Geriatric Odontoid Fractures

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1 Geriatric Odontoid Fractures M A R K E S K E N A Z I, M. D. S P I N E I N S T I T U T E O F S O U T H F L O R I D A A F F I L I A T E A S S I S T A N T P R O F E S S O R O F C L I N I C A L B I O M E D I C A L S C I E N C E F L O R I D A A T L A N T I C U N I V E R S I T Y C H A R L E S E. S C H M I D T C O L L E G E O F M E D I C I N E

2 Odontoid Fractures Biphasic Distribution Geriatric Low Energy -- Fall Male:Female 1:1 Young patients High Energy -- MVA Male:Female 3:1

3

4 Anatomy of the Odontoid Process Cortical Thinning Decreasing Trabecular Bone Volume Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases Matthias Gebauer E, et al Eur Spine J Mar; 15(3):

5 Anderson and D Alonzo / Grauer Classification Odontoid Fractures: Update on Management Hsu, Wellington K. MD; Anderson, Paul A. MDJournal of the American Academy of Orthopaedic Surgeons: July Volume 18 - Issue 7 - p

6 Type II Odontoid Fracture

7 Why Type II Fractures Don t Heal Fracture through thin cortical bone Lack of cancellous (highly vascular) bone Disrupted Blood Supply? Angiogram study refutes Inadequate immobilization Lack of Bony apposition Maximal displacement consistent with fx healing 20% Fractures of the odontoid process AN ANGIOGRAPHIC AND CLINICAL STUDY S. Govender, J. F. Maharaj, M. R. Haffajee JBJS. VOL. 82-B, NO. 8, NOVEMBER 2000

8 Type II Dens Fracture Mortality 156 Patients Average Age 82 3 years post injury 39 % Mortality Operative 21 % Mortality at One Year Non-Operative 36 % Mortality at One Year Surgery protective in patients years Type II Odontoid Fractures of the Cervical Spine: Does Treatment Type and Medical Comorbidities Affect Mortality in Elderly Patients? Schoenfeld, Andrew J., et al. Spine. 36(11): , May 15, 2011.

9 Risk of Living With a Non-United Fracture Type II Odontoid Fractures 130 Patients Average Age % of Odontoid Fractures were chronic non-united, untreated fractures 18 % of Chronic non-united fractures had new neurologic deficit 16 % of Acute fractures had new neurologic deficit Low energy injuries in a geriatric population Selection bias toward more significantly injured patients referred to center Neurologic injury because of trauma after Type II odontoid nonunion Christopher K. Kepler, MD, et al. The Spine Journal Volume 14, Issue 6, Pages (June 2014)

10 Morbidity/Mortality Surgery Operative and Non-operative treatment in geriatric population have high risk of poor outcome Meta Analysis One year mortality after surgery for Odontoid Fracture % % >85 45 % Higher complication rate with Anterior vs. Posterior Nonunion, Revision, Hardware failure 6% Mortality in-hospital in surgically treated fxs Morbidity and Mortality Related to Odontoid Fracture Surgery in the Elderly Population. White, Andrew P. MD, et al. Spine. Volume 35 pp S146-S157

11 Treatment Options Cervical Collar Halo Vest Anterior Odontoid Screw Posterior C1-C2 Fusion

12 Rigid Collar Treatment Collar for 12 Weeks Most patients pretty miserable Skin breakdown Fibrous union in the majority

13 Rigid Collar Treatment 34 Patients Average 84 Years old <50 % Displacement Rigid Collar x 12 Weeks 15 month followup 12 % Mortality 6 % Healed (Bridging Bone) 70 % Mobile Non-Union 6 % Significant Skin Breakdown Neck pain and disability scores not significantly different from controls Rigid cervical collar treatment for geriatric type II odontoid fractures. Molinari, et al. European Spine Journal May 2012, Volume 21, Issue 5, pp

14 Halo Vest Complications 75 Patients > 65 Years old 8 % Mortality 23 % Significant Pulmonary Complications Aspiration Pneumonia Complications of Cervical Halo-Vest Orthoses in Elderly Patients Lisa A. Taitsman, MD, MPH; Daniel T. Altman, MD; Andrew C. Hecht, MD; Frank X. Pedlow, MD Orthopedics May Volume 31 Issue 5

15 Halo Vest Complications 78 Patients Average Age 80 years old Complications of Halo Vest Aspiration Pneumonia 34 % Cardiac Arrest 26 % In-Hospital Mortality Halo Vest 42 % Other Non-op tx 20 % Tashjian RZ, Majercik S, Biffl WL, Palumbo MA, Cioffi WG: Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma 2006;60(1):

16 Posterior Fusion

17 Posterior Fusion PSF for Type II Odontoid Fx 26 Patients Average Age 79 Years 19 % Mortality at 13 Months 66 % Fracture Non-Union Rate All stable non-unions No Difference in Disability / Neck Pain to Age Matched Cohort Functional Outcomes, Morbidity, Mortality, and Fracture Healing in 26 Consecutive Geriatric Odontoid Fracture Patients Treated With Posterior Fusion. Molinari, Robert William MD, et al. Journal of Spinal Disorders & Techniques: Volume 26 Issue 3 pp

18 Anterior Odontoid Screw Fixation

19 Anterior Odontoid Screw Fixation 57 Patients > 70 Years old Stable fixation with 2 screws in 96 % 25 % Required Feeding Tube 19 % Aspiration Pneumonia J Neurosurg Spine Jan;12(1):1-8. Anterior fixation of odontoid fractures in an elderly population. Dailey, AT et al.

20 What We Do Level 1 Trauma Center HUGE Geriatric population Very common injury Fall >> MVA

21 What We Do Vast majority of Type II fractures treated with Cervical Collar Anterior Odontoid screw fixation in selected patients with fracture pattern and body habitus amenable to procedure C1 C2 PSF for markedly displaced fractures Can t remember the last time I put a halo on an elderly patient.

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