A Nationwide Analysis of Geriatric Odontoid Fracture Incidence, Complications, Mortality, and Cost

Ram Alluri, MD; Gabriel Bouz, MD; Samantha Solaru, BS; Hyunwoo Kang, MD; Jeffrey Wang, MD; Raymond J. Hah, MD


Spine. 2021;46(2):131-137. 

In This Article


From 2003 to 2017, 144,425 patients between the ages of 65 to 90 years sustained an odontoid fracture, of which 32,419 (22%) met inclusion criteria. The annual incidence of geriatric odontoid fractures remained relatively constant during the study time period, insignificantly increasing 11.6 cases per year (P = 0.44). Operative treatment occurred in 21,954 (67%) patients and nonoperative treatment occurred in 10,465 (32%) during the study period. In 2003, operative treatment occurred in 46% of patients and nearly doubled to 86% in 2017, with an average increase of 3.7% per year (P < 0.001); a corresponding decrease occurred in nonoperative treatment (P < 0.001) (Figure 1). Among all patients with an odontoid fracture, cervical collar use remained relatively constant, decreasing 0.1% per year (P = 0.283); however, halo application decreased 3.6% per year (P < 0.001) (Figure 2), mirroring the increase in operative management.

Figure 1.

Annual percentage of operative and nonoperative treatments of geriatric odontoid fractures.

Figure 2.

Annual use percentage of treatment types for geriatric odontoid fractures.

A subanalysis of patients who received nonoperative treatment demonstrated that cervical collar immobilization occurred in 11.6% of patients in 2003, and 37.7% of patients in 2017, significantly increasing 2.1% per year (P < 0.001); the rate nearly doubled to 3.9% per year (P < 0.001) after 2010 (Figure 3). Corresponding decreases in halo application were seen in nonoperatively treated patients (Figure 3).

Figure 3.

Annual use percentage of treatment types for nonoperative management of geriatric odontoid fractures.

Demographic characteristics are presented in Table 1. In both treatment groups, average age was 77 years and 54% were female. Operative patients more commonly had Medicare (83% vs. 75%, P < 0.001) while nonoperative patients more commonly had private insurance (20% vs. 13%, P < 0.001). Comorbidity analysis is presented in Table 2. Patients undergoing operative management had a lower prevalence of at least one major medical comorbidity (76% vs. 83%, P < 0.001). Patients undergoing operative treatment more frequently had rheumatoid arthritis (5.6% vs. 3.9%, P = 0.004) and chronic pulmonary disease (19.0% vs. 16.2%, P = 0.012). Other comorbidities were similar between the two treatment groups.

Inpatient complications are presented in Table 3. Patients undergoing operative treatment demonstrated higher odds of developing most complications assessed, particularly pulmonary, gastrointestinal, and renal complications. Inpatient mortality was 5.9% in patients receiving nonoperative treatment and 3.6% in patients receiving operative treatment (P < 0.001).

Analysis of hospital characteristics (Table 4) demonstrated that operative treatment occurred more frequently at teaching hospitals than non-teaching hospitals (P < 0.001). Length of stay was longer for operative treatment at 10.2 versus 7.8 days (P < 0.001). Average cost per episode of care during the study period was $131,855 for operative treatment and $65,374 for nonoperative treatment (P < 0.001). In the final year of analysis, 2017, cost per episode of care was $156,228 for operative treatment and $131,836 for nonoperative treatment (P < 0.001).