The ideal treatment choice for minimally displaced Type II dens fractures in the elderly remains unclear, with some recent literature suggesting decreased mortality and better clinical outcomes in those treated with surgery.1 There has been no RCT comparing surgical and non-operative treatment in this population, so no firm conclusions can be made based on the available observational studies given the high likelihood of selection bias and confounding inherent in this study design. In the current investigation, Dr. Smith and his co-authors focused on the fate of the non-operative patients in the recent AOSpine North America cohort study. There were 58 patients initially treated non-operatively, of whom 8 died within 90 days of enrollment and were excluded from the study. The remaining 50 patients were included and classified into union and non-union groups. Interestingly, the definition of union did not require evidence of bony healing and included patients who had no gross motion on radiographs and no persistent symptoms requiring further treatment. Thus, asymptomatic patients with stable, fibrous unions were analyzed in the union group. Eleven patients were classified as non-unions, of whom 7 required delayed surgery. In addition, 4 patients initially classified as having undergone union went onto late fracture displacement and were treated surgically. Thus, eleven of fifty patients required delayed surgery, while 78% did not need surgical treatment within the first year. Comparison of the Neck Disability Index and SF-36 scores between the union and non-union groups showed no significant differences, though the results of the patients treated surgically were included.
With the lack of a high quality RCT evaluating this topic, it remains unclear whether an initial surgical or non-operative strategy is preferred in these patients. Surgery is likely associated with increased short term morbidity related to the operation, but it may decrease long-term complications and improve patient-reported outcomes. On the other hand, this analysis suggests that surgery can likely be avoided in78% of patients, and there is no suggestion that delayed surgery leads to worse outcomes than early surgery (though this direct comparison was not made in this paper). It remains unclear if any of the deaths in the non-operative group could have been prevented by surgery, and there is no cause of death analysis presented. Similarly, there is no discussion about the risk of progressive neurological deficit or the development of myelopathy in the non-operative group, so the risk of these complications remains unknown. If surgery does not reduce mortality or the risk of neurological decline, has similar clinical outcomes when performed in an early and delayed fashion, and can be avoided in 78% of patients, it seems as though a protocol of initial non-operative treatment with close observation may be favored in some patients. The challenge currently facing surgeons is determining which patients benefit from early surgery, and there is currently no data available to help make this decision based on individual patient characteristics. The current study demonstrated an increased risk of non-union among men, a finding that makes sense given that men are generally at lower risk for fragility fractures and men who suffer them tend to be markedly less healthy and have worse bone health. However, there is currently no data to suggest whether or not men are better off with initial surgical or non-operative treatment. Another limitation of this study is that there was not a clear protocol regarding the indications for delayed surgery. It is possible that some non-operative patients with persistent symptoms may have benefited from delayed surgery, while some patients who underwent delayed surgery would have done well without it. While the authors do not conclude that initial non-operative treatment may be favored in many elderly patients with Type II dens fractures, the data do suggest that initial treatment in a collar with close observation and delayed surgery in patients who go onto a symptomatic non-union may be a reasonable approach that can be successful in the majority of patients. The best treatment approach to this increasingly common problem is likely going to remain unknown until a multicenter RCT is performed, and it is unclear if such a study will ever be performed. In the meantime, patients and their families are best served with a frank discussion about the likely surgical and non-operative outcomes that allows them to make as much of an informed treatment decision as is possible with the currently available data. Studies such as this one will certainly aid in these discussions.
Please read Dr. Smith’s article on this topic in the December 15 issue and his accompanying blog post. Does this article change how you approach Type II dens fractures in the elderly? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor
1. Vaccaro AR, Kepler CK, Kopjar B, et al. Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. The Journal of bone and joint surgery American volume 2013;95:729-35.