Frangen Thomas M, Zilkens Christoph, Muhr Gert, Schinkel Christian
Department of Surgery, Kliniken Bergmannsheil, Ruhr University, Bochum, Germany.
J Trauma. 2007 Jul;63(1):83-9. doi: 10.1097/TA.0b013e318060d2b9.
Odontoid fractures in geriatric patients occur frequently and are associated with a high morbidity and mortality. The decision for operative or nonoperative therapy is still controversial. Recent studies confirmed that external stabilization with halo-vest immobilization is associated with high complication rates and mortality. An operation has a high perioperative risk because of comorbidities, but previous data suggest improved outcome in this group.
To test this hypothesis, we retrospectively analyzed geriatric patients that underwent operation for isolated unstable type II odontoid fractures (Anderson and D'Alonzo classification) in our institution between March 2003 and March 2005. Twenty-seven patients (17 female, 10 male) with a median age of 85.5 (range, 63-98) years were stabilized by posterior C1/C2 fusion with transarticular screws and an additional modified Gallie fusion with a bone graft. Postoperatively, a rigid cervical collar was applied for 6 to 12 weeks.
Six patients died during the observation period (median, 40 days after trauma). Three patients (11%) died perioperatively (cardiac or pulmonary failure, pneumonia), and the other three died as a result of the same after discharge. All 21 surviving patients were reevaluated an average of 3 months after trauma. All but one showed a stable fusion, and all reported no or minor neck pain. No wound infections occurred; one reoperation was necessary for screw misplacement. An initial neurologic deficit improved in two of three cases. Patients were mobilized on day 1 after operation. About two-thirds of patients were discharged directly home.
Posterior stabilization of unstable odontoid fractures with transarticular screws and modified Gallie fusion in old patients can be performed safely, with good clinical results and few complications. However, mortality remains high, but is lower than reported after halo-vest immobilization alone. Dorsal C1/C2 Fusion is superior to halo-vest immobilization in terms of nonunion rate and mortality. Thus, it might be the treatment of choice in this high-risk patient population.
老年患者齿状突骨折频发，且发病率和死亡率较高。手术治疗还是非手术治疗的决策仍存在争议。近期研究证实，头环背心固定的外固定治疗并发症发生率和死亡率较高。由于并存疾病，手术具有较高的围手术期风险，但既往数据表明该组患者的预后有所改善。
为验证这一假设，我们回顾性分析了2003年3月至2005年3月间在我院接受手术治疗孤立性不稳定II型齿状突骨折（Anderson和D’Alonzo分类）的老年患者。27例患者（17例女性，10例男性），中位年龄85.5岁（范围63 - 98岁），通过经关节螺钉进行C1/C2后路融合及附加改良Gallie融合并植骨实现稳定。术后，佩戴硬质颈托6至12周。
6例患者在观察期内死亡（中位时间为创伤后40天）。3例患者（11%）围手术期死亡（心功能或肺功能衰竭、肺炎），另外3例在出院后因同样原因死亡。所有21例存活患者在创伤后平均3个月接受重新评估。除1例患者外，其余均显示融合稳定，且所有患者均报告无颈部疼痛或仅有轻微颈部疼痛。未发生伤口感染；因螺钉位置不当进行了1次再次手术。3例初始存在神经功能缺损的患者中有2例得到改善。患者术后第1天即可活动。约三分之二的患者直接出院回家。
老年患者经关节螺钉和改良Gallie融合对不稳定齿状突骨折进行后路稳定治疗可安全实施，临床效果良好且并发症较少。然而，死亡率仍然较高，但低于单独采用头环背心固定治疗后的报告。就不愈合率和死亡率而言，C1/C2后路融合优于头环背心固定。因此，它可能是这类高危患者群体的首选治疗方法。
