conflicts of interest related to this study.

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Cited by (58)

Regional variations in C1–C2 bone density on quantitated computed tomography and clinical implications
2023, North American Spine Society Journal
Our elderly population is growing and the number of spine fractures in the elderly is also growing. The elderly population in general may be considered as poor surgical candidates experience a high rate of fractures at C1 and C2 compared with the general population. Nonoperative management of upper cervical fractures is not benign as there is a high nonunion rate for both C1 and C2 fractures in the elderly, and orthosis compliance is often suboptimal, or complicated by skin breakdown. The optimal technique for upper cervical stabilization in the elderly may be different than in younger populations as the bone quality is inferior in the elderly. The objective of this basic science study is to determine whether the bone mineral density (BMD) of C1 and C2 vary by region, and if this is a gender difference in this elderly age group.
Twenty cadaveric spines from 45 to 83 years of age were used to obtain BMD using quantitated computed tomography (QCT). BMD was measured using a QCT. For C1, 8 regions were determined: anterior tubercle, bilateral anterior and medial lateral masses, bilateral posterior arches, and posterior tubercle. For C2, 7 regional BMDs were determined: top of odontoid, base of odontoid-body interface, mid body, bilateral lateral masses, anterior inferior body near the discs space, and the C2 spinous process.
The BMD was greatest at the C1 anterior tubercle (564.4±175.8 mg/cm³) and C1 posterior ring (420.8±110.2 mg/cm³), and least at the anterior and medial lateral masses (262.8±59.5 mg/cm³, 316.9±72.6 mg/cm³). At C2 QCT BMD was greatest at the top of the dens (400.6±107.9 mg/cm³) decreasing down through the odontoid-C2 body junction (267.8±103.5 mg/cm³) and least in the mid C2 body 249.1±68.8 mg/cm³). The posterior arch of C1 and the spinous process of C2 had higher BMD's 420.8±110.2 mg/cm³ and 284.1±93.0 mg/cm³, respectively. A high correlation was observed between the BMD at the interface of the dens-vertebral body with the vertebral body with a Pearson correlation coefficient of 0.86. The BMD of the top of dens was significantly higher (p<.05) than all the regions in C2.
Regional and segmental BMD variations at C1 and C2 have clinical implications for surgical constructs in the elderly population. Given the higher BMDs of the C1 and C2 spinous process and posterior arches, consideration should be given to incorporate these areas using various C1–C2 wiring techniques. In the elderly, lateral masses particularly at C1 with lower BMD may result in potential screw loosening and nonunion in this age group. Old-school wiring techniques have a track record of efficacy and safety with less blood loss, reduced operative time, reduced X-ray exposure, and should be considered in the elderly as a primary stabilization technique or a belt-over suspenders approach based on regional variations in BMD in the elderly.
Mortality related to and functional outcomes of upper cervical spine fractures in the elderly
2022, Journal of Orthopaedic Science
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.
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.
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.
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.
Management of C2 odontoid peg fragility fractures – A UK survey of spinal surgeons
2022, Injury
Citation Excerpt :
The incidence of cervical trauma in this age group is increasing year on year [21], with peg fractures being the most common injury seen in this age group [21]. The outcomes of these injuries are poor with a mortality of up to 10% at 30 days and morbidity reported at up to 91% [5,6,22]. Very few patients suffer complications of the injury itself [5], with the most common cause of death being aspiration pneumonia which may be exacerbated by treatment with a cervical orthosis [15].
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.
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.
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.
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.
Surgical treatment for cervical spine injury in nonagenarians: A report of three cases
2021, Trauma Case Reports
Citation Excerpt :
In the present cases, if we choose conservative treatment, resting or continuous fixation with a halo-vest for long periods would be adopted. A systematic review of upper cervical spine injury in elderly patients revealed that halo-vest treatment had the highest rate of complications and mortality [7]. Therefore, in nonagenarians, prolonged use of halo-vest immobilization would easily lead to adverse events.
