Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities.

BACKGROUND CONTEXT: Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED). PURPOSE: This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF). STUDY DESIGN: This is a retrospective cohort study. PATIENT SAMPLE: Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded. OUTCOME MEASURES: The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs. METHODS: Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs. RESULTS: A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001). CONCLUSIONS: This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.

Biomechanical Assessment of Fracture Loads and Patterns of the Odontoid Process.

STUDY DESIGN: Laboratory study. OBJECTIVE: This study aimed to investigate the biomechanical competence and fracture characteristics of the odontoid process. SUMMARY OF BACKGROUND DATA: Odontoid fractures of the second cervical vertebra (C2) represent the most common spine fracture type in the elderly. However, very little is known about the underlying biomechanical fracture mechanisms. MATERIALS AND METHODS: A total of 42 C2 human anatomic specimens were scanned via computed tomography, divided in six groups, and subjected to combined quasistatic loading at -15°, 0°, and 15° in sagittal plane and -50° and 0° in transverse plane until fracturing. Bone mineral density (BMD), height, fusion state of the ossification centers, stiffness, yield load, and ultimate load were assessed. RESULTS: While lowest values for stiffness, yield load, and ultimate load were observed at load inclination of 15° in sagittal plane, no statistically significant differences were observed between the study groups ( P ≥0.235). BMD correlated positively with yield load ( r2 =0.350, P <0.001) and ultimate load ( r2 =0.955, P <0.001) but not with stiffness ( r2 =0.082, P =0.07). The specimens with clearly distinguishable fusion of the ossification centers revealed less data scattering of the biomechanical outcomes. CONCLUSION: Load direction plays a subordinate role in traumatic fractures of the odontoid process. BMD was associated with significant correlation to the biomechanical outcomes. Thus, odontoid fractures appear to result from of an interaction between the load magnitude and bone quality.

Cost Effectiveness of Operative Versus Non-Operative Treatment of Geriatric Type-II Odontoid Fracture.

STUDY DESIGN: Cost-effectiveness analysis. OBJECTIVE: To examine the cost-effectiveness of operative versus non-operative treatment of type-II odontoid fractures in patients older than 64 years old. SUMMARY OF BACKGROUND DATA: Significant controversy exists regarding the optimum treatment of geriatric patients with type-II odontoid fractures. Operative treatment leads to lower rates of non-union but carries surgical risks. Non-operative treatment does not carry surgical risks but has higher non-union rates. METHODS: A decision-analytic model was created to compare operative and non-operative treatment of type-II odontoid fractures among three age cohorts (65-74, 75-84, >84) based on expected costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs; cost per QALY gained). Age-specific mortality rates for both treatments, costs for treatment, and complication rates were taken from the literature, and data from 2010 US life tables were used for age-specific life expectancy. Costs of complications were estimated using data obtained at a level-I trauma center using micro-costing. Sensitivity analyses of all model parameters were conducted. RESULTS: Among the 65- to 74-year-old cohort, operative treatment was more costly ($53,407 vs. $30,553) and more effective (12.00 vs. 10.11 QALY), with an ICER of $12,078/QALY. Among the 75- to 84-year-old cohort, operative treatment was more costly ($51,308 vs. $29,789) and more effective (6.85 vs. 6.31 QALY), with an ICER of $40,467/QALY. Among the over-84 cohort, operative treatment was dominated by non-operative treatment as it was both more costly ($45,978 vs. $28,872) and less effective (2.48 vs. 3.73 QALY). The model was robust to sensitivity analysis across reasonable ranges for utility of union, disutility of complications and delayed surgery, and probabilities of non-union and complications. CONCLUSION: Operative treatment is cost-effective in patients age 65 to 84 when using $100,000/QALY as a benchmark but less effective and more costly than non-operative treatment in patients older than 84 years. LEVEL OF EVIDENCE: 2.

A comparison of the Gallie technique and casting versus the harms technique for the treatment of odontoid fractures.

OBJECTIVE: The objective of this study was to compare perioperative, clinical parameters, complications, and reoperation rate of the Gallie technique and head-neck-chest plaster with the Harms technique in the treatment of odontoid fractures. DESIGN: A retrospective study. SETTING: Level I spine center. PATIENTS: Fifty-seven patients with odontoid fractures treated either with the Gallie technique and casting or the Harms technique between July 2002 and June 2008. INTERVENTION: Surgery. MAIN OUTCOME MEASUREMENTS: At a minimum of 2-year follow-up, comparison of the two groups was conducted in terms of hospital stay, blood loss, operation time, cost of the first admission, total cost, time to fusion, time to return to previous occupation, Japanese Orthopedic Association scores, visual analog scale scores of neck pain, complications (nonunion, delayed union, hardware breakage, wound infection), and reoperation rate. RESULTS: There were no significant differences in terms of hospital stay, time to fusion, Japanese Orthopedic Association scores, neck pain visual analog scale scores, complications, or reoperation rate between the two groups. Blood loss, operation time, cost of the first admission, and total cost were significantly lower in the Gallie group than that in the Harms group. However, the Gallie group took longer to return to previous occupation than the Harms group (P < 0.001). CONCLUSIONS: Management of odontoid fractures by either the Gallie technique and casting or the Harms technique was found to be similar in clinical outcomes. Although the Harms technique was associated with more blood loss, operation time, and cost, the Harms technique was found to be superior to the Gallie technique with casting in terms of time to return to previous occupation.

