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M A R K E S K E N A Z I , M . D .
S P I N E I N S T I T U T E O F S O U T H F L O R I D A
A F F I L I A T E A S S I S T A N T P R O F E S S O R O F C L I N I C A L B I O M E D I C A L S C I E N C E
F L O R I D A A T L A N T I C U N I V E R S I T Y C H A R L E S E . S C H M I D T C O L L E G E O F M E D I C I N E
Geriatric Odontoid Fractures
Odontoid Fractures
Biphasic Distribution
Geriatric Low Energy -- Fall
Male:Female 1:1
Young patients High Energy -- MVA
Male:Female 3:1
Anatomy of the Odontoid Process
Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases Matthias Gebauer E, et al Eur Spine J. 2006 Mar; 15(3): 292–298.
Cortical Thinning Decreasing Trabecular Bone Volume
Anderson and D’Alonzo / Grauer Classification
Odontoid Fractures: Update on Management Hsu, Wellington K. MD; Anderson, Paul A. MDJournal of the American Academy of Orthopaedic Surgeons: July 2010 - Volume 18 - Issue 7 - p 383–394
Type II Odontoid Fracture
Why Type II Fractures Don’t Heal
Fracture through thin cortical bone
Lack of cancellous (highly vascular) bone
Disrupted Blood Supply ? Angiogram study refutes
Inadequate immobilization
Lack of Bony apposition Maximal displacement consistent with fx healing 20%
Fractures of the odontoid process AN ANGIOGRAPHIC AND CLINICAL STUDY S. Govender, J. F. Maharaj, M. R. Haffajee JBJS. VOL. 82-B, NO. 8, NOVEMBER 2000
Type II Dens Fracture Mortality
156 Patients Average Age 82 3 years post injury 39 % Mortality Operative 21 % Mortality at One Year Non-Operative 36 % Mortality at One Year Surgery protective in patients 65 -74 years
Type II Odontoid Fractures of the Cervical Spine: Does Treatment Type and Medical Comorbidities Affect Mortality in Elderly Patients ? Schoenfeld, Andrew J., et al. Spine. 36(11):879-885, May 15, 2011.
Risk of Living With a Non-United Fracture
Type II Odontoid Fractures
130 Patients Average Age 79 30 % of Odontoid Fractures were chronic non-united, untreated fractures 18 % of Chronic non-united fractures had new neurologic deficit 16 % of Acute fractures had new neurologic deficit Low energy injuries in a geriatric population Selection bias toward more significantly injured patients referred to center Neurologic injury because of trauma after Type II odontoid nonunion Christopher K.
Kepler, MD, et al. The Spine Journal Volume 14, Issue 6, Pages 903-908 (June 2014)
Morbidity/Mortality Surgery
Operative and Non-operative treatment in geriatric population have high risk of poor outcome – Meta Analysis
One year mortality after surgery for Odontoid Fracture
65 -74 21 %
75 – 84 29 %
>85 45 %
Higher complication rate with Anterior vs. Posterior
Nonunion, Revision, Hardware failure
6% Mortality in-hospital in surgically treated fxs
Morbidity and Mortality Related to Odontoid Fracture Surgery in the Elderly Population. White, Andrew P. MD, et al. Spine. Volume 35 pp S146-S157
Treatment Options
Cervical Collar
Halo Vest
Anterior Odontoid Screw
Posterior C1-C2 Fusion
Rigid Collar Treatment
Collar for 12 Weeks
Most patients pretty miserable
Skin breakdown
Fibrous union in the majority
Rigid Collar Treatment
34 Patients Average 84 Years old
<50 % Displacement
Rigid Collar x 12 Weeks
15 month followup
12 % Mortality
6 % Healed (Bridging Bone)
70 % Mobile Non-Union
6 % Significant Skin Breakdown
Neck pain and disability scores not significantly different from controls
Rigid cervical collar treatment for geriatric type II odontoid fractures. Molinari, et al. European Spine Journal May 2012, Volume 21, Issue 5, pp 855-862.
Halo Vest Complications
75 Patients > 65 Years old
8 % Mortality
23 % Significant Pulmonary Complications Aspiration Pneumonia
Complications of Cervical Halo-Vest Orthoses in Elderly Patients Lisa A. Taitsman, MD, MPH; Daniel T. Altman, MD; Andrew C. Hecht, MD; Frank X. Pedlow, MD Orthopedics May 2008 - Volume 31 · Issue 5
Halo Vest Complications
78 Patients Average Age 80 years old
Complications of Halo Vest Aspiration Pneumonia 34 %
Cardiac Arrest 26 %
In-Hospital Mortality Halo Vest 42 %
Other Non-op tx 20 %
Tashjian RZ, Majercik S, Biffl WL, Palumbo MA, Cioffi WG: Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma 2006;60(1):199-203.
Posterior Fusion
Posterior Fusion
PSF for Type II Odontoid Fx
26 Patients Average Age 79 Years
19 % Mortality at 13 Months
66 % Fracture Non-Union Rate All stable non-unions
No Difference in Disability / Neck Pain to Age Matched Cohort
Functional Outcomes, Morbidity, Mortality, and Fracture Healing in 26 Consecutive Geriatric Odontoid Fracture Patients Treated With Posterior Fusion. Molinari, Robert William MD, et al. Journal of Spinal Disorders & Techniques: Volume 26 – Issue 3 pp 119-126
Anterior Odontoid Screw Fixation
Anterior Odontoid Screw Fixation
57 Patients > 70 Years old
Stable fixation with 2 screws in 96 %
25 % Required Feeding Tube
19 % Aspiration Pneumonia
J Neurosurg Spine. 2010 Jan;12(1):1-8. Anterior fixation of odontoid fractures in an elderly population. Dailey, AT et al.
What We Do
Level 1 Trauma Center
HUGE Geriatric population
Very common injury
Fall >> MVA
What We Do
Vast majority of Type II fractures treated with Cervical Collar
Anterior Odontoid screw fixation in selected patients with fracture pattern and body habitus amenable to procedure
C1 – C2 PSF for markedly displaced fractures
Can’t remember the last time I put a halo on an elderly patient.