Background: Dens fractures are relatively common in the elderly. The treatment of Type-II dens fractures remains controversial. The aim of this multicenter prospective cohort study was to compare outcomes (assessed with use of validated clinical measures) and complications of nonsurgical and surgical treatment of Type-II dens fractures in patients sixty-five years of age or older.
Methods: One hundred and fifty-nine patients with a Type-II dens fracture were enrolled in a multicenter prospective study. Subjects were treated either surgically (n = 101) or nonsurgically (n = 58) as determined by the treatment preferences of the treating physicians and the patients. The subjects were followed at six and twelve months with validated outcome measures, including the Neck Disability Index (NDI) and Short Form-36v2 (SF-36v2). Treatment complications were prospectively recorded. Statistical analysis was performed to compare outcome measures before and after adjustment for confounding variables.
Results: The two groups were similar with regard to baseline characteristics. The most common surgical treatment was posterior C1-C2 arthrodesis (eighty of 101, or 79%) while the most common nonsurgical treatment was immobilization with use of a hard collar (forty-seven of fifty-eight, or 81%). The overall mortality rate was 18% over the twelve-month follow-up period. At twelve months, the NDI had increased (worsened) by 14.7 points in the nonsurgical cohort (p < 0.0001) compared with a nonsignificant increase (worsening) of 5.7 points in the surgical group (p = 0.0555). The surgical group had significantly better outcomes as measured by the NDI and SF-36v2 Bodily Pain dimension compared with the nonsurgical group, and these differences persisted after adjustment. There was no difference in the overall rate of complications, but the surgical group had a significantly lower rate of nonunion (5% versus 21% in the nonsurgical group; p = 0.0033). Mortality was higher in the nonsurgical group compared with the surgical group (annual mortality rates of 26% and 14%, respectively; p = 0.059).
Conclusions: We demonstrated a significant benefit with surgical treatment of dens fractures as measured by the NDI, a disease-specific functional outcome measure. As a result of the nonrandomized nature of the study, the results are vulnerable to the effects of possible residual confounding. We recommend that elderly patients with a Type-II dens fracture who are healthy enough for general anesthesia be considered for surgical stabilization to improve functional outcome as well as the union and fusion rates.
Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
1Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for A.R. Vaccaro: firstname.lastname@example.org
2University of Washington, Box 359455, 4333 Brooklyn Avenue N.E., Room 14-315, Seattle, WA 98195-9455
3University of Washington, 325 Ninth Avenue, Seattle, WA 98104
4University of Virginia, P.O. Box 800386, Charlottesville, VA 22908-0386
5University of Kansas, 3901 Rainbow Boulevard, Mail Stop 3021, Kansas City, KS 66160
6Johns Hopkins University, Meyer 7-109, 600 North Wolfe Street, Baltimore, MD 21287
7University of Utah, 590 Wakara Way, Salt Lake City, UT 84108
8West Virginia University, One Medical Center Drive, Morgantown, WV 26506
9Mayo Clinic, 200 First Avenue S.W., Rochester, MN 55902
10Indiana Spine Group, 8402 Harcourt Road, Suite 400, Indianapolis, IN 46260
11Emory University, 59 Executive Park South, Atlanta, GA 30329
12Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
13Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, PA 19107
14Toronto Western Hospital, West Wing, 4th Floor, Room 4WW449, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada