Surgical Management of Acute Odontoid Fractures: : surgery-related complications and long-term outcomes in a consecutive series of 97 patients

Background: The purpose of this study was to determine the incidence of surgery for odontoid fractures and to study surgical mortality, surgical morbidity and long-term outcome in a large, contemporary, consecutive, single institution, surgical series of odontoid fractures. Methods: This is a retrospective study of all odontoid fractures treated by open surgery at our hospital during 2002–2009. The fractures were classified according to Grauer. Follow-up data, clinical examinations and cervical CTs were collected in 2010. Results: This study included 97 consecutive patients with a median age of 73.0 years. The incidence of open fixation of odontoid fractures in this population was 0.45 per 100.000, and the incidence increased with age. The fractures were classified as type IIA in 3 patients, type IIB in 63 patients, type IIC in 8 patients and type III in 23 patients. Anterior fixation and posterior fixation were performed in 41 and 56 patients, respectively. Immediate postoperative neurological status was unchanged or improved in 97% of the patients. None of the patients developed postoperative hematoma, wound infection, deep venous thrombosis or pulmonary embolism. Eleven patients underwent resurgery during the follow-up period; five had suboptimal reposition after the first surgery, one had suboptimal position of an anterior odontoid screw, two had rupture of fixation materials, and three developed pseudarthrosis. Overall survival (OS) rates after 1, 12 and 24 months were 96%, 84% and 75%, respectively. Fifty-seven patients were available for follow-up evaluation with a mean time of 37 months. Radiological follow-up showed definite bony fusion in 82% of the patients and uncertain bony fusion in 18% of the patients. Flexion-extension radiographs were obtained in six of the ten patients with uncertain bony fusion; five of these were defined as stable (fibrous union), and one was unstable. Multivariate logistic regression demonstrated increased odds of non-bony fusion in more displaced fractures (OR 1.44, 95% CI (1.04-2.16), p = 0.04) and when using the anterior fusion technique (OR 0.17, 95% CI (0.03-0.75), p = 0.02). There was no significant association between neck pain and fusion method (Mann-Whitney test, p = 0.86). Patients treated with a posterior fusion approach had significantly more neck stiffness than patients who underwent fusion with an anterior odontoid screw (Fisher test, p = 0.04). Conclusions: The annual incidence of open fixation of odontoid fractures was 0.45 per 100,000 inhabitants, and the incidence increased with age. Median age at time of surgery was 73.0 years, and the surgical mortality was 4%. Increased odds of non-bony fusion were observed in more displaced fractures and after anterior screw fixations. There were no significant differences between patients treated with anterior screw fixation versus posterior wiring with respect to neck pain, but patients fused with a posterior approach reported significantly more neck stiffness. Key words: Odontoid fracture, trauma, surgery, outcome, fusion rate

Management of acute odontoid fractures

Odontoid fracture (OFx) is the most common cervical fracture in the elderly population. Primary surgical fixation has been recommended for OFx type II and III with a major translation of the odontoid fragment and for all OFx type II in patients ≥50 years. This recommendation has been challenged due to the high surgical risk in these elderly, and often severely comorbid, patients. In a population-based cohort study, Rizvi et al estimated the incidence of traumatic OFx in Norway to be 2.8/100,000 persons/year. The majority of patients were elderly and often had severe comorbidities and dependent living. The compliance with current treatment recommendations was low, and the main deviation was underuse of surgery in patients with OFx type II. In an observational cohort study, Rizvi et al found that primary conservative treatment of elderly comorbid patients with OFx type II appears to be safe and should be regarded as good clinical practice. They also verified that nonsurgical treatment of OFx type III is still the preferred treatment in the majority of patients. These findings have implications for future treatment of patients with odontoid fracture

The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway

Aim: The aim of this study was to estimate the incidence of traumatic cervical spine fractures (CS-fx) in a general population. Background: The incidence of CS-fx in the general population is largely unknown. Methods: All CS-fx (C0/C1 to C7/Th1) patients diagnosed with cervical-CT in Southeast Norway (2.7 million inhabitants) during the time period from April 27, 2010-April 26, 2011 were prospectively registered in this observational cohort study. Results: Over a one-year period, 319 patients with CS-fx at one or more levels were registered, constituting an estimated incidence of 11.8/100,000/year. The median age of the patients was 56 years (range 4–101 years), and 68% were males. The relative incidence of CS-fx increased significantly with age. The trauma mechanisms were falls in 60%, motorized vehicle accidents in 21%, bicycling in 8%, diving in 4% and others in 7% of patients. Neurological status was normal in 79%, 5% had a radiculopathy, 8% had an incomplete spinal cord injury (SCI), 2% had a complete SCI, and neurological function could not be determined in 6%. The mortality rates after 1 and 3 months were 7 and 9%, respectively. Among 319 patients, 26.6% were treated with open surgery, 68.7% were treated with external immobilization with a stiff collar and 4.7% were considered stable and not in need of any specific treatment. The estimated incidence of surgically treated CS-fx in our population was 3.1/100,000/year. Conclusions: This study estimates the incidence of traumatic CS-fx in a general Norwegian population to be 11.8/100,000/year. A male predominance was observed and the incidence increased with increasing age. Falls were the most common trauma mechanism, and SCI was observed in 10%. The 1- and 3-month mortality rates were 7 and 9%, respectively. The incidence of open surgery for the fixation of CS-fx in this population was 3.1/100,000/year. Level of evidence: This is a prospective observational cohort study and level II-2 according to US Preventive Services Task Force. Keywords: Cervical vertebrae, Spinal fractures, Trauma, Incidence, Epidemiolog

