Original Research

Mortality Rates Associated With Odontoid and Subaxial Cervical Spine Fractures

Am J Orthop. 2015 June;44(6):E173-E179

Cervical spine fractures can lead to many devastating consequences. However, mortality rates of older individuals with odontoid or subaxial spine fractures have not been definitively established.

We conducted a retrospective review of all patients who underwent computed tomography of the cervical spine in the emergency department of a level I trauma center over 9 years to compare mortality rates after odontoid and subaxial fractures in elderly persons with those of the general population. We searched the National Death Index for patient death records, and compared mortality rates at 3 months, 1 year, and 2 years to sex- and age-matched data from the general population.

Odontoid fracture survival was 84.4% at 3 months, 82.2% at 1 year, and 72.9% at 2 years. Male survival was significantly worse compared with age- and sex-matched counterparts (P < .001), but female survival was not (P = .568). In subaxial fractures, survival was 87.9% at 3 months and 85.7% at 1 and 2 years. Male survival was decreased compared with age- and sex-matched counterparts (P < .0001), whereas female survival was not (P = .554).

In conclusion, the mortality of men with either fracture was greater compared with age-matched men initially, but this normalized. Female survival was not affected by either fracture.

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References

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Mortality rate is an important indicator of the severity of traumatic injuries, and these values have been described for different orthopedic injuries and fractures. Studies have identified 3 distinct trends in patient survival when compared with the age- and sex-matched uninjured population:

1. Hip fractures bring about a transient increase in mortality relative to age-matched controls that normalizes after a few months to 1 year.^1-10

2. Thoracic and lumbar compression fractures are associated with an ongoing, lifelong increase in mortality rate relative to age-matched controls without an initial marked upswing.^11-15

3. Certain injuries such as isolated rib or wrist fractures do not adversely affect survival relative to age-matched controls.^12,16-18

Understanding the mortality patterns after these injuries can help guide management and even facilitate the development of appropriate treatment algorithms.^19-21 While studies have examined mortality in specific odontoid fracture types,²² such mortality trends have not been broadly established in persons with cervical spine fractures.

Cervical spine fractures are common: 60% of spine fractures localize to this region,^23-26 and this equates to 2% to 3% of all blunt-trauma patients.^27,28 These injuries can lead to devastating consequences, including neurologic compromise, permanent disability, and death.^29-31

Studies have estimated that up to 20% of cervical fractures involve the odontoid process.^23-26 These injuries are more common among the elderly population because of their greater prevalence of osteoporosis and likelihood of falling.³² Because of demographic similarities to those of the hip fracture population, a survival analysis of all odontoid fractures is particularly interesting. Published odontoid mortality rates vary significantly, with reports ranging from 13% to 44%.^22,33-35 Unfortunately, these studies largely evaluated survival rates specific to an individual treatment modality, such as nonoperative compared with operative, or specific to certain odontoid fracture types (eg, type II). Additionally, studies have generally only considered survivorship during initial hospitalization, have been specific to a constrained age group, or have been based solely on inpatient records that do not permit the longer-term follow-up critical to determining the effect of odontoid fractures on overall mortality.^36-39

Likewise, mortality rates after fractures of the subaxial spine (ie, the motion segments between C3 and C7) have yet to be established. In 1 study, the mortality risk of a cohort of elderly patients with cervical fractures appeared to be elevated for the first 6 to 12 months after the traumatic event.⁴⁰ However, the sample size was too small to examine mortality beyond 1 year.

In this context, the purpose of the current study was to determine the mortality rates at several time points (3 months, 1 year, and 2 years) of patients 50 years or older (start of the second mode of the bimodal age distribution of odontoid fractures^41-44) with fractures of the odontoid and subaxial cervical spine. A secondary purpose of this study was to compare survival rates of these 2 cohorts relative to each other and to the general population.

Materials and Methods

Identification of Cervical Fractures and Collection of Demographic Information

This protocol was approved by the human investigation committee of our institution. Every computed tomography (CT) scan of the cervical spine performed in the emergency department (ED) of an academic hospital between November 27, 1997, and December 31, 2006, was identified. Since the threshold for obtaining a CT scan of a patient with suspected cervical spine trauma is relatively low, it was assumed that virtually all acute cervical spine fractures during this time period would be successfully identified through this approach.

Radiology reports for all identified CT scans were reviewed for any findings consistent with acute fractures and/or dislocations of the cervical spine (Figure 1). Every study noted to be positive or equivocal for cervical trauma was directly visualized, including those that did not specifically mention the presence or absence of an injury. Scans with no signs of acute trauma or that showed fractures caused by a pathologic process or penetrating mechanism (eg, metastatic lesions or gunshot wounds) were omitted from this series. Finally, relevant demographic information, such as the medical record number, age, gender, and date of study, was recorded for every subject in this group.

Fracture Classification

Next, the level and the type of cervical injury were documented for each patient. Fractures were segregated according to their involvement with the odontoid or the subaxial vertebrae.

Odontoid fractures were categorized into type I (limited to the tip), type II (across the base of the process) and type III (through the base with extension into the C2 vertebral body).^45,46 Since many systems for classifying subaxial cervical spine trauma require a subjective inference of the injury mechanism, which is difficult to ascertain from imaging studies alone, all of these fractures were pooled together.