Geriatric Odontoid Fractures Alexander R. Vaccaro, MD, PhD, MBA - - PowerPoint PPT Presentation

Geriatric Odontoid Fractures

Alexander R. Vaccaro, MD, PhD, MBA

Professor, Chairman

Department of Orthopaedics and Neurosurgery Thomas Jefferson University

President Rothman Institute

Philadelphia, PA

Disclosure

• Grant Support/ Royalties/Stock
• ptions/Consulting/Editorial Board:
• Depuy, Nuvasive, Medronics, Stryker, Globus, Stout

Medical, Aesculap, Alphatec, Paradigm Spine, Replication Medica, Spinology, Bonovo Spine, Dimension Orthotics, Gamma Spine, IT, SBI, RI related holdings, Gerson Lehrman, Guidepoint Global, Medacorp, ISD, ASIP, PST, ICOM, Orthobullets, Vertiflex, Vexim, SpineWave, Atlas Spine, Avaz Surgical, AO Spine, Spine, ESJ, JNS, PSI

• Board Member: CSRS
• Editor in Chief : Clinical Spine Surgery
• President: Rothman Institute

Geriatric Spine

• Limited physiological

reserve

• Concurrent medical

conditions

• Increasing propensity of

falls

• Worsening eyesight
• Possible ataxia
• Loss of sensation
• Vestibular disorders
• Syncopal episodes
• Loss of neurological functions

Elderly

• Age above 85 yrs-fastest growing

demographic in the United States

• Number of individuals over 85

projected to double by 2025 (U.S. Census Bureau)

• In the elderly, odontoid fractures

account for the majority of all spine fractures, most Type II

Geriatric SCI – Single Institution

Annual SCI admissions ↑ 60% over the last 20 yrs Geriatric (age >70) admissions ↑ 580%

Mortality - Single Institution

Geriatric vs Other Adults

In Hospital 1-Year Age <70 3.2% 5.4% Age >70 27.7% 44.4%

(p < 0.001) (p < 0.001)

Geriatric SCI Mortality

Relationship with ASIA

Hospital Mortality

• A vs D (p = 0.06)

1-Yr Mortality

• A vs D (p < 0.01)

Odontoid Fractures Elderly at higher risk of nonunion

• Type II Geriatric Odontoid Fractures (GOF) all tx

with Halo Vest

• Case-control study, study variable= nonunion
• Age > 50 risk factor for nonunion (p= 0.002)
• Risk of nonunion 21x higher in patients 50+
• Risk likely even higher with cervical orthosis

Lennarson, Spine, 2000

Efficacy of Nonsurgical Treatment

• Retrospective study of Type II GOF
• N= 12 conservative treatment with

halo (8), Minerva (2) or hard collar (2)

• 5 failed within 30 days with 1 death

 5 secondary surgeries

Kuntz, Neurosurg Focus, 2000

High Complication Rate for Nonoperative Treatment

• Retrospective study of type II/III GOF
• n= 23, 22 type II, 1 type III
• n= 18 treated nonoperatively (3 halo, 15 collar)
• 6 deaths (33% )
• 5 loss of reduction/nonunion (28% )
• 5 delayed surgery (28% )
• Overall major complication rate > 50%

Muller, Eur Spine J, 1999

Conservative vs. Surgical

• Type II Geriatric Odontoid Fractures (GOF)
• Conservative treatment (retrospective, n= 19)
• vs. surgical treatment (prospective, n= 11)
• Conservative cohort (halo vest)
• In-hospital mortality 42%
• Surgical cohort (C1-2 PCF)
• Ave. Charlson index> 4 (Expected 1 yr mortality≈35%)
• In-hospital mortality 0%
• 91% union, 1 asymptomatic nonunion
• Bednar, JBJS, 1995

Molinari, Global S

Spine J, 2013

Nonunion Leading to Myelopathy

• Retrospective series, N= 49
• 9 patients treated conservatively

developed nonunion (8 type II, 1 type III)

• 5/9 developed myelopathy
• 1/9 developed spontaneous neuro deficit
• All 6 improved after subsequent PCF

Anderson, JBJS, 1974

• Retrospective series, n= 19
• C1-2 subluxation from fracture

displacement

• Progressive myelopathy
• Treated surgically with reduction, PCF
• 12/19 improved neurologically, rest stable

Kirankumar, Neurosurgery, 2005

Nonunion Leading to Myelopathy

Presence of Instability

Evaniew, Spine J

J, 2015

What Are the Long Term Risks

• f Pseudarthrosis?

