Odontoid Fractures and the Silver Tsunami

Graffeo, Christopher S.; Perry, Avital; Puffer, Ross C.; Carlstrom, Lucas P.; Chang, Wendy; Mallory, Grant W.; Clarke, Michelle J.

doi:10.1227/neu.0000000000001279

Cited by 7 publications

(5 citation statements)

References 49 publications

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“…This aims to promote bony fusion and prevent neurological deterioration or instability pain 1 5 11. However, hard collars only restrict 40%–50% of neck movements,12 13 and bony fusion rates of 20%–80% are variable across fracture types, management, age and frailty 1 5 11 14–18. Further, bony fusion may not be associated with pain, quality of life (QoL), mortality or functional outcomes in older people,8 19 20 and late neurological deterioration is very rare 5 11 21.…”

Section: Introductionmentioning

confidence: 99%

Duration of External Neck Stabilisation (DENS) following odontoid fracture in older or frail adults: protocol for a randomised controlled trial of collar versus no collar

et al. 2022

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IntroductionFractures of the odontoid process frequently result from low impact falls in frail or older adults. These are increasing in incidence and importance as the population ages. In the UK, odontoid fractures in older adults are usually managed in hard collars to immobilise the fracture and promote bony healing. However, bony healing does not always occur in older adults, and bony healing is not associated with quality of life, functional, or pain outcomes. Further, hard collars can cause complications such as skin pressure ulcers, swallowing difficulties and difficulties with personal care. We hypothesise that management with no immobilisation may be superior to management in a hard collar for older or frail adults with odontoid fractures.Methods and analysesThis is the protocol for the Duration of External Neck Stabilisation (DENS) trial—a non-blinded randomised controlled trial comparing management in a hard collar with management without a collar for older (≥65 years) or frail (Rockwood Clinical Frailty Scale ≥5) adults with a new odontoid fracture. 887 neurologically intact participants with any odontoid process fracture type will be randomised to continuing with a hard collar (standard care) or removal of the collar (intervention). The primary outcome is quality of life measured using the EQ-5D-5L at 12 weeks. Secondary outcomes include pain scores, neck disability index, health and social care use and costs, and mortality.Ethics and disseminationInformed consent for participation will be sought from those able to provide it. We will also include those who lack capacity to ensure representativeness of frail and acutely unwell older adults. Results will be disseminated via scientific publication, lay summary, and visual abstract. The DENS trial received a favourable ethical opinion from the Scotland A Research Ethics Committee (21/SS/0036) and the Leeds West Research Ethics Committee (21/YH/0141).Trial registration numberNCT04895644.

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Section: Introductionmentioning

confidence: 99%

Duration of External Neck Stabilisation (DENS) following odontoid fracture in older or frail adults: protocol for a randomised controlled trial of collar versus no collar

et al. 2022

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“…Thus, a stable nonunion may be considered a safe fracture-healing outcome and thus surgical mortality would approximate nonsurgical mortality. 11,50 It should be noted that the propensity score weights adjusted more substantially with increasing age but were still able to identify a potential treatment effect from surgery. The 64 to 74 age-group retained significant treatment effect even after adjusting for measured confounding supporting better surgeon prediction of good outcome in this age-group.…”

Section: Discussionmentioning

confidence: 99%

Comparative Propensity-Weighted Mortality After Isolated Acute Traumatic Axis Fractures in Older Adults

Catalino¹,

Pate²,

Stürmer³

et al. 2020

Geriatr Orthop Surg Rehabil

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Introduction: In older patients with axis fractures, the survival benefit from surgery is unclear due to high baseline mortality. Comparative effectiveness research can provide evidence from population level cohorts. Propensity weighting is the preferred methodology for reducing bias when analyzing national administrative cohort data for these purposes but has not yet been utilized for this important surgical conundrum. We estimate the effect of surgery on mortality after isolated acute traumatic axis fracture in older adults. Materials and Methods: We used a retrospective population-based cohort of Medicare patients and generated a propensity score-weighted nonsurgical cohort and compared mortality with and without surgery. This balanced the comorbid conditions of the treatment groups. Incident fractures were defined using a predetermined algorithm based on enrollment, code timing, and billing location. The primary outcome was adjusted all-cause 1-year mortality. Results: From 12 372 beneficiaries with 1-year continuous enrollment and a coded axis fracture, 2676 patients met final inclusion/exclusion criteria. Estimated incidence was 16.5 per 100 000 person-years overall in 2014 (95% confidence interval [CI]: 15.0-18.0) and was stable from 2008 through 2014. Patients with axis fracture had a mean age of 82.8 years, 30.2% were male, and 91.9% were Caucasian. Mortality was 3.8 times higher (CI 3.6-4.1) compared with the general population of older US adults. Propensity-weighted mortality at 1 year for nonsurgical patients was 26.7 of 100 (CI: 24.5-29.0). Mortality for surgical patients was significantly lower (19.7/100; CI 14.5-25.0). Risk difference was 7.0 fewer surgical deaths per 100 patients (CI: 1.3-12.7). Surgical patients aged 65 to 74 years had the largest difference in mortality with 11.2 fewer deaths per 100 (CI: 1.1-21.3). Discussion: Patients with axis fractures are predominantly older Caucasian women and have a higher mortality rate than the general population. Propensity-weighted mortality at 1-year was lower in the surgical patients with the largest risk difference occurring in patients 65 to 74 years old. Conclusions: Surgery may provide an independent survival benefit in patients aged 65 to 75 years, and the mortality difference diminishes thereafter.

