Geriatric Odontoid Fractures Alexander R. Vaccaro, MD, PhD, MBA - PowerPoint PPT Presentation

Geriatric Odontoid Fractures Alexander R. Vaccaro, MD, PhD, MBA Professor, Chairman Department of Orthopaedics and Neurosurgery Thomas Jefferson University President Rothman Institute Philadelphia, PA

Disclosure • Grant Support/ Royalties/Stock options/Consulting/Editorial Board: Depuy, Nuvasive, Medronics, Stryker, Globus, Stout • Medical, Aesculap, Alphatec, Paradigm Spine, Replication Medica, Spinology, Bonovo Spine, Dimension Orthotics, Gamma Spine, IT, SBI, RI related holdings, Gerson Lehrman, Guidepoint Global, Medacorp, ISD, ASIP, PST, ICOM, Orthobullets, Vertiflex, Vexim, SpineWave, Atlas Spine, Avaz Surgical, AO Spine, Spine, ESJ, JNS, PSI Board Member: CSRS • Editor in Chief : Clinical Spine Surgery • President: Rothman Institute •

Geriatric Spine • Limited physiological reserve • Concurrent medical conditions • Increasing propensity of falls • Worsening eyesight • Possible ataxia • Loss of sensation • Vestibular disorders • Syncopal episodes • Loss of neurological functions

Elderly • Age above 85 yrs-fastest growing demographic in the United States • Number of individuals over 85 projected to double by 2025 (U.S. Census Bureau) • In the elderly, odontoid fractures account for the majority of all spine fractures, most Type II

Geriatric SCI – Single Institution Annual SCI admissions ↑ 60% over the last 20 yrs Geriatric (age >70) admissions ↑ 580%

Mortality - Single Institution Geriatric vs Other Adults In Hospital 1-Year 3.2% 5.4% Age <70 27.7% 44.4% Age >70 (p < 0.001) (p < 0.001)

Geriatric SCI Mortality Relationship with ASIA Hospital Mortality • A vs D (p = 0.06) 1-Yr Mortality • A vs D (p < 0.01)

Odontoid Fractures Elderly at higher risk of nonunion • Type II Geriatric Odontoid Fractures (GOF) all tx with Halo Vest • Case-control study, study variable= nonunion • Age > 50 risk factor for nonunion (p= 0.002) • Risk of nonunion 21x higher in patients 50+ • Risk likely even higher with cervical orthosis Lennarson, Spine, 2000

Efficacy of Nonsurgical Treatment • Retrospective study of Type II GOF • N= 12 conservative treatment with halo (8), Minerva (2) or hard collar (2) • 5 failed within 30 days with 1 death  5 secondary surgeries Kuntz, Neurosurg Focus, 2000

High Complication Rate for Nonoperative Treatment • Retrospective study of type II/III GOF • n= 23, 22 type II, 1 type III • n= 18 treated nonoperatively (3 halo, 15 collar) • 6 deaths (33% ) • 5 loss of reduction/nonunion (28% ) • 5 delayed surgery (28% ) • Overall major complication rate > 50% Muller, Eur Spine J, 1999

Conservative vs. Surgical • Type II Geriatric Odontoid Fractures (GOF) • Conservative treatment (retrospective, n= 19) vs. surgical treatment (prospective, n= 11) • Conservative cohort (halo vest) In-hospital mortality 42% • • Surgical cohort (C1-2 PCF) Ave. Charlson index> 4 (Expected 1 yr mortality≈35%) • In-hospital mortality 0% • 91% union, 1 asymptomatic nonunion • Bednar, JBJS, 1995 •

Molinari, Global S Spine J , 2013

Nonunion Leading to Myelopathy • Retrospective series, N= 49 • 9 patients treated conservatively developed nonunion (8 type II, 1 type III) • 5/9 developed myelopathy • 1/9 developed spontaneous neuro deficit • All 6 improved after subsequent PCF Anderson, JBJS, 1974

