Systematic review on surgical and nonsurgical treatment of type II odontoid fractures in the elderly

Yohan Robinson, Anna-Lena Robinson, Claes Olerud, Yohan Robinson, Anna-Lena Robinson, Claes Olerud

Abstract

Odontoid fractures type II according to Anderson and d'Alonzo are not uncommon in the elderly patients. Still, due to the paucity of evidence the published treatment guidelines are far from equivocal. This systematic review focuses on the published results of type II odontoid fracture treatment in the elderly with regard to survival, nonunion, and complications. After a systematic literature research 38 publications were included. A cumulative analysis of 1284 published cases found greater survival if elderly patients with odontoid fractures type II received surgical treatment (RR = 0.64). With regard to nonunion in 669 published cases primary posterior fusion had the best fusion results. The systematic literature review came to the following conclusions. (1) Surgical stabilisation of odontoid fractures type II improves survival in patients between 65 and 85 years of age compared to nonsurgical treatment. (2) Posterior atlantoaxial fusion for odontoid fractures type II in the elderly has the greatest bony union rate. (3) Odontoid nonunion is not associated with worse clinical or functional results in the elderly. (4) The complication rate of nonsurgical treatment is similar to the complication rate of surgical treatment of odontoid fractures type II in the elderly.

Figures

Figure 1
Figure 1
Flow chart depicting results from literature research in PubMed MEDLINE, Ovid MEDLINE, and ISI Web of Knowledge (MeSH terms: “odontoid,” “fracture,” and “elderly”).
Figure 2
Figure 2
Kaplan-Meier survival functions for included cases with surgically and nonsurgically treated odontoid fractures type II in the elderly (n = 1284).

