Patel Amit, Zakaria Rasheed, Al-Mahfoudh Rafid, Clark Simon, Barrett Chris, Sarsam Zaid, Pillay Robin, Pigott Tim Drummond, Wilby Martin J
Department of Neurosurgery, The Walton Centre NHS Foundation Trust , Liverpool , UK.
Br J Neurosurg. 2015 Apr;29(2):249-53. doi: 10.3109/02688697.2014.958055. Epub 2014 Sep 18.
The optimal management of odontoid fractures in the elderly population is unclear and management of this group of patients is complicated by multiple co-morbidities. This study aimed to determine the outcomes after conservative management strategies were applied in this patient group.
We carried out retrospective and prospective analyses of all patients with axial cervical spine injuries, at a single centre. We included patients aged over 60 years with type II and III odontoid fractures. Information was gathered on demographics, ASA grading-associated injuries and complications. The outcome measures were rates and type of union, pain and neurological functions, specifically ambulation.
Fifty-seven adult patients with a median age of 78 years (range 60-92 years) were included. There were 42 type II and 15 type III odontoid fractures. Three patients required surgical fixation due to displaced fractures, which could not be reduced with manual traction. Twenty-four (41%) patients were managed with a rigid pinned halo orthosis to obtain adequate reduction and immobilisation. The remaining 30 (53%) were managed in a hard cervical collar. Patients managed with a halo were significantly younger and had more associated injuries than patients managed in a collar (age: t-test=4.05, p<0.01, associated injuries: Chi-square=4.38, p<0.05). At a mean follow-up of 25 weeks, 87% of type II and 100% of type III fractures had achieved bony union or stable, fibrous non-union. There were no statistical differences in fracture type, follow-up or neurological outcomes between the halo and collar groups. However, overall more patients managed in a collar developed stable fibrous non-union than bony fusion (Fisher's exact test, p<0.05), although this was not significant when analysed by each fracture type individually. A regression model was constructed and identified fracture type as the only independent predictor of time to union, with type III fractures healing faster than type II.
High rates of bony union and stable fibrous non-union with a good functional outcome can be achieved in the elderly population sustaining type II or III odontoid fractures, when managed non-surgically. Halo orthosis may not offer any clear advantage over hard collar in this group. Close follow-up is needed for late complications and there must be a willingness to perform surgery if conservative measures fail.
老年人群齿状突骨折的最佳治疗方法尚不清楚，且这类患者的治疗因多种合并症而变得复杂。本研究旨在确定对该患者群体应用保守治疗策略后的结果。
我们在单一中心对所有颈椎轴性损伤患者进行了回顾性和前瞻性分析。我们纳入了60岁以上的II型和III型齿状突骨折患者。收集了人口统计学、与美国麻醉医师协会（ASA）分级相关的损伤和并发症信息。结局指标为愈合率及类型、疼痛和神经功能，特别是行走能力。
纳入了57例成年患者，中位年龄为78岁（范围60 - 92岁）。有42例II型和15例III型齿状突骨折。3例患者因骨折移位需要手术固定，手法牵引无法复位。24例（41%）患者采用刚性带针 Halo 支具治疗以获得充分复位和固定。其余30例（53%）采用硬颈托治疗。采用 Halo 支具治疗的患者比采用颈托治疗的患者明显更年轻且合并伤更多（年龄：t检验 = 4.05，p < 0.01；合并伤：卡方检验 = 4.38，p < 0.05）。平均随访25周时，87%的II型骨折和100%的III型骨折实现了骨愈合或稳定的纤维性不愈合。Halo 支具组和颈托组在骨折类型、随访或神经学结局方面无统计学差异。然而，总体而言，采用颈托治疗的患者发生稳定纤维性不愈合的比骨融合的更多（Fisher精确检验，p < 0.05），尽管按每种骨折类型单独分析时这并不显著。构建了一个回归模型，确定骨折类型是愈合时间的唯一独立预测因素，III型骨折比II型骨折愈合更快。
对于遭受II型或III型齿状突骨折的老年人群，非手术治疗可实现较高的骨愈合率和稳定的纤维性不愈合率，并获得良好的功能结局。在该群体中，Halo 支具可能并不比硬颈托具有明显优势。需要密切随访以观察晚期并发症，并且如果保守措施失败，必须愿意进行手术。
