Original ArticlePerioperative Complications and Mortality Following Anterior Odontoid Screw Fixation in Elderly Patients: A National Database Analysis
Introduction
The number of elderly Americans is projected to increase markedly over the next several decades, with more than one fifth of the population expected to be older 60 years of age by 2050.1 With this, clinicians can expect to encounter conditions that are more prevalent in this age group, including odontoid fractures2—the most common cervical fracture in patients aged older than 70 years.3 The Anderson−D'Alonzo classification categorizes these fractures into 3 types.4 Generally, Type I and Type III fractures are treated nonoperatively, but Type II fractures often require surgery in the presence of neurologic compromise, high risk of nonunion, excessive angulation, or ligamentous injury.2, 5, 6
Although there are circumstances that require posterior fixation, anterior odontoid screw fixation confers several advantages, such as maintenance of atlantoaxial rotation, shorter operative times, and reduced bleeding risk.7, 8 Current guidelines from the American Association of Neurological Surgeons and Congress of Neurological Surgeons suggest that surgical management of odontoid fracture is appropriate for patients aged older than 50 years (Level II recommendation) using either an anterior or posterior approach (Level III recommendation).2, 9 Several studies examined in small cohorts postoperative complications and mortality in patients treated with anterior odontoid screw fixation; however, there is limited literature describing risk factors.10, 11, 12, 13 With perioperative mortality ranging from 7% to 9%, the aim of this study was to identify risk factors for postoperative complications and mortality in patients older than 60 years undergoing anterior odontoid screw fixation.11, 12, 13
Section snippets
Study Design and Data Source
Deidentified patient records were extracted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. This multi-institutional database collects patient information on perioperative parameters from more than 600 participating institutions.14, 15 Patient records were captured using Current Procedural Terminology codes. Inclusion required an assigned Current Procedural Terminology code for anterior odontoid screw fixation (22318, 22319). The final
Baseline Characteristics
A total of 198 patients aged ≥60 years who underwent anterior fixation of the odontoid process were included in this study. Baseline characteristics of the cohort are reported in Table 1. Mean age of the cohort was 78 ± 9 years. The sex distribution was 120 women (61%) and 78 men (39%). Common comorbidities in this population were hypertension (72%) diabetes (15%), and functional dependence (11%). In terms of preoperative characteristics, 14 patients (7%) met the criteria for SIRS, 27 patients
Discussion
The literature offers a consistent foundation for clinicians to estimate perioperative mortality following odontoid screw placement. White et al.12 described an in-hospital mortality rate of 7% following an anterior approach in 44 patients. Similarly, Cutler et al.11 described a 30-day postoperative mortality rate of 7% using 103 cases from the NSQIP database from 2007 to 2013. A 50-day mortality rate of 9% after anterior fixation of odontoid fractures also was reported by Joestl et al.13 in a
Conclusions
Preoperative functional dependence was a stronger predictor of perioperative mortality than age in this cohort of elderly patients who underwent odontoid screw placement. The results of this study will enable surgeons to better risk stratify patients with odontoid fractures and allow for better preoperative counseling. Further study of the effect of functional status in odontoid fracture patients using standardized indices is encouraged.
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Cited by (6)
Clinical and radiological outcome after minimally invasive surgical approach for type II unstable odontoid fractures
2021, NeurochirurgieCitation Excerpt :Compared to posterior approaches however, AOSF offers several edges, such as preservation of atlo-axial rotation, reduced surgical risk and trauma and a shorter hospital stay [11–13]. Current literature reports new minimally invasive percutaneous approaches to perform AOSF [14–16], but further insight into technical details, clinical and radiological outcomes are needed. The aim of this study is to share our recent experience in management of type II fractures by AOSF and prompt the discussion on its application in such challenging patients; as the primary endpoint of our study is to evaluate the postoperative results of minimally invasive odontoid screw insertion in terms of outcome, fusion rate and stability of cranio-cervical junction.
Predicting Mortality Following Odontoid Fracture Fixation in Elderly Patients: CAADS-16 Score
2023, Global Spine JournalComparison of Hard and Soft Cervical Collars for the Management of Odontoid Peg Fractures in the Elderly
2022, Geriatric Orthopaedic Surgery and Rehabilitation
Conflict of interest statement: Dr. Reza Yassari is a consultant for Stryker.