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Effect of Type II Odontoid Fracture Nonunion on Outcome Among Elderly Patients Treated Without Surgery: Based on the AOSpine North America Geriatric Odontoid Fracture Study

Smith, Justin S. MD, PhD*; Kepler, Christopher K. MD, MBA; Kopjar, Branko MD, PhD; Harrop, James S. MD; Arnold, Paul MD§; Chapman, Jens R. MD; Fehlings, Michael G. MD, PhD; Vaccaro, Alexander R. MD, PhD; Shaffrey, Christopher I. MD*

doi: 10.1097/BRS.0000000000000009
Cervical Spine
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Study Design. Subgroup analysis of a prospective multicenter study.

Objective. Outcome analysis of nonoperatively treated elderly patients with type II odontoid fractures, including assessment of consequence of a fracture nonunion.

Summary of Background Data. Odontoid fractures are among the most common fractures in the elderly, and controversy exists regarding treatment.

Methods. Subgroup analysis of a prospective multicenter study of elderly patients (≥65 yr) with type II odontoid fracture. Neck Disability Index and Short-Form 36 (SF-36) version 2 were collected at baseline and 6 and 12 months. Fifty-eight (36.5%) of the 159 patients were treated nonoperatively.

Results. Of the 58 patients initially treated nonoperatively, 8 died within 90 days and were excluded. Of the remaining 50 patients, 11 (22.0%) developed nonunion, with 7 (63.6%) requiring surgery. Four of the 39 (10.3%) patients classified as having “successful union” required surgery due to late fracture displacement. Thus, 15 (30.0%) patients developed primary or secondary nonunion and 11 (22.0%) required surgery. The overall 12-month mortality was 14.0% (nonunion = 2, union = 5; P= 0.6407). For union and nonunion groups, Neck Disability Index and SF-36 version 2 declined significantly at 12 months compared with preinjury values (P< 0.05), except for SF-36 version 2 Physical Functioning (P= 0.1370). There were no significant differences in outcome parameters based on union status at 12 months (P> 0.05); however, it is important to emphasize that the 12-month outcomes for the nonunion patients reflect the status of the patient after delayed surgical treatment in the majority of these cases.

Conclusion. Nonoperative treatment for type II odontoid fracture in the elderly has high rates of nonunion and mortality. Patients with nonunion did not report worse outcomes compared with those who achieved union at 12 months; however, the majority of patients with nonunion required delayed surgical treatment. These findings may prove useful for patients who are not surgical candidates or elect for nonoperative treatment.

Level of Evidence: 2

Nonoperative treatment for type II odontoid fracture in the elderly has high rates of nonunion and mortality. Patients with nonunion did not report worse outcomes compared with those who achieved union at 12 months; however, the majority of patients with nonunion required delayed surgical treatment.

*Department of Neurosurgery, University of Virginia, Charlottesville, VA

Department of Neurological and Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA

Department of Health Services, University of Washington, Seattle, WA

§Department of Neurosurgery, University of Kansas Medical Center, Kansas City, KS

Department of Orthopaedic Surgery, University of Washington, Seattle, WA; and

Department of Neurosurgery, University of Toronto, Ontario, Canada.

Address correspondence and reprint requests to Justin S. Smith, MD, PhD, University of Virginia Health Sciences Center, Department of Neurosurgery, Box 800212, Charlottesville VA, 22908; E-mail: jss7f@virginia.edu

The manuscript submitted does not contain information about medical device(s)/drug(s).

AOSpine North America funds were received to support this work.

Relevant financial activities outside the submitted work: board membership, consultancy, expert testimony, grants/grants pending, payment for lectures, patents, royalties, stock/stock options and payment for development of educational presentations.

© 2013 by Lippincott Williams & Wilkins