Friday, March 13, 2020
Are spine fractures becoming more common?
Spine care providers see many low energy fractures, especially in the elderly, and the incidence of these fractures seems to be on the rise. Conversely, high-energy fractures from road traffic accidents seem to be less common as automobiles have become safer. In order to better understand the trends in spine fracture epidemiology, Dr. Ponkilainen and colleagues from Finland analyzed the Finnish National Hospital Discharge Register from 1998-2017. This database captures 100% of hospitalizations in the country of 5.5 million people, which provides healthcare through a single national health service. Over the period under study, the rate of hospitalization for spine fractures increased 57%, from 57 per 100,000 person-years to 89 per 100,000 person-years. The overall surgical rate was nearly unchanged, increasing from 9.3% of fractures to 9.9% of fractures. The authors analyzed trends stratified by spine region, which demonstrated lumbar fractures were the most common fracture (58% of all fractures), and the incidence of cervical fractures increased the most (120% increase). Interestingly, the rate of surgery for lumbar fractures actually decreased by 43%, while the rate of surgery for cervical and thoracic fractures increased by 29% and 46%, respectively. The greatest increase in the incidence of fractures and surgery was for cervical fractures in the elderly, with the incidence of cervical spine fracture surgery increasing 400% in patients over 60 years old.
This paper offers a nice portrait of the trends in spine fracture incidence and surgical rates in Finland over 20 years. It seems likely that the general trends apply to most economically advanced nations. The methods used in this paper are very reliable, using a database that captures all hospital data for an entire nation. The authors note the database may miss a low number of fractures treated without hospitalization or those associated with multi-trauma in which all injuries may not be coded. The major limitation is the lack of detail in the database about fracture type and outcomes. The increase in incidence over time seems due to two factors: a larger, more active elderly population at risk for fracture and the increasing use of CT scan that detects fractures that may have been missed in the early part of the study period. Even more interesting are the trends in surgical treatment. The rate of surgery for lumbar fractures has decreased substantially. This could be due to surgeons choosing to treat stable lumbar burst fractures non-operatively later in the study period and the denominator of fractures increasing later in the study period due to greater detection of minor fractures like transverse process fractures. There is relatively strong evidence that thoracolumbar burst fractures in the neurologically intact patient with an intact posterior ligamentous complex can be treated non-operatively, and it seems as though surgeons may be using this evidence to inform their decision-making. The increasing rate of cervical surgery in the elderly may be due to the recognition that extension-distraction injuries are unstable and that the hardware available to treat these injuries has made surgical treatment easier and more effective. Anesthetic care for the elderly has also improved, and surgeons and anesthesiologists may have become more willing to operate on elderly patients over time. Both of these trends in surgical rates are likely evidence-based, which is reassuring to see.
Please read Dr. Ponkilainen's article on this topic in the April 1 issue. Does the Finnish experience mirror what you have seen in practice?
Adam Pearson, MD, MS
Associate Web Editor