As the population ages, the number of dens fractures in the elderly has increased and placed a large burden on the healthcare system. These patients frequently have multiple comorbidities, leading to high rates of complications and mortality whether they are treated surgically or with non-operative treatment. Additionally, the best treatment for the geriatric odontoid fracture remains controversial, with a recent, large observational trial suggesting better patient reported outcomes measures and lower mortality with surgery.1 However, this study was not randomized and there were likely unmeasured differences between the surgery and non-operative group that could have confounded the results. Given the increasing number of these fractures and the high cost to society associated with their treatment, Dr. Daniels and his colleagues from Providence performed a retrospective administrative database analysis using the National Inpatient Sample from 2000-2010. They found that the overall incidence increased over two-fold over the decade, with the greatest increase in patients over age 84 (3 fold increase). The use of a halo-vest decreased from 25% to 10%, while the rate of surgical treatment increased from 13% to 16%, changes consistent with recommendations in the literature. Not surprisingly, the comorbidity burden increased, which was likely responsible for the non-significant increase in inpatient mortality (4.9% to 6.7%). The inpatient mortality rate was lower for patients undergoing surgery compared to those treated non-operatively (3.1% vs. 7.5%), though the surgery patients were healthier. Inpatient hospital charges were approximately twice as high for surgical patients compared to patients not undergoing surgery.
The findings of this paper suggest that we might have an epidemic of C2 fractures on our hands. While the fracture incidence could plausibly be increasing due to a more active elderly population or the prolonged life expectancy of less healthy patients at greater risk for C2 fracture, given the increased incidence even in younger age groups suggests other factors may also be contributing. The authors point out that the rate of advanced imaging has likely increased over the past decade, and the likelihood of diagnosis is much greater with a CT scan than with plain radiographs. Additionally, coders may have become more likely to code the specific fracture level over time, which could also give the appearance of an increased incidence. Even if the incidence was not increasing, the absolute number of fractures would be increasing simply due to the increasing number of elderly patients in the population. The authors indicate that hospital charges for C2 fractures exceeded $1.5 billion dollars in 2010, so this is clearly a problem that needs further study. Given that prevention will likely be difficult, determining the most cost-effective treatment for dens fractures is essential. While surgery may lead to better outcomes and lower mortality in certain subgroups, it may be less beneficial or harmful in others.2 Future studies should focus on determining the most cost-effective treatment for patients based on their specific characteristics.
Please read Dr. Daniels’s article on this topic in the August 15 issue. Does it change how you look at C2 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.
2. Schoenfeld AJ, Bono CM, Reichmann WM, et al. Type II Odontoid Fractures of the Cervical Spine: Do Treatment Type and Medical Comorbidities Affect Mortality in Elderly Patients? Spine (Phila Pa 1976) 2011;36:879-85.