Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients

Osterhoff, Georg; Schnake, Klaus John; Scheyerer, Max J.; Ullrich, Bernhard; Hartmann, Frank; Franck, Alexander; Koepp, Holger; Reinhold, M.; Schmeiser, Gregor; Sprengel, Kai; Zimmermann, Volker; Siekmann, Holger; Badke, Andreas; Gebhard, Harry; Täubel, Kai C.; Grüninger, Sebastian; Verheyden, A. P.; Schleicher, Philipp; Spiegl, Ulrich

doi:10.1055/a-0989-2791

Cited by 13 publications

(7 citation statements)

References 51 publications

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“…The described surgical procedures such as C1-2 internal fixator, transarticular screw fixation according to Magerl and occipito-cervical fusion via a posterior approach offer a greater stability in osteoporotic bone or with accompanying stiffening disease in comparison to the anterior technique with one/two screws. 21 Generally, there are recommendations preferring an initially posterior approach in patients or injuries with a high biomechanical instability, thus as geriatric patients with a stiffening disease (M. Bechterew or Forestier) or with highly unstable translational injuries. 22 As long as closed reduction is feasible, posterior stabilization as described by Magerl 23 or an anterior approach is possible.…”

Section: Discussionmentioning

confidence: 99%

Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation

Spiegl¹,

Keil

Krause

et al. 2023

Global Spine Journal

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Study Design Systematic review. Objective The aim of this study was to conduct a systematic overview of the pathogenesis and the treatment options of combined odontoid and atlas fractures in geriatric patients. Methods This review is based on articles retrieved by a systematic search in the PubMed and Web of Science databases for articles published until February 2021 dealing with combination fractures of C1 and C2 in geriatric patients. Results Altogether, 438 articles were retrieved from the literature search. A total of 430 articles were excluded. The remaining eight original articles were included in this systematic review depicting the topics pathogenesis, non-operative treatment, posterior approach, and anterior approach. The overall level of evidence of the studies is low. Conclusion Combined odontoid and atlas fractures in the geriatric population are commonly caused by simple falls and seem to be associated with atlanto-odontoid osteoarthritis. Non-operative treatment with a cervical orthosis is a feasible treatment option in the majority of patients with stable C2 fractures. In case of surgery posterior C1 and C 2 stabilization and anterior triple or quadruple screw fixation are possible techniques. Some patients may also deserve an occipito-cervical fusion. A possible treatment algorithm is proposed.

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Section: Discussionmentioning

confidence: 99%

Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation

Spiegl¹,

Keil

Krause

et al. 2023

Global Spine Journal

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“…Notably, CT outperforms plain radiography, and plain radiography should not be used alone during the initial diagnostic phase of care. 23,24 Validated standardized indicators of instability have not been identified and are a worthwhile future endeavor. 18,25 Cervical myelopathy and cerebrovascular disease were associated with delayed instability among nonoperatively managed patients.…”

Section: Discussionmentioning

confidence: 99%

Institutional review of the management of type II odontoid fractures: associations and outcomes with fibrous union

