Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly

Abstract

IntroductionFractures of the odontoid process of the axis have been the subject of many investigations, but most articles do not consider the biological impact of age. Few publications cover the subject in the elderly population, although odontoid fractures are the most common fractures of the cervical spine in this age group. There is still a lack of agreement on the best method of treatment among patients over 65 years of age. Conservative treatment carries a high risk of developing non-union [15,19] as does halovest treatment [8]. Posterior C1-C2 fusion according to Gallie has long been the method of choice. The Gallie technique, however, is not biomechanically optimal and has a failure rate of 1/5 [9]. By adding transarticular screws the mechanical situation was improved [14,16]. Recently, the anterior screw technique according to has gained increased popularity. In most reports, younger and older patients have been grouped together. Few publications have examined the results explicitly in the elderly population. Berlemann and Schwarzenbach [5] advocated the anterior screw technique in the elderly.The present study is a review of a consecutive series of odontoid fractures in patients over 65 years of age treated at our department between 1988 and 1994. The results of anterior screw fixation, posterior C1-C2 fusion, and conservative treatment are compared. Materials and methodsThe series consists of 29 consecutive patients (18 women) with a mean age of 78 (66-99) years with odontoid fractures treated at our department between 1988 and 1994. Patient demographics and results are presented in the Table 1. Twenty-four of the fractures were Abstract This study is a retrospective analysis of patients older than 65 years with odontoid fractures. The series consisted of 29 consecutive patients with odontoid fractures (18 women, mean age 78, range 66-99 years). Twenty-six patients were neurologically intact, Frankel E, whereas three had neurological symptoms: two Frankel D and one Frankel C. Eleven patients were treated with anterior screw fixation according to Böhler, seven with a posterior C1-C2 fusion. Ten patients with either minimally displaced fractures or with complicating medical conditions were treated conservatively. At follow-up, 7/7 patients with posterior fusion had healed without any problems, whereas 8/11 patients treated with anterior screw fixation, and 7/10 conservatively treated patients were either failures or had healed, but after a complicated course of events. We conclude that anterior screw fixation according to Böhler is associated with an unacceptably high rate of problems in the elderly. Probable causes may be osteoporosis with comminution at the fracture site, or stiffness of the cervical spine preventing ideal positioning of the screws. As non-operative treatment also often fails, the method of choice seems to be posterior C1-C2 fusion.

Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion

“…Nevertheless, anterior fixation requires intraoperative double fluoroscopy, which is not always available in every hospital and it is not always indicated because of the type of fracture (small cranial fragment; difficult reduction) or because of the age of the patient (lesser healing potential in the elderly) [8,9]. Harms proposes to stabilize the vertebrae without fusion, and removing the hardware once the fracture is healed [4].…”

Anterior screw fixation of type IIB odontoid fractures in octogenarians

“…Moreover, conservative treatment could lead to the development of delayed myelopathy in patients with non-union of the OF [4]. Posterior fusion of the C1/C2 complex is superior to external immobilisation in terms of radiological outcome and morbidity and mortality [2,8] and produces the highest fusion rates among the different types of surgical fixation [19]. Nonetheless, this surgical approach deteriorates posterior soft tissue, blocks C1/C2 axial rotation, carries the risk of vertebral artery injury of the neck and requires bone grafting.…”

“…Several management options are described in the literature: rigid and non-rigid immobilisations, anterior screw fixation of the odontoid and posterior fusion of the C1/C2 complex [19]. Authors advocating surgical treatment criticize the morbidity associated with prolonged cervical immobilisation [15] whereas authors advocating orthopaedic treatment invoke the risks of surgical intervention [2,11]. The initial surgical treatment by posterior fusion of the C1/C2 complex provides the highest fusion rates [2,8].…”

“…Authors advocating surgical treatment criticize the morbidity associated with prolonged cervical immobilisation [15] whereas authors advocating orthopaedic treatment invoke the risks of surgical intervention [2,11]. The initial surgical treatment by posterior fusion of the C1/C2 complex provides the highest fusion rates [2,8]. However, this procedure requires bone grafting, eliminates C1/C2 rotary motion, deteriorates the posterior soft tissue of the neck and includes the risk of vertebral artery injury.…”

Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures

“…The impact of patients' age at index surgery on outcome was discussed controversially. While it was shown to have significant impact on union rates in several studies [6][7][8][9][10]30], other authors did not find a significant correlation between age and union rates [15,18,20,31]. Besides age, the number of screws used for AOSF might have significant impact on union rates, too.…”