Lightning Podiums: Value and Outcomes in Spinal Surgery - Room 801B

Presented by: E. Koh

Author(s):

S. Clark(1), A. Nash(1), I. Bussey(1), D. Gelb(1), E. Koh(1), K. Banagan(1), S. Ludwig(1)

(1) University of Maryland, Orthopedics, Baltimore, MD, United States

Abstract

Introduction: The treatment of unstable type II odontoid fractures in elderly patients can present challenges. Recent evidence indicates in patients older than 80 years, posterior C1-2 fusion resulted in improved survival as compared to other modes of treatment. This study aimed to analyze 30-day and one-year mortality rates as well as the most common complications associated with posterior C1-2 fusion.

Methods: Following IRB approval, review of our university database was performed for patients who underwent posterior C1-C2 fusion for management of unstable type II odontoid fracture by 4 fellowship trained spine surgeons at a single institution between January 2006 and June 2016. Patients who underwent surgical management of a primary cervical fracture other than type II odontoid fracture were excluded. Surgical technique utilized was fixation with C1 lateral mass screw and C2 pedicle screw construct in 35 patients, with 8 patients alternatively receiving a C2 translaminar screw in place of a C2 pedicle screw due to C2 venous plexus bleeding or anatomical variants of the pedicle and vertebral artery. For statistical analysis, Fisher's Exact test, survival analysis and logistic regression analysis were performed.

Results: A total of 43 patients were included in this study, who had a mean age of 84.3±3.1 years, a mean Charlson Comorbidities Index of 1.4±1.5 points (range 1.6 points), and a mean BMI of 24.8±4.2 kg/m2. To the date of review completion, 25 of 43 patients had expired (58.1%), with a median survival of 1.76 years (range 0.02-8.81 years) from the date of surgery. Thirty-day and one-year mortality rates were 2.3% and 18.6%, respectively. The mean fracture displacement was 5.1±3.6mm and mean absolute value of angulation of 20.7±12.2°. The most common complications were altered mental status (41.9%, n=18), and dysphagia (27.9%, n=12), with 50% of those patients (6 of 12) requiring a feeding tube, and reintubation (9.3%, n=4). Dysphagia was found to be associated with significantly increased odds for one-year mortality (OR 14.5, CI: 2.3-90.0; p=0.003). When accounting for gender and CCI, degree of fracture displacement was also significantly associated with mortality (OR 1.3 per unit change (mm), CI: 1.03-1.73; p=0.0159).

Conclusion: Posterior C1-2 fusion in octogenarians with unstable type II odontoid fracture had 30-day and 1-year mortality rates that were significantly lower than those found in current literature. Based on this study, we consider posterior C1-2 fusion by screw construct to be an appropriate treatment option in the octogenarians with unstable type II odontoid fractures. Additionally, our results indicate initial fracture displacement and postoperative dysphagia are associated with higher mortality rate in this patient population.