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.