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  • Surgical Versus Non-operative Management of Type II Odontoid Process Fractures in Octogenarians

    Final Number:

    Christopher Salvatore Graffeo MD; Avital Perry MD; Ross Puffer MD; Lucas Carlstrom; Grant William Mallory MD; Michelle J. Clarke MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: Odontoid fracture is a common injury, particularly in elderly, fall-prone patients. Previous studies comparing surgical and non-operative management have classified elderly patients as all individuals over 65 years, or those 65-80 years. We compare surgical and non-operative management in octogenarians (>79 years), a medically-distinct population.

    Methods: A prospectively maintained trauma database was reviewed for all C2 fractures between 1998-2014. Blinded radiographic review confirmed Anderson/D’Alonzo type II fracture pattern. Outcomes included surgical intervention, cord injury, additional cervical fracture, Glasgow Coma Score (GCS), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and 30-day and 1-year mortality. Statistical tests included student’s t, Chi-square, Fisher’s exact, Kaplan-Meier, Cox proportional hazard.

    Results: 111 patients with type II fractures were identified. Mortality or 1-year follow-up was available for 100%. Seventeen underwent surgery (20%). Mean age at injury was 87 (range 80-104, 55% female). Mean time to mortality or last follow-up was 22 months (range 0-129). Overall mortality was 26% at 30 days and 41% at 1 year. There was a trend toward longer median survival after surgery (69 vs. 40 months, p=0.66), though there was no mortality difference at one year (41% vs 41%, p=0.98). Cord injury was associated with 30-day and 1-year mortality (OR=8.3 p=0.0093; OR=9.6 p=0.0122). GCS, AIS, and ISS were associated with 30-day mortality (p<0.0001; p=0.0015; p=0.0029); GCS and AIS were significantly associated with 1-year mortality (p=0.0027; p=0.0113). Halo placement and additional cervical fracture were not associated with increased mortality. Surgery was not associated with any outcomes. Kaplan-Meier analysis did not show an association between any variable and survival.

    Conclusions: Type II odontoid fracture is highly morbid among octogenarians, with 1-year mortality approaching one-in-two. Neither surgical nor non-operative management is associated with a survival benefit. Cord injury, GCS, AIS, and ISS are significant predictors of poor prognosis.

    Patient Care: Based on our data, neither surgery nor non-operative management is associated with a significant survival benefit. We anticipate that this will inform important conversations with patients and families regarding the appropriateness of either strategy, with the goal of creating individually tailored treatment plans.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the mortality associated with type II odontoid fractures in the elderly, 2) Discuss the evidence regarding operative and non-operative management of type II odontoid fractures, with respect to survival, 3) Highlight statistically significant clinical variables associated with increased mortality in type II odontoid fracture.

    References: Fehlings, Michael G., et al. "Predictors of treatment outcomes in geriatric patients with odontoid fractures: AOSpine North America multi-centre prospective GOF study." Spine 38.11 (2013): 881. Smith, Justin S., et al. "Effect of type II odontoid fracture nonunion on outcome among elderly patients treated without surgery: based on the AOSpine North America geriatric odontoid fracture study." Spine 38.26 (2013): 2240-2246.

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