Among the elderly, even minor injuries can cause cervical spine fractures. With the increasing number of nonagenarians, the opportunities for treatment of cervical spine injuries in nonagenarians are getting to be more common. Conservative therapy is often chosen in nonagenarians with cervical spine injuries because of high risk associated with surgical treatment; however, we present herein the cases of three patients in nonagenarians who underwent surgical treatment for cervical spine injury. After a fall, three cases of nonagenarians who lived alone and independent were diagnosed with a Jefferson fracture and minor dislocated type II odontoid fracture, a C4 fracture with diffuse idiopathic skeletal hyperostosis, and a fracture-dislocation of C2, respectively. Their past medical history included several diseases, but we decided that spine surgery under general anesthesia was acceptable based on their pre-injury condition. We performed posterior fixation for all cases. As a result, while two patients developed postoperative minor complications, all cases showed favorable postoperative courses. They acquired independent or partially assisted walking and were transferred to the hospital for rehabilitation. If fundamental activity of daily living and general condition permit, posterior fixation seems to be a good choice even in nonagenarians.
Spinal injuries in the elderly population
2020, Orthopaedics and Trauma
The average age of the population is increasing and spinal traumatic injuries of the elderly are significantly more common. This frail population is prone to suffering serious injuries from minor or low-impact trauma when compared to younger patients. The reduced agility and ability to avoid falls in the elderly population may be the result of a combination of decreased stability due to altered sensory mechanisms, progressive spinal deformity, increased rigidity, osteoarthritis and neurological disorders, reduced cognitive function and hypotension, along with polypharmacy. Associated risk factors, including metabolic and autoimmune conditions may significantly increase the risk of morbidity and disability in this group. The most frequent injuries are odontoid fractures, vertebral compression fractures and traumatic central cord syndrome, all of which may be frequently associated with other lesions. Patient resilience and expectations will determine selection of consensual treatment aiming for a balance between maintaining function and achieving recovery. Conservative management is often the preferred method of treatment in the most common spinal injuries in the elderly as non-union or some degree of spinal deformity may be clinically well tolerated. Surgical treatment may provide benefit in the presence of persistent cord compression or spinal instability in patients that can tolerate the procedure. Ultimately, treatment should be tailored individually. Prevention of these injuries should be the focus in a world population with an ever-increasing proportion of elderly people.
Elderly Patients With Cervical Spine Fractures After Ground Level Falls Are at Risk for Blunt Cerebrovascular Injury
2020, Journal of Surgical Research
Osteopenia is common in the elderly, increasing their risk of sustaining cervical fractures after ground level falls (GLFs). We sought to examine the incidence of blunt cerebrovascular injury (BCVI) and subsequent stroke in elderly GLF patients as compared with other higher injury mechanisms.
The Trauma Quality Improvement Program database (2011-2016) was used to identify blunt trauma patients with isolated (other body region abbreviated injury scale <3) cervical spine (C1-C7) fractures. Patients were stratified into three groups: nonelderly patients (<65) with all mechanisms of injury, elderly patients (≥65) with GLF, and elderly patients with all other mechanism of injury. Multivariable logistic regression was used to determine predictors for BCVI, stroke, spinal cord injury, and acute kidney injury.
Seventeen thousand six hundred twenty-eight patients with cervical spine injuries were identified. BCVI was highest in the <65 group (0.8%) and lowest in elderly patients with GLF (0.3%, P = 0.001). When controlling for other factors, elderly patients with GLF were less likely to sustain BCVI (adjusted odds ratio: 0.46, P = 0.03) but had comparable rates of stroke attributable to BCVI (18.2% versus 6.5%, P = 0.184) and comparable rate of acute kidney injury compared with elderly patients with other mechanism of injury.
In elderly patients with isolated cervical spine fracture after GLF, BCVI occurs less frequently but is associated with a comparable rate of stroke as compared with other mechanisms. Low injury mechanism should not preclude BCVI screening in the presence of cervical spine fractures.

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

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Conflict of Interest Statement

J Orthop Sci

Injury

Surg Neurol

Cervical vertebral injuries in the elderly: A 10-year study

Emerg Radiol

Mortality in elderly patients after cervical spine fractures

J Bone Joint Surg Am

Evaluation of morbidity, mortality and outcome following cervical spine injuries in elderly patients

Eur Spine J

Cervical spine injuries in the elderly: acute postoperative mortality

Spine

Acute outcomes of cervical spine injuries in the elderly: atlantaxial vs subaxial injuries

J Spinal Cord Med

Conservative treatment of upper cervical spine injuries with the halo vest: an appropriate option for all patients independent of their age?

J Neurosurg Spine

Surgical treatment of C2 fractures in the elderly: a multicenter retrospective analysis

J Spinal Disord Tech

Cervical spine fractures in the elderly: factors influencing survival in 65 cases

Acta Orthop Scand

Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures

J Trauma

Complications of halo fixation in the elderly

J Neurosurg Spine