Type II Odontoid Fracture Highly Morbid in Octogenarians

Meg Barbor

October 07, 2015

NEW ORLEANS — Neither surgical nor nonoperative management is associated with a survival benefit among octogenarians with type II odontoid fracture, but certain markers can help identify those with a particularly poor prognosis, a new study suggests.

Odontoid fracture is a common injury, particularly in elderly patients, but previous studies comparing surgical and nonoperative management have used various age cut-offs, which leaves some questions unanswered about how very elderly patients fare, said lead author Christopher Graffeo, MD, a neurologic surgery resident at the Mayo Clinic in Rochester, Minnesota.

Some studies have classified elderly patients as all individuals older than age 65 years or those between 65 and 80 years, without sole focus on individuals aged 80 years and older, Dr Graffeo said.

"We wanted to evaluate spinal cord injury in our oldest patients, and what the implications are for treatment versus conservative management," he said.

Dr Graffeo and his colleagues compared surgical and nonoperative management in octogenarians (>79 years), a medically distinct population, and presented their results here at the Congress of Neurological Surgeons (CNS) 2015 Annual Meeting.

Controversy Surrounding Optimal Management

C2 odontoid process fracture is common among fall-prone, elderly patients, and it accounts for 11% of all traumatic cervical spine injuries and more than 60% of spinal injuries in patients older than 65 years.

These injuries are categorized using the Anderson and D'Alonzo classification scheme. Type I is defined as isolated avulsion of the odontoid peg, type II is a fracture through the odontoid "neck," and type III is a fracture extending through the C2 body or odontoid base.

"What this means in terms of treatment is still somewhat debated, but thus far the existing evidence supports nonoperative immobilization in type I and III injuries," said Dr Graffeo. "Those are somewhat less controversial areas of neurosurgery, but the type II injury is a more murky entity."

"The reason for this controversy is that the low fusion rates, at least theoretically, risk a delayed myelopathy," he explained. However, operative mortality rates are fairly high, and fusion rates remain low even with instrumentation.

This conflict is magnified in elderly patients because they represent a higher fraction of the type II injury population, they are more prone to falls (a low-impact mechanism commonly causing type II fracture), poor bone quality due to osteoporosis in this population leads to lower fusion rates, and a host of medical comorbidities result in higher rates of surgical and anesthesia-related complications at baseline.

The researchers reviewed a single-center, prospectively maintained trauma database for all C2 fractures between 1998 and 2014. Cervical computed tomography images were reviewed by neurosurgeons blinded to treatment and outcome, and odontoid type II fracture was confirmed and classified using the Anderson and D'Alonzo schema.

Primary endpoints included 30-day and 1-year mortality; secondary outcomes included cord injury, additional cervical fracture, Glasgow Coma Score (GCS), Abbreviated Injury Scale (AIS), and Injury Severity Score (ISS).

Mean age at injury was 87 (range, 80 to 104) years; 57% of patients were female. The mechanism for fracture was overwhelmingly fall from standing (86%), with small contributions from motor vehicle accidents (7%) and other unknown causes (7%).

GCS, AIS, and ISS scores were similar and nonsignificant between the two groups, as was the presence of additional cervical fractures or cord injury to the spinal cord.

No Survival Advantage Observed

A total of 111 patients with type II fractures were identified among 1101 patients with cervical fracture screened; mortality or 1-year follow-up data were obtained for 100% of the population. Seventeen patients underwent surgery (15%), and 94 were in the nonoperative cohort (85%).

Overall mean time to death or last follow-up was 22 months (range, 0 to 129 months), and mean follow-up was similar between the two groups.

A nonsignificant trend toward shorter median survival was observed in the nonoperative group, although mortality at 30 days and 1 year did not significantly differ between the two groups. A Kaplan-Meier analysis did not show a significant survival advantage for either of the treatment strategies, but cord injury and GCS, AIS, and ISS scores were all significantly associated with 30-day and 1-year mortality.

Table. Outcomes in Nonoperative and Surgery Populations

Outcome Nonoperative (n=94) Surgery (n=17) P Value
Median survival (mo) 40 69 0.7
30-d mortality, n (%) 25 (27) 4 (24) 0.8
1-y mortality, n (%) 39 (41) 7 (41) 1.0


"This is a problem that we as neurosurgeons see very frequently, so I think this is an important study," said Gregory Murad, MD, assistant professor and associate residency program director in the Department of Neurosurgery at the University of Florida College of Medicine. "It's a treatment conundrum for neurosurgeons in practice as to what's the best treatment for very elderly people when they have these kinds of fractures."

"Forty-percent of people were dead within a year after this fracture, so it's not because of the fracture itself, but it's kind of a marker of all of their other disabilities and lack of mobility." he told Medscape Medical News.

"Overall mortality was almost shockingly high," said Dr Graffeo. "And this underscores the grave prognosis associated with type II odontoid fracture among octogenarians." Additionally, cord injury and GCS, AIS, and ISS scores were significant predictors of poor outcomes in this population.

Type II odontoid fracture was highly morbid among octogenarians, with 1-year mortality approaching 50%. Investigators conclude that the data do not demonstrate a survival advantage associated with surgical management in this particular population, as compared with prior analyses conducted on patients older than age 65.

This abstract won the Depuy Synthes Award for Resident Research on Spinal Cord and Spinal Cord Injury at the Congress of Neurological Surgeons 2015 Annual Meeting. Dr Graffeo and Dr Murad have disclosed no relevant financial relationships.

Congress of Neurological Surgeons (CNS) 2015 Annual Meeting. Presented September 29, 2015.


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