Complications and long-term outcomes after open surgery for traumatic subaxial cervical spine fractures: a consecutive series of 303 patients

Background: Patient selection for surgical treatment of subaxial cervical spine fractures (S-CS-fx) may be challenging and is dependent on fracture morphology, the integrity of the discoligamentous complex, neurological status, comorbidity, risks of surgery and the expected long-term outcomes. The purpose of this study is to evaluate complications and long-term outcomes in a consecutive series of 303 patients with S-CS-fx treated with open surgical fixation. Methods: Medical charts were retrospectively reviewed. The surviving patients participated in a prospective long-term follow-up, including clinical history, physical examination and updated cervical CT. Patients with ankylosing spondylitis were excluded from this study. Results: The median patient age was 48 years (range 14.7–93.9), and 74 % were males. Preoperatively, 43 % had spinal cord injury (SCI), and 27 % exhibited isolated radiculopathy. The median time from injury to surgery was 2 days (range 0–136). The risks of SCI deterioration and new-onset radiculopathy after surgery were 2.0 % and 1.3 %, respectively. Surgical mortality (death within 30 days after surgery) was 2.3 %. The reoperation rate was 7.3 %. At the long-term follow-up conducted a median of 2.6 years after trauma (range 0.5–9.1), 256 (99.2 %) of the patients who had survived and were living in Norway participated. Of the patients with American Injury Severity Scale (AIS) A–D at presentation, 51 % had improved one or more AIS grades. At the time of follow-up, 89 % of the patients with preoperative radiculopathy were without symptoms. Furthermore, 11 % of the patients reported severe neck stiffness, 5 % reported severe neck pain (Visual Analog Scale (VAS) ≥7), 6 % reported hoarseness, and 9 % reported dysphagia at the follow-up. The stable fusion rate, as evaluated using cervical-CT, was 98 %. Conclusions: In this large consecutive series of patients with S-CS-fx treated with open surgical fixation, the surgical mortality was 2.3 %, the risk of neurological deterioration was 3.3 % and the reoperation rate (any cause) was 7.3 %. The neurological long-term results were good, with 51 % improvement in AIS grade and resolution of radiculopathy in 89 % of the patients. Stable fusion was excellent and was achieved in 98 % of the follow-up group. Keywords: Spinal fractures, Cervical vertebrae, Subaxial, Injuries, Surgery, Complications, Mortality, Outcom

Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients

BACKGROUND CONTEXT The surgical fixation rate of type II odontoid fracture (OFx) in the elderly (≥65 years) is much lower than expected if the treatment adheres to current general treatment recommendations. Outcome data after conservative treatment for elderly patients with these fractures are sparse. PURPOSE The main aim of this study was to determine the long-term outcome after conservative and surgical treatments of type II OFx (all age-groups) to evaluate whether nonoperative treatment yields an acceptable outcome. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred eighty-two consecutive patients with type II OFx treated at Oslo University Hospital over an 8-year period. OUTCOME MEASURES Long-term rates of bony fusion, fibrous union, pseudarthrosis, crossover from primary conservative treatment to surgical fixation, new-onset spinal cord injury (SCI), and neck pain were the outcome measures used. METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures. All ages were included. In addition, long-term follow-up of alive patients was performed during the years 2018–2019. The follow-up included neurological examination, radiological examination, and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new-onset SCI, neck pain, and Neck Disability Index (NDI score). Data are described by counts, percentages, medians, means, ranges and standard deviations where appropriate. For statistical analyses the Mann-Whitney U test, Wilcoxon signed-rank test, and t tests were used. RESULTS During the eight-year study period, we registered 282 consecutive patients with type II OFx; 54% were males, patient age ranged from 15 to 101 years, 84% were ≥65 years of age (WHO definition of elderly), and 51% were ≥80 years of age. Severe comorbidities (American Society of Anesthesiologists, ASA ≥3) were seen in 67%, whereas nonindependent living was registered in 32%. Severe comorbidities and nonindependent living were significantly associated with increasing age (p<.001). SCI secondary to the OFx was seen in 5.3%. Primary treatment of the OFx was conservative (external immobilization alone) in 193 patients (68.4%), open surgical fixation in 87 patients (30.9%), and no treatment in two critically injured patients. At the time of long-term follow-up, 125 patients had died, nine patients declined the invitation to follow-up, and five patients did not respond. Thus, 143 patients were available for follow-up with a median follow-up time of 39 months (range 5–115 months). At long-term follow-up, the fusion status was bony fusion in 39.2% of patients, fibrous union in 57.3%, and pseudarthrosis in 3.5%. The proportion of bony fusion was significantly higher in the primary surgical fixation group (p=.005). No patients had new-onset SCI presenting after the start of primary treatment. The proportion of crossover from primary external immobilization to surgery was 14.4%, whereas proportion of revision surgery in the primary surgical group was 9.5%. There was no significant difference between the primary surgical fixation group and the primary conservative treatment group at long-term follow-up with respect to the proportion of pseudarthrosis and degree of neck pain. CONCLUSIONS Primary conservative treatment of elderly patients with type II OFx appears to be safe and should be regarded a viable treatment option

Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients

BACKGROUND CONTEXT The recommended primary treatment for type III odontoid fractures (OFx) is external immobilization, except for patients having major displacement of the odontoid fragment. The bony fusion rate of type III OFx has been reported to be >85%. High compliance to treatment recommendations is favorable only if the treatment leads to a good outcome. PURPOSE The primary aim of this study was to determine the long-term outcome after conservative and surgical treatment of type III OFx and to reaffirm that primary external immobilization is the best treatment for most type III fractures. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred twelve consecutive patients with type III OFx treated at Oslo University Hospital over an 8-year period (2009–2017). OUTCOME MEASURES Long-term rates of bony fusion, crossover from primary conservative treatment to surgical fixation, new onset spinal cord injury (SCI), severe persistent neck pain (visual analogue scale - VAS), and persistent disability measured with Neck Disability index (NDI). METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures from a general population. During the years 2018 to 2019 long-term follow-up of alive patients was performed (median follow-up time was 38.0 months; range 3.0–108.0 months). The follow-up included neurological examination, radiological examination and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new onset SCI, neck pain, and Neck Disability Index (NDI score). RESULTS In this consecutive series of 212 patients with type III acute OFx, median patient age was 72 years, 56% had severe preinjury comorbidities (ASA score ≥3) and 22% lived dependently. Severe comorbidities and dependent living were significantly associated with increasing age (p<.001). The trauma mechanism was fall injury in 82%. The median age of patients injured by falls was significantly higher than in patients with a nonfall injury (p<.001). At the time of diagnosis, 4% had an OFx related SCI. Primary treatment was external immobilization alone in 95.3% and open surgical fixation in 4.7%. Patients treated with primary external immobilization alone presented with significantly less translation of the odontoid fragment (p<.001) and less angulation of the odontoid fragment (p=.025) than patients treated with primary surgery. Subsequent crossover to surgical fixation was performed in 5.4%. At long-term follow-up, 95.7% of patients had bony fusion of the OFx, 80.5% had minimal/no neck pain, and none developed new onset SCI. There was no significant difference in long-term follow-up VAS (p=.444) or NDI (p=.562) between the primary external immobilization group and the primary surgical group. CONCLUSION This study reaffirms that nonsurgical treatment remains the preferable option in the majority of patients with type III OFx

Jeelo Dobara (Live Life Again): a cross-sectional survey to understand the use of social media and community experience and perceptions around COVID-19 vaccine uptake in three low vaccine uptake districts in Karachi, Pakistan

Objective To gather preliminary insights through formative research on social media usage, and experiences, attitudes and perceptions around COVID-19 and COVID-19 vaccination in three high-risk, underserved districts in Karachi, Pakistan.Design Cross-sectional mixed-method design.Participants 392 adults (361 surveys and 30 in-depth interviews (IDI)) from districts South, East and Korangi in Karachi, Pakistan.Main outcome measures Social media usage and knowledge, perception and behaviour towards COVID-19 infection and vaccination.Results Using social media was associated with an increased probability of getting vaccinated by 1.61 units. Most of the respondents (65%) reported using social media, mainly to watch videos and/or keep in touch with family/friends. 84.76% knew of COVID-19 while 88.37% knew about the COVID-19 vaccination, with 71.19% reported vaccine receipt; reasons to vaccinate included belief that vaccines protect from the virus, and vaccination being mandatory for work. However, only 56.7% of respondents believed they were at risk of disease. Of the 54 unvaccinated individuals, 27.78% did not vaccinate as they did not believe in COVID-19. Despite this, 78.38% of respondents scored high on vaccine confidence. In IDIs, most respondents knew about COVID-19 vaccines: ‘This vaccine will create immunity in your body. Therefore, I think we should get vaccinated’, and over half knew how COVID-19 spreads. Most considered COVID-19 a serious public health problem and thought it important that people get vaccinated. However, there was a low-risk perception of self as only a little over half felt that they were at risk of contracting COVID-19.Conclusion With our conflicting results regarding COVID-19 vaccine confidence, that is, high vaccine coverage but low perception of risk to self, it is likely that vaccine coverage is more a result of mandates and coercion than true vaccine confidence. Our findings imply that interactive social media could be valuable in fostering provaccine sentiment