Evaluation of morbidity, mortality and outcome following cervical spine injuries in elderly patients

Abstract

We analysed the morbidity, mortality and outcome of cervical spine injuries in patients over the age of 65 years. This study was a retrospective review of 107 elderly patients admitted to our tertiary referral spinal injuries unit with cervical spine injuries between 1994 and 2002. The data was acquired by analysis of the national spinal unit database, hospital inpatient enquiry system, chart and radiographic review. Mean age was 74 years (range 66-93 years). The male to female ratio was 2.1:1 (M = 72, F = 35). The mean follow-up was 4.4 years (1-9 years) and mean in-hospital stay was 10 days (2-90 days). The mechanism of injury was a fall in 75 and road traffic accident in the remaining 32 patients. The level involved was atlanto-axial in 44 cases, sub-axial in 52 cases and the remaining 11 had no bony injury. Multilevel involvement occurred in 48 patients. C2 dominated the single level injury and most of them were type II odontoid fractures. Four patients had complete neurology, 27 had incomplete neurology, and the remaining 76 had no neurological deficit. Treatment included cervical orthosis in 67 cases, halo immobilization in 25, posterior stabilization in 12 patients and anterior cervical fusion in three patients. The overall complication rate was 18.6% with an associated in-hospital mortality of 11.2%. The complications included loss of reduction due to halo and Minerva loosening, non-union and delayed union among conservatively treated patients, pin site and wound infection, gastrointestinal bleeding and complication due to associated injuries. Among the 28.9% patients with neurological involvement, 37.7% had significant neurological recovery. Outcome was assessed using a cervical spine outcome questionnaire from Johns Hopkins School of Medicine. Sixty-seven patients (70%) completed the form, 20 patients (19%) were deceased at review and 8 patients (7%) were uncontactable. Functional disability was more marked in the patients with neurologically deficit at time of injury. Outcome of the injury was related to increasing age, co-morbidity and the severity of neurological deficit. Injuries of the cervical spine are not infrequent occurrence in the elderly and occur with relatively minor trauma. Neck pain in the elderly patients should be thoroughly evaluated to exclude C2 injuries. Most patients can be managed in an orthosis but unstable injuries require rigid external immobilization or surgical stabilization.

Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications

“…The mortality in the follow-up phase was higher in DISH patients than in AS patients, regardless of type of treatment received. Several authors have stated that advancing age, obesity and diabetes mellitus are associated with higher mortality rates in trauma patients [13,46,53,56,72,78,84]. In addition, some authors have reported the treatment with a halo frame or other immobilization device in elderly patients with cervical fractures to be associated with higher morbidity and mortality rates [47, 71,115].…”

Osteoporosis in acute fractures of the cervical spine: the role of opportunistic CT screening

“…28 This is a significant problem, because previous studies have shown a greater level of morbidity and death in older patients. 2,4,6,17,18,32 The debate is particularly prominent in regard to older patients with a Type II fracture with limited displacement. In this population, the risk-benefit consideration of a surgical or nonsurgical approach may be more equivocal given the increase in the complexity of these patients' overall medical and comorbidity profile.…”

“…30 A dichotomy exists between surgical and nonsurgical management of Type II odontoid fractures. Although some experts have documented very good clinical outcomes with the use of halo braces in patients with these fractures, 17,30 the halo vest was also associated with death and morbidity in several studies, 14,22,26,27,31,32 and some authors question the ability of older patients to tolerate these devices. 28 Regardless of the treatment modality, in-hospital mortality rates for patients with a Type II odontoid fracture remain significant at 10% 28 to 25%.…”

Mortality in Elderly Patients After Cervical Spine Fractures

“…Recently, several studies have found a risk of acute (inhospital) mortality of >20% for elderly patients with isolated cervical spine fractures 14,15 . While osteoporosis and ankylosis are generally thought to place elderly individuals at increased risk for cervical spine fractures 15,16 , there is little published information on the rate of mortality after these injuries. This deficiency in the literature contributes to a lack of consensus on the optimal treatment of cervical fractures in elderly individuals.…”