Odontoid fractures: impact of age and comorbidities on surgical decision making

Abstract

Background Surgical fixation is recommended for type II and III odontoid fractures (OFx) with major translation of the odontoid fragment, regardless of the patient’s age, and for all type II OFx in patients aged ≥50 years. The level of compliance with this recommendation is unknown, and our hypothesis is that open surgical fixation is less frequently performed than recommended. We suspect that this discrepancy might be due to the older age and comorbidities among patients with OFx. Methods We present a prospective observational cohort study of all patients in the southeastern Norwegian population (3.0 million) diagnosed with a traumatic OFx in the period from 2015 to 2018. Results Three hundred thirty-six patients with an OFx were diagnosed, resulting in an overall incidence of 2.8/100000 persons/year. The median age of the patients was 80 years, and 45% were females. According to the Anderson and D’Alonzo classification, the OFx were type II in 199 patients (59%) and type III in 137 patients (41%). The primary fracture treatment was rigid collar alone in 79% of patients and open surgical fixation in 21%. In the multivariate analysis, the following parameters were significantly associated with surgery as the primary treatment: independent living, less serious comorbidities prior to the injury, type II OFx and major sagittal translation of the odontoid fragment. Conversion from external immobilization alone to subsequent open surgical fixation was performed in 10% of patients. Significant differences the in conversion rate were not observed between patients with type II and III fractures. The level of compliance with the treatment recommendations for OFx was low. The main deviation was the underuse of primary surgical fixation for type II OFx. The most common reasons listed for choosing primary external immobilization instead of primary surgical fixation were an older age and comorbidities. Conclusion Major comorbidities and an older age appear to be significant factors contributing to physicians’ decision to refrain from the surgical fixation of OFx. Hence, comorbidities and age should be considered for inclusion in the decision tree for the choice of treatment for OFx in future guidelines.

Epidemiology of Traumatic Cervical Spinal Fractures in a General Western Population

“…The level of CS-Fx was C0 -C2 in 38%, C3 -C7 in 55%, and both C0 -C2 and C3 -C7 in 7%. The most frequent Fx in the upper cervical spine was C2 odontoid Fx (the most common Fx in the elderly), which is in line with other reports [3,22]. The most frequent C3 -C7 (subaxial)…”

“…Surgical xation has previously been recommended for type II odontoid fractures. We have recently documented that most of these patients can be managed with external immobilization alone, thereby avoiding a surgical procedure associated with high risk in frail older people [20][21][22].…”

Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients

“…Recent reports have challenged the recommendation of surgical fixation of almost all type II OFx and indicated that fibrous/nonbony fusion can be a satisfactory outcome in frail elderly patients [8,9,14,29]. Among our patients available for long-term follow-up, 39% had bony fusion, 57% had fibrous union, and only 4% had pseudarthrosis.…”

“…We have recently shown that primary surgical fixation of type II OFx was only performed in 33% of our patients in the 4-year time period 2015 -2018 [14]. The reasons given for choosing primary external immobilization instead of primary surgical fixation for these patients were a combination of age and comorbidity in 88%, nonsurvivable injury in 6% and delayed diagnosis in 6%.…”

“…However, the proportion of surgical fixation in our cohort was only 30.9%. This discrepancy has been attributed to high surgical risk due to older age and high comorbidity [14]. We will discuss if this is a good practice based on this population-based follow-up study.…”