1Department of Neurosurgery, University of Arizona, Tucson; and.
2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
J Neurosurg Spine. 2023 Sep 29;40(1):45-53. doi: 10.3171/2023.6.SPINE22920. Print 2024 Jan 1.
Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the inherently increased surgical risks in older patients. The objective of this study was to compare fusion rates and outcomes between operative and nonoperative treatments of type II odontoid fractures in the older population.
A systematic literature review was performed to identify studies reporting the management of type II odontoid fractures in patients older than 65 years from database inception to September 2022. A meta-analysis was performed to compare rates of fusion, stable and unstable nonunion, mortality, and complication.
Forty-six articles were included in the final review. There were 2822 patients included in the different studies (48.9% female, 51.1% male), with a mean ± SD age of 81.5 ± 3.6 years. Patients in the operative group were significantly younger than patients in the nonoperative group (81.5 ± 3.5 vs 83.4 ± 2.5 years, p < 0.001). The overall (operative and nonoperative patients) fusion rate was 52.9% (720/1361). The fusion rate was higher in patients who underwent surgery (74.3%) than in those who underwent nonoperative management (40.3%) (OR 4.27, 95% CI 3.36-5.44). The likelihood of stable or unstable nonunion was lower in patients who underwent surgery (OR 0.37, 95% CI 0.28-0.49 vs OR 0.32, 95% CI 0.22-0.47). Overall, 4.8% (46/964) of nonoperatively managed patients subsequently required surgery due to treatment failure. Patient mortality across all studies was 16.6% (452/2721), lower in the operative cohort (13.2%) than the nonoperative cohort (19.0%) (OR 0.64, 95% CI 0.52-0.80). Complications were more likely in patients who underwent surgery (26.0% vs 18.5%) (OR 1.55, 95% CI 1.23-1.95). Length of stay was also higher with surgery (13.6 ± 3.8 vs 8.1 ± 1.9 days, p < 0.001).
Patients older than 65 years of age with type II odontoid fractures had higher fusion rates when treated with surgery and higher stable nonunion rates when managed nonoperatively. Complications and length of stay were higher in the surgical cohort. Mortality rates were lower in patients managed with surgery, but this phenomenon could be related to surgical selection bias. Fewer than 5% of patients who underwent nonoperative treatment required revision surgery due to treatment failure, suggesting that stable nonunion is an acceptable treatment goal.
寰椎骨折是 65 岁以上成年人中最常见的颈椎骨折。由于老年患者手术风险增加，骨折的治疗仍存在争议。本研究的目的是比较手术和非手术治疗Ⅱ型齿状突骨折在老年人群中的融合率和结果。
从数据库建立到 2022 年 9 月，进行了系统的文献回顾，以确定报告 65 岁以上患者Ⅱ型齿状突骨折治疗的研究。进行了荟萃分析，以比较融合率、稳定和不稳定非融合、死亡率和并发症。
最终综述纳入了 46 篇文章。不同研究中共有 2822 例患者（48.9%女性，51.1%男性），平均年龄±标准差为 81.5±3.6 岁。手术组患者明显比非手术组年轻（81.5±3.5 岁比 83.4±2.5 岁，p<0.001）。总体（手术和非手术患者）融合率为 52.9%（720/1361）。手术组的融合率（74.3%）明显高于非手术组（40.3%）（OR 4.27，95%CI 3.36-5.44）。手术组稳定或不稳定非融合的可能性较低（OR 0.37，95%CI 0.28-0.49 比 OR 0.32，95%CI 0.22-0.47）。总体而言，4.8%（46/964）非手术治疗的患者因治疗失败后需要手术。所有研究的患者死亡率为 16.6%（452/2721），手术组（13.2%）低于非手术组（19.0%）（OR 0.64，95%CI 0.52-0.80）。手术组的并发症更常见（26.0%比 18.5%）（OR 1.55，95%CI 1.23-1.95）。手术组的住院时间也更长（13.6±3.8 天比 8.1±1.9 天，p<0.001）。
65 岁以上的Ⅱ型齿状突骨折患者，手术治疗的融合率更高，非手术治疗的稳定非融合率更高。手术组的并发症和住院时间更长。手术组的死亡率较低，但这种现象可能与手术选择偏倚有关。不到 5%的非手术治疗患者因治疗失败需要再次手术，这表明稳定的非融合是可以接受的治疗目标。