Nonunion Leading to Myelopathy • Retrospective series, n= 19 • C1-2 subluxation from fracture displacement • Progressive myelopathy • Treated surgically with reduction, PCF • 12/19 improved neurologically, rest stable Kirankumar, Neurosurgery, 2005

Presence of Instability Evaniew, Spine J J , 2015

What Are the Long Term Risks of Pseudarthrosis? 7/40 (17.5%) Patients with Non-Unions Presented with New Neuro Deficit (2 Sensory) Kepler, Spine J J , 2014

Odds ratio < 1 for surgical mortality favoring surgery Schroeder, Neuro rg , 2015 rosurg

Yang, Ort rg Res , 2015 rt hop Tra raum at ol Surg

The AOSpine North America Geriatric Odontoid Fracture Study: Mortality Outcomes in Surgical vs. Conservative Treatment in 322 Patients with Long Term Follow-up • Retrospective data review • Consecutive subjects > 65 yr treated for Type II Odontoid fractures • 322 patients. Long term follow up Chapman, Vaccaro, Spine 2013

The AOSpine North America Geriatric Odontoid Fracture Study: Mortality Outcomes in Surgical vs. Conservative Treatment in 322 Patients with Long Term Follow-up Overall Mortality Results Variable Expired (N=142) Alive (N=180) P-value Gender 0.013 Male 70 (52%) 64 (48%) Female 72 (38%) 116 (62%) Treatment 0.016 Operative 62 (38%) 103 (62%) Nonoperative 80 (51%) 77 (49%) 30 Day Mortality Results Variable Expired (N=46) Alive (N=276) P-value Gender 0.7119 Male 18 (13%) 116 (87%) Female 28 (15%) 160 (85%) Treatment <.0001 Operative 11 (7%) 154 (93%) Nonoperative 35 (22%) 122 (78%)

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study Prospective multi-center cohort study of 159 subjects > • 65 yrs old with a Type II odontoid fracture at 13 sites in North America. Patients received non-operative or surgical treatment at • the discretion of the surgical team Followed for 12 months, or until expired, whatever • occurred first. Outcomes assessments included the SF36, Neck • Disability Index (NDI) and rates of mortality and complications. Vaccaro, JBJS, 2013

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study Type of Treatment • Surgical treatment (patients) 101 ( 63.5%) 12 (11.9%) Anterior Odontoid Screw Posterior C1- C2 Screw Fixation 80 (79.2%) Posterior Transarticular Screw Fixation 7 (6.9%) Brooks Fusion C1-C2 Sublamina 1 (1.0%) Wire Placement Occipital-Cervical Fusion 1 (1.0%) • Conservative treatment 58 (36.5%) Soft Collar Immobilization 5 (8.6%) Hard Collar Immobilization 47 (81%) Halo Immobilization 6 (10.3%)

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study Treatment Related Complication Events Complication Type Surgical Conservative P-value Major complication events 17 17 Minor complication events 31 20 Total events 48 37 0.4805 Nonunion 5 (5%) 12 (20.7%) 0.003 Vaccaro, JBJS, 2013

Functional and Quality of Life Outcomes in Geriatric Patients with Type II Odontoid Fracture: One Year Results from the AOSpine North America Multi-Center GOF Prospective Study GOF Mortality Results P-value Conservative (N=57) Surgical (N=102) Mortality 15 patients (25.9%) .0512 14 patients (13.9%) (29 patients) Vaccaro, JBJS, 2013

Case Example • 70 yr old female fell from standing height • No neurologic deficits

Case Example • C1-C2 fusion • Discharged from hospital • Doing well 1 year post-op

Case Example 85 yr old female fell from • standing height Initial nondisplaced type • II odontoid fx Collar immobilization • Displaced at 6wks • Collar decubiti - elected • observation Lost ability to ambulate at • 3 mo post fx

Summary Patients treated • operatively have a Decrease in short term • mortality Decrease in mortality at • one year Increased HRQOL • metrics

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