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Surgical treatment improves survival of elderly with axis fracture: a national population-based multi-registry cohort study
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Stockholm Spine Center, Löwenströmska Sjukhuset, 194 89 Upplands-Väsby, Sweden.ORCID iD: 0000-0002-0705-033X
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.ORCID iD: 0000-0002-2111-6868
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Department of Research and Development, Swedish Armed Forces Centre for Defence Medicine, Box 5155, 425 05 Västra Frölunda, Sweden.ORCID iD: 0000-0002-2724-6372
2018 (English)In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 18, p. 1853-1860Article in journal (Refereed) Published
Abstract [en]

Background Context

Fractures of the axis (C2) are the most common cervical spinal injuries in the elderly population. Several authors have reported improved survival among elderly patients with C2 fractures when treated surgically.

Purpose

We aimed to analyze whether surgery improves survival of elderly with C2 fractures.

Study Design/Setting

An observational population-based longitudinal multi-registry study was carried out.

Patient Sample

Swedish Patient Registry 1997 to 2014 and Swedish Cause of Death Registry 1997 to 2014 served as source of patient sample.

Outcome measures

Survival after C2 fracture according to non-surgical and surgical treatment was the outcome measure.

Methods

We included all patients treated for the primary diagnosis of C2 fracture (10th revision of the International Statistical Classification of Diseases and Related Health Problems or ICD-10: S12.1) at an age ≥70 years and receiving treatment at a health-care facility. Non-surgical treatment comprises cervical collar or halo-vest treatment. Surgical treatment was identified in the Swedish patient registry extract using the Swedish classification of procedural codes. Survival was determined using the Kaplan-Meier method. Comorbidity was determined using the Charlson Comorbidity Index.

Results

Of the included 3,375 elderly patients with C2 fractures (43% men, aged 83±7 years), 22% were treated surgically. Surgical treatment was assigned based on age, gender, and year of treatment. The 1-year survival of 2,618 non-surgically treated patients was 72% (n=1,856), and 81% (n=614) for the 757 surgically treated (p<.001, relative risk reduction=11%). Adjusted for age, gender, comorbidity, and year of injury, surgically treated patients had greater survival than non-surgically treated patients (hazard ratio=0.88, 95% confidence interval: 0.79–0.97). Among those above 88 years of age (95% confidence interval: 85–92), surgical treatment lost its effect on survival.

Conclusions

Despite the frailty of elderly patients, the morbidity of cervical external immobilization with a rigid collar seemingly weighs greater than surgical morbidity, even in octogenarians. For those above 88 years of age, non-surgical treatment should be primarily attempted.

Place, publisher, year, edition, pages
2018. Vol. 18, p. 1853-1860
Keywords [en]
Axis fractures, odontoid fractures, surgical treatment, mortality, elderly, spinal fractures
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:uu:diva-333896DOI: 10.1016/j.spinee.2018.03.021ISI: 000449830800015PubMedID: 29649609OAI: oai:DiVA.org:uu-333896DiVA, id: diva2:1158221
Available from: 2017-11-18 Created: 2017-11-18 Last updated: 2018-12-21Bibliographically approved
In thesis
1. Axis Fractures in Elderly: Epidemiology and Treatment related outcome
Open this publication in new window or tab >>Axis Fractures in Elderly: Epidemiology and Treatment related outcome
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Axis fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. Knowledge of the incidence of these fractures, as well as their treatment, outcome and mortality rate, will improve knowledge and decision-making processes for this fragile group of patients.

Objectives: This thesis aims (1) to review the literature on the non-surgical and surgical treatment of odontoid fractures type 2 in the elderly population, (2) to provide an updated overview of axis fracture subtypes, their incidence and their treatment in a cohort in two university cities, (3) to map the incidence of fractures and the treatment of these patients in Sweden, (4) to investigate the effect on mortality of both the surgical and non-surgical treatment of axis fractures and (5) to present the protocol for a randomized controlled trial (RCT) on the treatment of odontoid fractures type 2 in the elderly population.

Methods: A systematic review was performed using the MeSH keywords “odontoid AND fracture AND elderly”. The data for the cohort study were extracted from the regional hospital information system. The radiographs were reviewed retrospectively. Data were extracted from the Swedish National Patient Registry (NPR) and the mortality registry for the national registry studies. Finally, the RCT protocol was carried out according to the SPIRIT and CONSORT statements for clinical trial reporting.

Results and conclusions: So far, there has been a scarcity of existing evidence on treatment of odontoid fractures type 2 in the elderly population. In this thesis, we found in two university cities an increased incidence, and a trend towards more surgical treatment of type 2 and 3 odontoid fractures 2002-2014. Between 1997 and 2014 in Sweden, there was an increasing incidence of C2 fractures, but the treatment trend went towards more non-surgical treatment. Surgically treated patients had a greater survival rate than non-surgically treated patients. Among those over 88 years of age, surgical treatment lost its effect on survival. In the RCT we will study the function of patients with odontoid fractures type 2 and by comparing non-surgical treatment with posterior C1-C2 fusion, the cost-effectiveness of the treatment options.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 84
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1399
Keywords
odontoid fracture, treatment, elderly, cervical spine, axis fracture
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-333901 (URN)978-91-513-0163-1 (ISBN)
Public defence
2018-01-12, Gunnesalen, Ing 10, Psykiatrins hus, Sjukhusvägen, Uppsala, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-12-21 Created: 2017-11-22 Last updated: 2018-03-08

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Robinson, Anna-LenaOlerud, ClaesRobinson, Yohan

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