Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
Spine J. 2021 Jul;21(7):1149-1158. doi: 10.1016/j.spinee.2021.02.003. Epub 2021 Feb 10.
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.
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.
Two hundred twelve consecutive patients with type III OFx treated at Oslo University Hospital over an 8-year period (2009-2017).
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).
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).
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.
This study reaffirms that nonsurgical treatment remains the preferable option in the majority of patients with type III OFx.
III 型齿状突骨折（OFx）的推荐主要治疗方法是外部固定，除非有齿状突骨折块的明显移位。III 型 OFx 的骨融合率已报道>85%。只有当治疗导致良好的结果时，治疗建议的高度依从性才是有利的。
本研究的主要目的是确定保守和手术治疗 III 型 OFx 的长期结果，并再次确认原发性外部固定是治疗大多数 III 型骨折的最佳方法。
研究设计/设置：基于前瞻性数据库的回顾性研究。
2009-2017 年期间在奥斯陆大学医院接受治疗的 212 例连续 III 型 OFx 患者。
骨融合的长期比率、从原发性保守治疗转为手术固定的交叉率、新发脊髓损伤（SCI）、严重持续性颈部疼痛（视觉模拟量表-VAS）和使用颈部残疾指数（NDI）测量的持续性残疾。
本研究基于我们一般人群急性颈椎骨折质量控制数据库中提取的数据。在 2018 年至 2019 年期间对存活患者进行了长期随访（中位随访时间为 38.0 个月；范围 3.0-108.0 个月）。随访包括神经学检查、影像学检查和骨融合状态评分、从原发性保守治疗转为手术固定、新发 SCI、颈部疼痛和颈部残疾指数（NDI 评分）。
在这一系列 212 例连续 III 型急性 OFx 患者中，中位患者年龄为 72 岁，56%有严重的术前合并症（ASA 评分≥3），22%生活依赖。严重合并症和生活依赖与年龄增长显著相关（p<.001）。创伤机制为 82%的跌倒损伤。跌倒损伤患者的中位年龄明显高于非跌倒损伤患者（p<.001）。在诊断时，有 4%的 OFx 相关 SCI。95.3%的患者接受单纯外部固定治疗，4.7%的患者接受开放性手术固定治疗。接受单纯外固定治疗的患者的齿状突骨折块移位明显较小（p<.001），齿状突骨折块成角明显较小（p=.025），与接受单纯手术治疗的患者相比。随后交叉到手术固定的比例为 5.4%。长期随访时，95.7%的患者 OFx 骨融合，80.5%的患者颈部疼痛最小/无，无新发 SCI。原发性外部固定组和原发性手术组在长期随访的 VAS（p=.444）或 NDI（p=.562）方面无显著差异。
本研究再次证实，非手术治疗仍然是大多数 III 型 OFx 患者的首选治疗方法。