References

    1. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. Journal of Bone and Joint Surgery A. 1974;56(8):1663–1674.
    1. Yoganandan N, Pintar FA. Odontoid fracture in motor vehicle environments. Accident Analysis and Prevention. 2005;37(3):505–514.
    1. Osti M, Philipp H, Meusburger B, Benedetto KP. Analysis of failure following anterior screw fixation of Type II odontoid fractures in geriatric patients. European Spine Journal. 2011;20(11):1915–1920.
    1. Brolin K, von Holst H. Cervical injuries in Sweden, a national survey of patient data from 1987 to 1999. Injury Control and Safety Promotion. 2002;9(1):40–52.
    1. Pepin JW, Bourne RB, Hawkins RJ. Odontoid fractures, with special reference to the elderly patient. Clinical Orthopaedics and Related Research. 1985;193:178–183.
    1. Müller EJ, Wick M, Russe O, Muhr G. Management of odontoid fractures in the elderly. European Spine Journal. 1999;8(5):360–365.
    1. McCabe MJ, McLachlin SD, Bailey SI, Gurr KR, Bailey CS, Dunning CE. The effect of soft tissue restraints following type II odontoid fractures in the elderly: a biomechanical study. Spine. 2012;37(12):1030–1035.
    1. Pointillart V, Lopez Orta A, Freitas J, Vital JM, Senegas J. Odontoid fractures. Review of 150 cases and practical application for treatment. European Spine Journal. 1994;3(5):282–285.
    1. Löhrer L, Raschke MJ, Thiesen D, et al. Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland. Injury. 2012;43(4):462–469.
    1. Smith HE, Vaccaro AR, Maltenfort M, et al. Trends in surgical management for type II odontoid fracture: 20 years of experience at a regional spinal cord injury center. Orthopedics. 2008;31(7):p. 650.
    1. Ardeshiri A, Asgari S, Lemonas E, et al. Elderly patients are at increased risk for mortality undergoing surgical repair of dens fractures. Clinical Neurology and Neurosurgery. 2013;115(10):2056–2061.
    1. Chapman J, Smith JS, Kopjar B, et al. The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine. 2013;38(13):1098–1104.
    1. Kohlhof H, Seidel U, Hoppe S, Keel MJ, Benneker LM. Cement-augmented anterior screw fixation of Type II odontoid fractures in elderly patients with osteoporosis. The Spine Journal. 2013;13(12):1858–1863.
    1. Molinari RW, Dahl J, Gruhn WL, Molinari WJ. Functional outcomes, morbidity, mortality, and fracture healing in 26 consecutive geriatric odontoid fracture patients treated with posterior fusion. Journal of Spinal Disorders and Techniques. 2013;26(3):119–126.
    1. Steltzlen C, Lazennec JY, Catonne Y, Rousseau MA. Unstable odontoid fracture: surgical strategy in a 22-case series, and literature review. Orthopaedics & Traumatology. 2013;99(5):615–623.
    1. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. British Medical Journal. 2004;328(7454):p. 1490.
    1. Dunn ME, Seljeskog EL. Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306–310.
    1. Lind B, Hordwall A, Sihlbom H. Odontoid fractures treated with halo-vest. Spine. 1987;12(2):173–177.
    1. Montesano PX, Anderson PA, Schlehr F, Thalgott JS, Lowrey G. Odontoid fractures treated by anterior odontoid screw fixation. Spine. 1991;16(3):S33–S37.
    1. Jeanneret B, Magerl F. Primary posterior fusion C 1/2 in odontoid fractures: Indications, technique, and results of transarticular screw fixation. Journal of Spinal Disorders. 1992;5(4):464–475.
    1. Hanigan WC, Powell FC, Elwood PW, Henderson JP. Odontoid fractures in elderly patients. Journal of Neurosurgery. 1993;78(1):32–35.
    1. Ryan MD, Taylor TKF. Odontoid fractures in the elderly. Journal of Spinal Disorders. 1993;6(5):397–401.
    1. Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative management of Types II and III odontoid fractures: the Philadelphia collar versus the halo vest. Neurosurgery. 1996;38(3):450–457.
    1. Berlemann U, Schwarzenbach O. Dens fractures in the elderly. Results of anterior screw fixation in 19 elderly patients. Acta Orthopaedica Scandinavica. 1997;68(4):319–324.
    1. Seybold EA, Bayley JC. Functional outcome of surgically and conservatively managed dens fractures. Spine. 1998;23(17):1837–1846.
    1. Stoney J, O’Brien J, Wilde P. Treatment of type-two odontoid fractures in halothoracic vests. Journal of Bone and Joint Surgery B. 1998;80(3):452–455.
    1. Kuntz 4th. C, Mirza SK, Jarell AD, Chapman JR, Shaffrey CI, Newell DW. Type II odontoid fractures in the elderly: early failure of nonsurgical treatment. Neurosurgical Focus. 2000;8(6):p. e7.
    1. Andersson S, Rodrigues M, Olerud C. Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly. European Spine Journal. 2000;9(1):56–60.
    1. Ziai WC, Hurlbert RJ. A six year review of odontoid fractures: the emerging role of surgical intervention. Canadian Journal of Neurological Sciences. 2000;27(4):297–301.
    1. Bórm W, Kast E, Richter H-P, et al. Anterior screw fixation in type II odontoid fractures: is there a difference in outcome between age groups? Neurosurgery. 2003;52(5):1089–1094.
