Original ArticleFusion, Failure, Fatality: Long-term Outcomes After Surgical Versus Nonoperative Management of Type II Odontoid Fracture in Octogenarians
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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Prevalence of dysphagia in patients after orthopedic surgery
2024, Archives of Gerontology and GeriatricsToo frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy
2021, Journal of Clinical NeuroscienceCitation Excerpt :Type II odontoid fractures in octogenarian patients present commonplace and highly nuanced clinical challenges. Although younger patients are reported to benefit from surgical stabilization, preceding work by our group and others has indicated that mortality in this population is exceedingly high, independent of operative or non-operative management strategy, with surgical intervention incurring considerable risk of secondary morbidity [9,10,13,16–18]. Given the apparent poor correlation between treatment strategy and outcome, the chief goal of the current study was to assess frailty as a potential predictor of unfavorable outcomes after type II odontoid fracture in octogenarian patients.
Conservative versus Surgical Treatment for Odontoid Fracture: Is the Surgical Treatment Harmful? Systematic Review and Meta-Analysis
2020, World NeurosurgeryCitation Excerpt :However, we found significantly fewer procedural complications in the surgical group, and we noted a trend toward less revision surgery. Neurologic complications and delayed myelopathy remain rare in both cases.34,52,53 Our conclusions remain limited by the heterogeneity of the included records, because the complication types and rates are different between anterior and posterior surgery.
Nonoperative versus operative management of type II odontoid fracture in older adults: a systematic review and meta-analysis
2024, Journal of Neurosurgery: SpineThe optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis
2023, European Spine Journal
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.