Wilson¹,

Hoyos²,

Huh³

et al. 2021

Journal of Neurosurgery: Spine

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OBJECTIVEType II odontoid fractures may be managed operatively or nonoperatively. If managed with bracing, bony union may never occur despite stability. This phenomenon is termed fibrous union. The authors aimed to determine associations with stable fibrous union and compare the morbidity of patients managed operatively and nonoperatively.METHODSThe authors performed a retrospective review of their spine trauma database for adults with type II odontoid fractures between 2015 and 2019. Two-sample t-tests and Fisher’s exact tests identified associations with follow-up stability and were used to compare operative and nonoperative outcomes. Sensitivity, specificity, and predictive values were calculated to validate initial stable upright cervical radiographs related to follow-up stability.RESULTSAmong 88 patients, 10% received upfront surgical fixation, and 90% were managed nonoperatively, of whom 22% had fracture instability on follow-up. Associations with instability after nonoperative management include myelopathy (OR 0.04, 95% CI 0.0–0.92), cerebrovascular disease (OR 0.23, 95% CI 0.06–1.0), and dens displacement ≥ 2 mm (OR 0.29, 95% CI 0.07–1.0). Advanced age was not associated with follow-up instability. Initial stability on upright radiographs was associated with stability on follow-up (OR 4.29, 95% CI 1.0–18) with excellent sensitivity and positive predictive value (sensitivity 89%, specificity 35%, positive predictive value 83%, and negative predictive value 46%). The overall complication rate and respiratory failure requiring ventilation on individual complication analysis were more common in operatively managed patients (33% vs 3%, respectively; p = 0.007), even though they were generally younger and healthier than those managed nonoperatively. Operative or nonoperative management conferred no difference in length of hospital or ICU stay, discharge disposition, or mortality.CONCLUSIONSThe authors delineate the validity of upright cervical radiographs on presentation in association with follow-up stability in type II odontoid fractures. In their experience, factors associated with instability included cervical myelopathy, cerebrovascular disease, and fracture displacement but not increased age. Operatively managed patients had higher complication rates than those managed without surgery. Fibrous union, which can occur with nonoperative management, provided adequate stability.

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“…Management of cervical spine injury in the elderly remains controversial because of many influencing factors such as the quality of the bone, osteoarthritis, classification, and type of the fracture [6,7,10,19,20]. Treatment might be complicated by numerous comorbidities and reduced bone quality.…”

Section: Discussionmentioning

confidence: 99%

Does isolated atlantoaxial fusion result in better clinical outcome compared to occipitocervical fusion?

Wenning

Hoffmann

2020

J Orthop Surg Res

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Background: The C0 to C2 region is the keystone for range of motion in the upper cervical spine. Posterior procedures usually include a fusion of at least one segment. Atlantoaxial fusion (AAF) only inhibits any motion in the C1/C2 segment whereas occipitocervical fusion (OCF) additionally interferes with the C0/C1 segment. The purpose of our study was to investigate clinical outcome of patients that underwent OCF or AAF for upper cervical spine injuries. Methods: Over a 5-year period (2010-2015), consecutive patients with upper cervical spine disorders were retrospectively identified as having been treated with OCF or AAF. The Numeric Pain Rating Scale (NPRS) and the Neck Disability Index (NDI) were used to evaluate postoperative neck pain and health restrictions. Demographics, follow-up, and clinical outcome parameters were evaluated. Infection, hematoma, screw malpositioning, and deaths were used as complication variables. Follow-up was at least 6 months postoperatively. Results: Ninety-six patients (male = 42, female = 54) underwent stabilization of the upper cervical spine. OCF was performed in 44 patients (45.8%), and 52 patients (54.2%) were treated with AAF. Patients with OCF were diagnosed with more comorbidities (p = 0.01). Follow-up was shorter in the OCF group compared to the AAF group (6.3 months and 14.3 months; p = 0.01). No differences were found related to infection (OCF 4.5%; AAF 7.7%) and revision rate (OCF 13.6%; AAF 17.3%; p > 0.05). Regarding bother and disability, no differences were discovered utilizing the NDI score (AAF 21.4%; OCF 37.4%; p > 0.05). A reduction of disability measured by the NDI was observed with greater follow-up for all patients (p = 0.01). Conclusion: Theoretically, AAF provides greater range of motion by preserving the C0/C1 motion segment resulting in less disability. The current study did not show any significant differences regarding clinical outcome measured by the NDI compared to OCF. No differences were found regarding complication and infection rates in both groups. Both techniques provide a stable treatment with comparable clinical outcome.

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Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients

Cited by 13 publications

References 51 publications

Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation

Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation

Institutional review of the management of type II odontoid fractures: associations and outcomes with fibrous union

Does isolated atlantoaxial fusion result in better clinical outcome compared to occipitocervical fusion?

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