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

Abstract

BACKGROUND CONTEXTThe surgical fixation rate of type II odontoid fracture (OFx) in the elderly (≥65 years) is much lower than expected if the treatment adheres to current general treatment recommendations. Outcome data after conservative treatment for elderly patients with these fractures are sparse. PURPOSEThe main aim of this study was to determine the long-term outcome after conservative and surgical treatments of type II OFx (all age-groups) to evaluate whether nonoperative treatment yields an acceptable outcome. STUDY DESIGN/SETTINGRetrospective study based on a prospective database. PATIENT SAMPLETwo hundred eighty-two consecutive patients with type II OFx treated at Oslo University Hospital over an 8-year period. OUTCOME MEASURESLong-term rates of bony fusion, fibrous union, pseudarthrosis, crossover from primary conservative treatment to surgical fixation, new-onset spinal cord injury (SCI), and neck pain were the outcome measures used. METHODSThe present study was based on data extracted from our quality control database for acute cervical spine fractures. All ages were included. In addition, long-term follow-up of alive patients was performed during the years 2018–2019. The follow-up included neurological examination, radiological examination, and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new-onset SCI, neck pain, and Neck Disability Index (NDI score). Data are described by counts, percentages, medians, means, ranges and standard deviations where appropriate. For statistical analyses the Mann-Whitney U test, Wilcoxon signed-rank test, and t tests were used. RESULTSDuring the eight-year study period, we registered 282 consecutive patients with type II OFx; 54% were males, patient age ranged from 15 to 101 years, 84% were ≥65 years of age (WHO definition of elderly), and 51% were ≥80 years of age. Severe comorbidities (American Society of Anesthesiologists, ASA ≥3) were seen in 67%, whereas nonindependent living was registered in 32%. Severe comorbidities and nonindependent living were significantly associated with increasing age (p<.001). SCI secondary to the OFx was seen in 5.3%. Primary treatment of the OFx was conservative (external immobilization alone) in 193 patients (68.4%), open surgical fixation in 87 patients (30.9%), and no treatment in two critically injured patients. At the time of long-term follow-up, 125 patients had died, nine patients declined the invitation to follow-up, and five patients did not respond. Thus, 143 patients were available for follow-up with a median follow-up time of 39 months (range 5–115 months). At long-term follow-up, the fusion status was bony fusion in 39.2% of patients, fibrous union in 57.3%, and pseudarthrosis in 3.5%. The proportion of bony fusion was significantly higher in the primary surgical fixation group (p=.005). No patients had new-onset SCI presenting after the start of primary treatment. The proportion of crossover from primary external immobilization to surgery was 14.4%, whereas proportion of revision surgery in the primary surgical group was 9.5%. There was no significant difference between the primary surgical fixation group and the primary conservative treatment group at long-term follow-up with respect to the proportion of pseudarthrosis and degree of neck pain. CONCLUSIONSPrimary conservative treatment of elderly patients with type II OFx appears to be safe and should be regarded a viable treatment option.