Huybregts Jeroen G J, Barot Karma A, Recio Camila, Doucette Joanne, Mekary Rania A, Vleggeert-Lankamp Carmen L A
Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, PO Box 9600, 2300 RC, Leiden, The Netherlands.
Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands.
Eur Spine J. 2023 Oct;32(10):3434-3449. doi: 10.1007/s00586-023-07779-1. Epub 2023 Jul 13.
Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the outcome of surgical and conservative treatments in elderly (≥ 65 years), by updating a systematic review published by the authors in 2013.
A comprehensive search was conducted in seven databases. Clinical outcome was the primary outcome. Fracture union- and stability were secondary outcomes. Pooled point estimates and their respective 95% confidence intervals (CIs) were derived using the random-effects model. A random-effects multivariable meta-regression model was used to correct for baseline co-variates when sufficiently reported.
Forty-one studies met the inclusion criteria, of which forty were case series and one a cohort study. No clinical differences in outcomes including the Neck Disability Index (NDI, 700 patients), Visual Analogue Scale pain (VAS, 180 patients), and Smiley-Webster Scale (SWS, 231 patients) scores were identified between surgical and conservative treatments. However, fracture union was higher in surgically treated patients (pooled incidence 72.7%, 95% CI 66.1%, 78.5%, 31 studies, 988 patients) than in conservatively treated patients (40.2%, 95% CI 32.0%, 49.0%, 22 studies, 912 patients). This difference remained after correcting for age and fracture type. Fracture stability (41 studies, 1917 patients), although numerically favoring surgery, did not appear to differ between treatment groups.
While surgically treated patients showed higher union rates than conservatively treated patients, no clinically relevant differences were observed in NDI, VAS pain, and SWS scores and stability rates. These results need to be further confirmed in well-designed comparative studies with proper adjustment for confounding, such as age, fracture characteristics, and osteoporosis degree.
齿状突骨折是老年人中最常见的颈椎骨折，其最佳治疗方法存在争议。本综述的目的是通过更新作者在2013年发表的系统评价，比较老年（≥65岁）患者手术治疗和保守治疗的结果。
在七个数据库中进行了全面检索。临床结果是主要结局。骨折愈合和稳定性是次要结局。使用随机效应模型得出合并点估计值及其各自的95%置信区间（CI）。当有充分报告时，使用随机效应多变量meta回归模型对基线协变量进行校正。
41项研究符合纳入标准，其中40项为病例系列研究，1项为队列研究。手术治疗和保守治疗在包括颈部残疾指数（NDI，700例患者）、视觉模拟评分疼痛（VAS，180例患者）和斯迈利-韦伯斯特量表（SWS，231例患者）评分等结局方面未发现临床差异。然而，手术治疗患者的骨折愈合率（合并发生率72.7%，95%CI 66.1%，78.5%，31项研究，988例患者）高于保守治疗患者（40.2%，95%CI 32.0%，49.0%，22项研究，912例患者）。在校正年龄和骨折类型后，这种差异仍然存在。骨折稳定性（41项研究，1917例患者）虽然在数值上有利于手术，但在治疗组之间似乎没有差异。
虽然手术治疗患者的愈合率高于保守治疗患者，但在NDI、VAS疼痛、SWS评分和稳定率方面未观察到临床相关差异。这些结果需要在设计良好的比较研究中进一步证实，并对年龄、骨折特征和骨质疏松程度等混杂因素进行适当调整。