    1. Cornefjord M, Henriques T, Alemany M, Olerud C. Posterior atlanto-axial fusion with the Olerud Cervical Fixation System for odontoid fractures and C1-C2 instability in rheumatoid arthritis. European Spine Journal. 2003;12(1):91–96.
    1. Frangen TM, Zilkens C, Muhr G, Schinkel C. Odontoid fractures in the elderly: dorsal C1/C2 fusion is superior to halo-vest immobilization. Journal of Trauma. 2007;63(1):83–89.
    1. Platzer P, Thalhammer G, Ostermann R, Wieland T, Vécsei V, Gaebler C. Anterior screw fixation of odontoid fractures comparing younger and elderly patients. Spine. 2007;32(16):1714–1720.
    1. Smith HE, Kerr SM, Maltenfort M, et al. Early complications of surgical versus conservative treatment of isolated type II odontoid fractures in octogenarians: a retrospective cohort study. Journal of Spinal Disorders and Techniques. 2008;21(8):535–539.
    1. Kaminski A, Gstrein A, Muhr G, Müller EJ. Transarticular C1-C2 screw fixation. Results of unstable odontoid fractures and pseudarthrosis in the elderly. Unfallchirurg. 2008;111(3):167–172.
    1. Koech F, Ackland HM, Varma DK, Williamson OD, Malham GM. Nonoperative management of type II odontoid fractures in the elderly. Spine. 2008;33(26):2881–2886.
    1. Štulik J, Šebesta P, Vyskočil T, Kryl J. Fractures of the dens in patients older than 65 years: direct osteosynthesis of the dens versus C1-C2 posterior fixation. Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca. 2008;75(2):99–105.
    1. Omeis I, Duggal N, Rubano J, et al. Surgical treatment of C2 fractures in the elderly: a multicenter retrospective analysis. Journal of Spinal Disorders and Techniques. 2009;22(2):91–95.
    1. Fagin AM, Cipolle MD, Barraco RD, et al. Odontoid fractures in the elderly: should we operate? Journal of Trauma. 2010;68(3):583–586.
    1. Butler JS, Dolan RT, Burbridge M, et al. The long-term functional outcome of type II odontoid fractures managed non-operatively. European Spine Journal. 2010;19(10):1635–1642.
    1. Chaudhary A, Drew B, Orr RD, Farrokhyar F. Management of type II odontoid fractures in the geriatric population: outcome of treatment in a rigid cervical orthosis. Journal of Spinal Disorders and Techniques. 2010;23(5):317–320.
    1. Dailey AT, Hart D, Finn MA, Schmidt MH, Apfelbaum RI. Anterior fixation of odontoid fractures in an elderly population: clinical article. Journal of Neurosurgery. 2010;12(1):1–8.
    1. Hou Y, Yuan W, Wang X. Clinical evaluation of anterior screw fixation for elderly patients with type II odontoid fractures. Journal of Spinal Disorders and Techniques. 2011;24(8):E75–E81.
    1. Schoenfeld AJ, Bono CM, Reichmann WM, et al. Type II odontoid fractures of the cervical spine: do treatment type and medical comorbidities affect mortality in elderly patients? Spine. 2011;36(11):879–885.
    1. Mayer M, Zenner J, Auffarth A, et al. Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures. European Spine Journal. 2011;20(9):1441–1449.
    1. Hénaux PL, Cueff F, Diabira S, et al. Anterior screw fixation of type IIB odontoid fractures in octogenarians. European Spine Journal. 2011;21(2):335–339.
    1. Fehlings MG, Arun R, Vaccaro AR, Arnold PM, Chapman JR, Kopjar B. Predictors of treatment outcomes in geriatric patients with odontoid fractures: AOSpine North America multi-centre prospective GOF study. Spine. 2013;38(11):881–886.
    1. Smith JS, Kepler CK, Kopjar B, et al. The effect of type II odontoid fracture nonunion on outcome among elderly patients treated without surgery. Spine. 2013;38(26):2240–2246.
    1. Vaccaro AR, Kepler CK, Kopjar B, et al. Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. The Journal of Bone & Joint Surgery. 2013;95(8):729–735.
    1. Patel A, Smith HE, Radcliff K, Yadlapalli N, Vaccaro AR. Odontoid fractures with neurologic deficit have higher mortality and morbidity. Clinical Orthopaedics and Related Research. 2011;470(6):1614–1620.
    1. Majercik S, Tashjian RZ, Biffl WL, et al. Halo vest immobilization in the elderly: a death sentence? Journal of Trauma. 2005;59(2):350–357.
    1. Phillips FM, Carlson G, Emery SE, Bohlman HH. Anterior cervical pseudarthrosis: natural history and treatment. Spine. 1997;22(14):1585–1589.
    1. Raizman NM, O’brien JR, Poehling-Monaghan KL, Yu WD. Pseudarthrosis of the spine. Journal of the American Academy of Orthopaedic Surgeons. 2009;17(8):494–503.
    1. Crockard HA, Heilman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features. Journal of Neurosurgery. 1993;78(4):579–586.
    1. Paradis GR, Janes JM. Posttraumatic atlantoaxial instability: the fate of the odontoid process fracture in 46 cases. Journal of Trauma. 1973;13(4):359–367.
    1. Hart R, Saterbak A, Rapp T, Clark C. Nonoperative management of dens fracture nonunion in elderly patients without myelopathy. Spine. 2000;25(11):1339–1343.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera