Elsevier

World Neurosurgery

Volume 110, February 2018, Pages e484-e489
World Neurosurgery

Original Article
Fusion, Failure, Fatality: Long-term Outcomes After Surgical Versus Nonoperative Management of Type II Odontoid Fracture in Octogenarians

Previous presentation: American Association of Neurological Surgeons Annual Meeting, 2017, Los Angeles, California.
https://doi.org/10.1016/j.wneu.2017.11.020Get rights and content

Background

Type II odontoid fracture is a highly morbid injury among octogenarians, with 41% 1-year mortality. Our objective was to assess long-term fusion, complication, and survival rates.

Methods

Retrospective review of prospective trauma registry and blinded review of follow-up radiographs.

Results

Follow-up cohort included 94 nonoperative and 17 operative patients (median, 52 and 79 months). The operative group had significantly higher rates of repeated surgery for primary treatment failure or complication (1% vs. 18%; P = 0.01) and dysphagia, aspiration events, or tracheostomy (29% vs. 78%, P = 0.002; 6% vs. 30%, P = 0.04; 1% vs. 18%, P = 0.01). Three-year all-cause mortalities were 71% and 76%, respectively (P = 0.78). No delayed myelopathy was observed. One-year postinjury radiographs were available for 13 and 6 patients in the nonoperative and operative groups (P = 0.9); bony union was observed in 3 and 5 patients (23% vs. 83%; P = 0.04). Retrolisthesis greater than 2 mm was observed in 2 and 1 patients (15% vs. 17%; P = 1.0). Two patients in the operative group underwent repeated surgery for primary treatment failure. Dysphagia was diagnosed in 3 and 5 operative patients (23% vs. 83%; P = 0.04), whereas aspiration events occurred in 0 and 3 patients (0% vs. 50%; P = 0.02). Three-year mortalities in this cohort were 38% and 67% (P = 0.35).

Conclusions

Radiographic union is significantly associated with operative management, but the corresponding clinical benefit is unclear. Complications were significantly more common after surgery. Long-term survival in octogenarians following type II odontoid fracture is poor, independent of management. Frequent complications without a proven survival benefit suggest that most patients are better managed conservatively.

Introduction

Odontoid fracture is a common and highly morbid injury, with a pronounced prevalence in older patients, among whom they represent more than 60% of all traumatic spinal injuries.1, 2, 3 As described by Anderson and D'Alonzo,4 the type II odontoid fracture is an injury specifically traversing the “neck” of the odontoid process without extending through the vertebral body. Type II odontoid fractures are the most frequently observed and controversially managed C2 injuries, particularly in octogenarians. These patients are prone to falls, tend to have poor bone quality and low fusion rates, and are subject to a high 1-year mortality rate—independent of management strategy.5, 6, 7, 8, 9

Octogenarians are a rapidly growing population in the United States, and one that is increasingly recognized as medically distinct, resulting in a mandate for more population-specific treatment data. This is particularly the case in the surgical sphere, given the high incidence of multiple baseline comorbidities, elevated treatment risks, and need for more nuanced goals-of-care collectively resulting in significantly more complex care.9, 10, 11, 12, 13

With respect to surgery for type II odontoid fractures in octogenarians, the key controversy surrounds the risk-benefit calculus of surgery versus observation. As we have demonstrated previously, mortality is more than 40% independent of management strategy; however, differences in long-term outcomes including fusion status have not been rigorously evaluated. Fusion status is an especially important endpoint given that nonunion has been theorized to increase risk of delayed myelopathy, and has historically justified operative intervention.14, 15, 16, 17, 18 Correspondingly, we sought to extend the findings of our previous analyses to evaluate key secondary outcomes in type II odontoid fracture, including fusion rates, delayed myelopathy, dysphagia and related complications, and their collective influence on long-term survival.

Section snippets

Patient Population

The study cohort was originally derived from a single-center prospectively maintained trauma database queried using ICD-9 codes specific for C2 fracture, with a study window of 1998–2014. Our initial search revealed 1101 patients, including 215 octogenarians. Computed tomography (CT) scans were multiply reviewed to confirm fracture location and type, identifying 111 patients including 17 operatively managed patients, as described previously.7

For inclusion in the core analysis, patients were

Results

From the initial study cohort of 111 octogenarians (94 nonoperative, 17 operative), 19 subjects had adequate radiographic and clinical follow-up data to meet inclusion criteria for core analysis as the radiographic cohort. Thirteen subjects had undergone initial nonoperative management with a recommended 12-week period of rigid cervical collar immobilization, while 6 subjects were in the operative group and underwent C1-2 posterior instrumented fusion (14% vs. 35%; P = 0.07). Within the

Discussion

Among the traumatic spine injuries prevalent in the octogenarian population, type II odontoid fracture is perhaps the most fraught with challenging management decisions. Postinjury mortality rates at 30 days, 1 year, and 3 years are approximately 25%, 40%, and 75%, respectively, independent of management strategy.7 Despite this grim reality, there has been considerable debate regarding the indications for surgical intervention, particularly given that preceding studies on patients 65 years and

Conclusion

Type II odontoid fracture is a major injury in the octogenarian population, with approximately 75% mortality at 3 years, independent of treatment strategy. Complications including dysphagia, aspiration, and tracheostomy are highly prevalent, and significantly more so among patients who undergo surgical treatment of the fracture. We present the first long-term follow-up analysis of these injuries, with special attention paid to fusion and swallowing outcomes. The study is limited by its small

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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