Trends in epidemiology and management of type II odontoid fractures: 20-year experience at a model system spine injury tertiary referral center.

STUDY DESIGN: A retrospective cohort study of consecutive type II Odontoid fractures presenting to a Level 1 Regional Model Systems Spinal Cord Injury Center between June 1985 and July 2006. OBJECTIVE: To assess trends in management of type II Odontoid fractures presenting to a Level 1 Model Systems Regional Spinal Cord Injury Center over a 20-year period. SUMMARY OF BACKGROUND DATA: Type II Odontoid fracture management is controversial, and a majority of studies have had relatively small cohorts. There is no consensus regarding definitive treatment, particularly in older patients. METHODS: Medical records of 263 consecutive type II Odontoid fractures from June 1985 to July 2006 were retrospectively reviewed. Patients were excluded if they had neurologic deficits, nonacute fracture, or ambiguous fracture classification. A cohort of 192 neurologically intact, acute type II odontoid fractures were identified. Admission records were reviewed for age, date of injury, date of admission, date of discharge, mechanism of injury, associated injuries, medical comorbidities, and radiologic findings. RESULTS: There was a statistically significant increase in the rate of presentation of type II odontoid fractures with time. The average age and medical comorbidities of the patient did not change over time. The probability of operative management markedly increased over time, corresponding to a statistically significant increase in length of hospital stay for patients undergoing surgery. The discharge disposition correlated significantly to both age of the patient and associated injuries. CONCLUSIONS: The number and frequency of type II odontoid fractures compared with other spine injuries seems to be increasing over the last 2 decades, which may be correlated with the increasing number of elderly persons in the population, given that referral patterns have been unchanged at our institution. Prospective outcomes data are needed to better elucidate optimal treatment algorithms from both, an outcomes and cost-efficacy perspective.

Study on accuracy and interobserver reliability of the assessment of odontoid fracture union using plain radiographs or CT scans.

In odontoid fracture research, outcome can be evaluated based on validated questionnaires, based on functional outcome in terms of atlantoaxial and total neck rotation, and based on the treatment-related union rate. Data on clinical and functional outcome are still sparse. In contrast, there is abundant information on union rates, although, frequently the rates differ widely. Odontoid union is the most frequently assessed outcome parameter and therefore it is imperative to investigate the interobserver reliability of fusion assessment using radiographs compared to CT scans. Our objective was to identify the diagnostic accuracy of plain radiographs in detecting union and nonunion after odontoid fractures and compare this to CT scans as the standard of reference. Complete sets of biplanar plain radiographs and CT scans of 21 patients treated for odontoid fractures were subjected to interobserver assessment of fusion. Image sets were presented to 18 international observers with a mean experience in fusion assessment of 10.7 years. Patients selected had complete radiographic follow-up at a mean of 63.3 +/- 53 months. Mean age of the patients at follow-up was 68.2 years. We calculated interobserver agreement of the diagnostic assessment using radiographs compared to using CT scans, as well as the sensitivity and specificity of the radiographic assessment. Agreement on the fusion status using radiographs compared to CT scans ranged between 62 and 90% depending on the observer. Concerning the assessment of non-union and fusion, the mean specificity was 62% and mean sensitivity was 77%. Statistical analysis revealed an agreement of 80-100% in 48% of cases only, between the biplanar radiographs and the reconstructed CT scans. In 50% of patients assessed there was an agreement of less than 80%. The mean sensitivity and specificity values indicate that radiographs are not a reliable measure to indicate odontoid fracture union or non-union. Regarding experience in years of all observers taking part in the study, there were no significant differences for specificity (P = 0.88) or sensitivity (P = 0.26). Further analysis revealed that if a non-union was judged present by an observer then, on average, each observer changed decision regarding the presence of a 'stable' or 'unstable non-union' in 4.2 of all the 21 cases (range 0-8 changes per observer). We investigated the interobserver reliability of the assessment of fusion in odontoid fractures using biplanar radiographs compared to CT scans. A sensitivity of 77% and a specificity of 62% for the radiographs resemble a substantial lack of agreement if different observers evaluate odontoid union. Biplanar radiographs are judged not a reliable measure to detect odontoid fracture union or non-union. The union rates of odontoid fractures have to be revisited and CT scans as the endpoint anchor in outcome studies of treatment related union rates are recommended.

[Instability of the atlantodental joint as a trauma sequela]. / Zur Frage der Instabilität des atlantodentalen Gelenks als Traumafolge.

In the region of the upper cervical spine a wide variety of morphological and functional positions is possible. This makes diagnosis and expert evaluation of whiplash injuries to the cervical spine very difficult. The problem is discussed with reference to a case report of a so-called whiplash injury. The upper cervical spine must be investigated in flexion and extension by means of MRT and/or CT as soon as possible.