Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA.
J Bone Joint Surg Am. 2013 Apr 17;95(8):729-35. doi: 10.2106/JBJS.K.01636.
Dens fractures are relatively common in the elderly. The treatment of Type-II dens fractures remains controversial. The aim of this multicenter prospective cohort study was to compare outcomes (assessed with use of validated clinical measures) and complications of nonsurgical and surgical treatment of Type-II dens fractures in patients sixty-five years of age or older.
One hundred and fifty-nine patients with a Type-II dens fracture were enrolled in a multicenter prospective study. Subjects were treated either surgically (n = 101) or nonsurgically (n = 58) as determined by the treatment preferences of the treating physicians and the patients. The subjects were followed at six and twelve months with validated outcome measures, including the Neck Disability Index (NDI) and Short Form-36v2 (SF-36v2). Treatment complications were prospectively recorded. Statistical analysis was performed to compare outcome measures before and after adjustment for confounding variables.
The two groups were similar with regard to baseline characteristics. The most common surgical treatment was posterior C1-C2 arthrodesis (eighty of 101, or 79%) while the most common nonsurgical treatment was immobilization with use of a hard collar (forty-seven of fifty-eight, or 81%). The overall mortality rate was 18% over the twelve-month follow-up period. At twelve months, the NDI had increased (worsened) by 14.7 points in the nonsurgical cohort (p < 0.0001) compared with a nonsignificant increase (worsening) of 5.7 points in the surgical group (p = 0.0555). The surgical group had significantly better outcomes as measured by the NDI and SF-36v2 Bodily Pain dimension compared with the nonsurgical group, and these differences persisted after adjustment. There was no difference in the overall rate of complications, but the surgical group had a significantly lower rate of nonunion (5% versus 21% in the nonsurgical group; p = 0.0033). Mortality was higher in the nonsurgical group compared with the surgical group (annual mortality rates of 26% and 14%, respectively; p = 0.059).
We demonstrated a significant benefit with surgical treatment of dens fractures as measured by the NDI, a disease-specific functional outcome measure. As a result of the nonrandomized nature of the study, the results are vulnerable to the effects of possible residual confounding. We recommend that elderly patients with a Type-II dens fracture who are healthy enough for general anesthesia be considered for surgical stabilization to improve functional outcome as well as the union and fusion rates.
老年人中椎骨骨折较为常见。对于 II 型齿状突骨折的治疗仍存在争议。本多中心前瞻性队列研究的目的是比较 65 岁及以上患者非手术和手术治疗 II 型齿状突骨折的结局（使用经过验证的临床指标评估）和并发症。
159 例 II 型齿状突骨折患者入组本多中心前瞻性研究。根据治疗医生和患者的治疗偏好，患者接受手术（n=101）或非手术（n=58）治疗。通过经过验证的结局指标，包括颈椎残障指数（NDI）和简明健康调查量表 36 简表第二版（SF-36v2），在 6 个月和 12 个月时对患者进行随访。前瞻性记录治疗并发症。进行统计分析以比较在调整混杂变量后之前和之后的结局指标。
两组患者的基线特征相似。最常见的手术治疗是后路 C1-C2 融合术（101 例中的 80 例，占 79%），最常见的非手术治疗是使用硬领固定（58 例中的 47 例，占 81%）。在 12 个月的随访期间，总死亡率为 18%。在非手术组中，NDI 在 12 个月时增加（恶化）了 14.7 分（p<0.0001），而手术组中 NDI 增加（恶化）了 5.7 分（p=0.0555），无显著差异。与非手术组相比，手术组的 NDI 和简明健康调查量表 36 简表第二版身体疼痛维度的结局明显更好，且这些差异在调整后仍然存在。两组并发症的总体发生率无差异，但手术组的不愈合率明显较低（5%与非手术组的 21%；p=0.0033）。与手术组相比，非手术组的死亡率更高（年死亡率分别为 26%和 14%；p=0.059）。
我们通过颈椎残障指数（一种疾病特异性功能结局指标）证实了手术治疗齿状突骨折的显著益处。由于研究的非随机性质，结果易受可能的残余混杂因素的影响。我们建议，对于足够健康接受全身麻醉的 II 型齿状突骨折老年患者，应考虑手术稳定以改善功能结局以及愈合和融合率。
