Odontoid Fracture in Elderly Population

1. Odontoid Fracture in Elderly Population Consultant orthopedic spine surgery Orthopedic oncology Amman Jordan Mohammad Alfawareh, MD Istanbul Spine Masters & ISMISS Turkey 2017 Koc University Hospital, Istanbul, Turkey October 26-29, 2017

2. Anatomy

6. Types • Type I • tip of the odontoid least common • Type II • Commonest type • Involves the junction of dens with the body of axis • Comminuted fragment at the base, type II A • Type III • The fracture line involves the body of C2 • In addition to passing through dens.

8. Anterior Approach • Preserves normal rotation C1-2 • Best anatomical and functional outcome • Rapid patient mobilization • Minimal postoperative pain • Short hospital stay. • Fusion rate 90% • One or two screws

9. Limitations • Adequate high cervical exposure • Anatomical limitations: • short neck • barrel chest • screw trajectory • No graft material • Prerequisites • Intact transverse ligament • Horizontal fracture line • Adequately alignment • Chronic odontoid fracture non-union • Technically demanding • Radiation

10. Posterior approach • Wedging a bone graft between C1&C2 • Sublaminar wiring • Gallie, Brooks and Sonntag techniques. • Fusion rate of about 74% • Elimination of the normal C1-2 rotation • Reduced flexion–extension by 10%

13. Posterior C1-2 transarticular screw (Magerl’s procedure) • Unilateral or bilateral screws • Excellent rotational stability • Preoperative CT is mandatory • Avoid VA • Alternatively occipitocervical fusion

14. In elderly population • Most common cervical spine fracture in patients above 65 years • Type I & III treated with orthosis • Optimal treatment for type II in elderly has been the topic of substantial research in recent years and controversy

15. Challenges • Optimal treatment to obtain bony union • Assessing ability to heal with bony union • Determining the stability of a nonunion • Understanding long-term consequences of nonunion • Elderly morbidity and mortality

16. challenging • physiological problem for bone healing • Osteoporotic bone • Watershed area for blood supply • High-strain location • Peudarthrosis rate in non-operative as high as 85% • Solid fusion does not necessarily means improved clinical outcome • Associated morbidity and possible mortality associated with operative intervention must be considered in the determination of the most appropriate treatment

17. A Systematic Review of the Treatment of GeriatricType II Odontoid Fractures

18. OBJECTIVE • To compare: • The short-term (< 3 months) mortality rate • Long-term (>12 months) mortality rate • Complication rates • Of patients >60 years of age • Type II odontoid fracture • Managed either operative or nonoperative.

19. Methods • Systematic review of literature • January 2000 & February 2015 • Treatment of type II odontoid • Patients above 60 years of age • Analysis of • Short-term mortality • Long-term mortality • The occurrence of complications

20. Treatment method • Surgical • Anterior • Posterior • Unspecified • Nonoperative treatment • Halo vest • Hard collar • Unspecified • The mortality rate were grouped into • short-term < 3 months • long-term mortality > 12 months

21. Complications • Failure of initial treatment • Nonoperative converted to operative • Revision • Surgical site infections • New postoperative neurological deficits • Significant medical complications • Myocardial infarction • Gastric ulcer • Pneumonia • Specific complications • NG feeding

23. RESULTS • A total of 452 articles • 400 excluded based on title and or abstract • 31 excluded after full article review • 12 included type I and type III fractures • 12 included patients < 60 years of age • 4 were included in another study • 21 articles with 1233 patients included

26. Operative vs nonoperative • Short-term mortality • (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) • Long-term mortality • (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) • Both were lower in operative group • No significant differences in complications rate • (odds ratio, 1.01; 95% confidence interval, 0.63-1.63)

27. Anterior vs posterior • Posterior (6) • Anterior (9) • No significant difference in mortality or complication rate • Short-term mortality • (odds ratio, 1.30; 95% CI, 0.45-3.72) • Long-term mortality • (odds ratio, 1.89; 95% CI, 0.81-4.40) • Presence of a complication • (odds ratio, 0.42; 95% CI, 0.03-4.73)

28. Nonoperative • Halo (2) • Hard collar (4) • Short-term mortality • (odds ratio, 0.22; 95% CI, 0.02-2.13) • Complication rate • (odds ratio, 3.46;95% CI, 0.51-23.32) • No difference in mortality or complication rate

29. In 2010, there were >40 million Americans • Odontoid fractures are the most common cervical spine fracture in elderly patients • The clear need that identifying evidence-based treatment algorithm • This review type II odontoid fracture treated surgically • have a significant decrease in both: short-term and long-term mortality. • The risk of complications is not increased in with surgery • Limitation level 3 & 4 evidence

30. Functional and quality-of-life outcomesin geriatric patients with type-II dens fracture • Vaccaro et al JBJS 2013 • Prospective level 2 study • 1-year mortality rate: • Operative pt. was 14% • Nonoperative 26% • Improve survival • Complication rate • Nonsignificant increase in surgical pt. • 36% vs 30%

31. Type II Odontoid Fractures in the Elderly:Risk of Mortality Based on Intervention • Andrew J. Schoenfeld et al • 156 patients • age 81.5 years • Nonoperative 112 • Surgery 44 • Conclusions: • This study showed that surgery was associated with lower 3 year mortality than nonoperative therapy • Survival advantage associated with surgery was restricted to < 85

32. Early Morbidity and Mortality Associated With Elderly Odontoid Fractures • John C. France et al • 37 patients aged > 65 years or older type II • 1994 and 2004, Follow-up was 28.7 weeks • Cause: falling down 75% • Comorbidities: • Hypertension • Heart disease • Rheumatoid arthritis • Non-operative: 25 (67%) • Halo vest or collar • Operative 12 (33%) • Anterior 7 vs Posterior 5 • Complication rate: 48.6% (18/ 37) • Mortality: 8.15% (3)

33. Complication • Surgical • anterior screw loosening (1) • anterior displacement (1) • posterior displacements (3) • unspecified displacement (1) • Medical • were the most common form of early morbidity in 9 pt. • Respiratory disease (6/9) • Aspiration • Pulmonary edema • Pneumonia • Acute respiratory failure • Other medical complications • Poor oral intake in (2) • Occipital nerve neuralgia in (1)

34. They Concluded • Regardless of the fracture treatment chosen these issues appear to exist • Should be prepared for a hospital course complicated by medical issues • Early mortality rates are significant; • One must anticipate respiratory, swallowing, balance, and cardiac problems • Management strategies should be individualized • Operative and nonoperative treatments remain viable options

35. Halo-Vest Immobilization Increases Early Morbidity and Mortality in Elderly Odontoid FracturesRobert Z. Tashjian et al

36. Conclusions • Type II odontoid fractures in elderly patients are a common • injury, and the mortality rate is substantial in patients treated with or without surgery • However, well-selected patients undergoing surgical treatment appear to have a decreased risk of short-term (<3 months) and long-term (>12 months) mortality • Without an increase in the risk of complications

37. Conclusions • Regardless of the fracture treatment chosen these issues appear to exist • Should be prepared for a hospital course complicated by medical issues and must be anticipated • Early mortality rates are significant • Management strategies should be individualized • Operative and nonoperative treatments remain viable options • Be prepared

38. Thank you