7/40 (17.5%) Patients with Non-Unions Presented with New Neuro Deficit (2 Sensory)

Kepler, Spine J

J, 2014

Schroeder, Neuro

rosurg rg, 2015

Odds ratio < 1 for surgical mortality favoring surgery

Yang, Ort

rt hop Tra raum at ol Surg rg Res, 2015

The AOSpine North America Geriatric Odontoid Fracture Study: Mortality Outcomes in Surgical vs. Conservative Treatment in 322 Patients with Long Term Follow-up

• Retrospective data review
• Consecutive subjects > 65 yr

treated for Type II Odontoid fractures

• 322 patients. Long term follow up

Chapman, Vaccaro, Spine 2013

Overall Mortality Results

Variable Expired (N=142) Alive (N=180) P-value Gender 0.013 Male 70 (52%) 64 (48%) Female 72 (38%) 116 (62%) Treatment 0.016 Operative 62 (38%) 103 (62%) Nonoperative 80 (51%) 77 (49%) Variable Expired (N=46) Alive (N=276) P-value Gender 0.7119 Male 18 (13%) 116 (87%) Female 28 (15%) 160 (85%) Treatment <.0001 Operative 11 (7%) 154 (93%) Nonoperative 35 (22%) 122 (78%)

30 Day Mortality Results The AOSpine North America Geriatric Odontoid Fracture Study: Mortality Outcomes in Surgical vs. Conservative Treatment in 322 Patients with Long Term Follow-up

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study

• Prospective multi-center cohort study of 159 subjects >

65 yrs old with a Type II odontoid fracture at 13 sites in North America.

• Patients received non-operative or surgical treatment at

the discretion of the surgical team

• Followed for 12 months, or until expired, whatever
• ccurred first.
• Outcomes assessments included the SF36, Neck

Disability Index (NDI) and rates of mortality and complications.

Vaccaro, JBJS, 2013

Type of Treatment

• Surgical treatment (patients)

101 ( 63.5%) Anterior Odontoid Screw 12 (11.9%) Posterior C1- C2 Screw Fixation 80 (79.2%) Posterior Transarticular Screw Fixation 7 (6.9%) Brooks Fusion C1-C2 Sublamina Wire Placement 1 (1.0%) Occipital-Cervical Fusion 1 (1.0%)

• Conservative treatment

58 (36.5%) Soft Collar Immobilization 5 (8.6%) Hard Collar Immobilization 47 (81%) Halo Immobilization 6 (10.3%)

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study

Treatment Related Complication Events

Complication Type Surgical Conservative P-value Major complication events 17 17 Minor complication events 31 20 Total events 48 37 0.4805 Nonunion 5 (5%) 12 (20.7%) 0.003

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study

Vaccaro, JBJS, 2013

GOF Mortality Results

Surgical (N=102) Conservative (N=57) P-value Mortality (29 patients) 14 patients (13.9%) 15 patients (25.9%) .0512

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study

Vaccaro, JBJS, 2013

Case Example

• 70 yr old female fell from

standing height

• No neurologic deficits

Case Example

• C1-C2 fusion
• Discharged from hospital
• Doing well 1 year post-op

Case Example

• 85 yr old female fell from

standing height

• Initial nondisplaced type

II odontoid fx

• Collar immobilization
• Displaced at 6wks
• Collar decubiti - elected
• bservation
• Lost ability to ambulate at

3 mo post fx

Summary

• Patients treated
• peratively have a
• Decrease in short term

mortality

• Decrease in mortality at
• ne year
• Increased HRQOL

metrics

Thank You