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“…Fractures of cervical vertebrae, including fractures of the second cervical vertebra (dens fractures), are increasing in frequency, occur predominantly in older (over 65 years) or frail people and mostly result from low‐velocity falls 1–5 . Due to increased surgical risk and poor bone quality, older and/or frail patients in the United Kingdom are usually managed nonsurgically with external immobilisation in a hard collar 6–8 . External immobilisation aims to provide cervical stability to promote bony fusion, prevent neurological deterioration and minimise short‐ and long‐term pain 7,9 .…”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3][4][5] Due to increased surgical risk and poor bone quality, older and/or frail patients in the United Kingdom are usually managed nonsurgically with external immobilisation in a hard collar. [6][7][8] External immobilisation aims to provide cervical stability to promote bony fusion, prevent neurological deterioration and minimise short-and long-term pain. 7,9 However, hard collars can lead to complications, including pressure sores and pneumonia.…”

mentioning

confidence: 99%

“…[6][7][8] External immobilisation aims to provide cervical stability to promote bony fusion, prevent neurological deterioration and minimise short-and long-term pain. 7,9 However, hard collars can lead to complications, including pressure sores and pneumonia. [10][11][12] They may also cause difficulties with swallowing and affect the ability to undertake routine activities of daily living, including self-care.…”

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confidence: 99%

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Understanding the quality‐of‐life experiences of older or frail adults following a new dens fracture: Nonsurgical management in a hard collar versus early removal of collar

Closs,

Brennan,

Niven

et al. 2024

Health Expectations

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IntroductionIn the United Kingdom, fractures of the cervical dens process in older and/or frail patients are usually managed nonsurgically in a hard collar. However, hard collars can lead to complications and this management approach is now being questioned, with growing interest in maximising patients' short‐term quality‐of‐life. It is vital that patients' perspectives are considered; yet, there is a dearth of literature examining the aspect. To help inform wider decision‐making about use of collar/no collar management of dens fractures in older/frail people, we explored older/frail people's experience of the two management approaches and how they affected their perceived quality‐of‐life.MethodsWe interviewed older and/or frail adults with a recent dens fracture (aged ≥65 years or with a clinical frailty score of ≥5) or their caregiver. Participants were recruited from both arms of a clinical trial comparing management using a hard collar for 12 weeks (SM) with early removal of the collar (ERC) and were interviewed following randomisation and again, 12–16 weeks later. Data were analysed using a framework approach.ResultsBoth participant groups (SM/ERC) reported substantial, negative quality‐of‐life (QoL) experiences, with the fall itself and lack of access to care services and information being frequent major contributory factors. Many negative experiences cut across both participant groups, including pain, fatigue, diminished autonomy and reduced involvement in personally meaningful activities. However, we identified some subtle, yet discernible, ways in which using SM/ERC reinforced or alleviated (negative) QoL impacts, with the perceived benefits/burdens to using SM/ERC varying between different individuals.ConclusionStudy findings can be used to support informed decision‐making about SM/ERC management of dens fractures in older/frail patients.Patient or Public ContributionPublic and patient involvement contributors were involved in the study design, development of interview topic guides and interpretation of study findings.

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Odontoid Fractures and the Silver Tsunami

Cited by 7 publications

References 49 publications

Duration of External Neck Stabilisation (DENS) following odontoid fracture in older or frail adults: protocol for a randomised controlled trial of collar versus no collar

Duration of External Neck Stabilisation (DENS) following odontoid fracture in older or frail adults: protocol for a randomised controlled trial of collar versus no collar

Comparative Propensity-Weighted Mortality After Isolated Acute Traumatic Axis Fractures in Older Adults

Understanding the quality‐of‐life experiences of older or frail adults following a new dens fracture: Nonsurgical management in a hard collar versus early removal of collar

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