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Mortality in Elderly Patients After Cervical Spine Fractures
Mitchel B. Harris, MD1; William M. Reichmann, MA1; Christopher M. Bono, MD1; Kim Bouchard, BA1; Kelly L. Corbett, BA1; Natalie Warholic, MA1; Josef B. Simon, MD1; Andrew J. Schoenfeld, MD1; Lawrence Maciolek, MD1; Paul Corsello, BA1; Elena Losina, PhD1; Jeffrey N. Katz, MD, MSc1
1 Department of Orthopedic Surgery (M.B.H., W.M.R., C.M.B., K.B., K.L.C., N.W., J.B.S., A.J.S., L.M., P.C., E.L., and J.N.K.), and the Division of Rheumatology, Immunology and Allergy (J.N.K.), Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for M.B. Harris: mbharris@partners.org
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Program for Research Incubation and Development, Department of Orthopedic Surgery, Brigham and Women's Hospital; the National Institutes of Health (P60 AR 47782 and K24 AR 02123); Synthes Spine; Stryker; DePuy; and Medtronic; and less than $10,000 from the Massachusetts Arthritis Foundation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopedic Surgery and the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Mar 01;92(3):567-574. doi: 10.2106/JBJS.I.00003
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Abstract

Background: 

Despite an increased risk of cervical spine fractures in older patients, little is known about the mortality associated with these fractures and there is no consensus on the optimal treatment. The purposes of this study were to determine the three-month and one-year mortality associated with cervical spine fractures in patients sixty-five years of age or older and to evaluate potential factors that may influence mortality.

Methods: 

We performed a retrospective review of all cervical spine fractures in patients sixty-five years of age or older from 1991 to 2006 at two institutions. Information regarding age, sex, race, treatment type, neurological involvement, injury mechanism, comorbidity, and mortality were collected. Overall risk of mortality and mortality stratified by the above factors were calculated at three months and one year. Cox proportional-hazard regression was performed to identify independent correlates of mortality.

Results: 

Six hundred and forty patients were included in our analysis. The mean age was eighty years (range, sixty-five to 101 years). Two hundred and ninety-four patients (46%) were male, and 116 (18%) were nonwhite. The risk of mortality was 19% at three months and 28% at one year. The effect of treatment on mortality varied with age at three months (p for interaction = 0.03) but not at one year (p for interaction = 0.08), with operative treatment being associated with less mortality for those between the ages of sixty-five and seventy-four years. A higher Charlson comorbidity score, male sex, and neurological involvement were all associated with increased risk of mortality.

Conclusions: 

Operative treatment of cervical spine fractures is associated with a lower mortality rate at three months but not at one year postoperatively for patients between sixty-five and seventy-four years old at the time of fracture.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mitchel Harris, MD, FACS
    Posted on April 12, 2010
    Dr. Harris and Mr. Reichmann respond to Dr. Rahimi-Movaghar and colleagues
    Brigham and Women's Hospital, Boston, Massachusetts

    Thank you for acknowledging our contribution to the current literature on the factors associated with mortality in elderly patients who have sustained cervical spine fractures. As you point out, there are many factors, both subtle and obvious, that make such an analysis both challenging and difficult. Thus we were quite fortunate to have access to such a rich database that facilitated creating a study cohort of 640 patients, all 65 years of age or older who had sustained a cervical spine fracture.

    Unfortunately, as stated in our discussion section (p 573), this study was NOT designed to compare mortality rates with those in a matched cohort without cervical spine fractures. We whole-heartedly agree that identifying the proximate cause of death would have been beneficial. However, in a retrospective analysis this was often impossible. Similarly, being able to more clearly identify the factors that the surgeon utilized to determine operative versus non-operative management would have been valuable information. In the referral medical centers in which we practice, and thus the database reflects, the reasons for transfer are often "failure of initial management". Whether the initial management attempt was operative or non-operative, this subtle recorded caveat further complicated our initial attempt to extract the surgical indication from the medical record.

    Finally, your question about utilizing a 30 day mortality risk ratherthan a three-month mortality risk merits some discussion. In previous publications, "early mortality" has been describes as within 30 days (ref #10 in our paper) or during initial hospitalization (refs #14, 15). We choose 3 months as it felt like a more practical approach. When discussing the management of spinal injuries in non-geriatric trauma victims, if non-operative management is selected, often a collar is worn initially, followed by a period of controlled mobilization while the collar is weaned. We wanted to be able to discuss with the patient and their family members what effect surgery versus non-operative management would have on mortality risks. Our results suggest a protective effect of surgical stabilization in the patients between the ages of 65 and 74 years (Hazard ratio = .4) whereas there was no such effect seen in the more elderly patients. When we re-analyzed the data at your request to assess 30 day mortality risk, there was no difference relative to our study results (Table 1).

    Table 1: One Month Mortality Rates by Specified Risk Factors
     
    1-Month Mortality Risk
    (95% Confidence Interval)
    Overall
    12.8% (10.2%, 15.4%)
    Age
      65-74
    8.4% (4.6%, 12.2%)
      75-84
    11.0% (7.1%, 14.9%)
      85+
    19.7% (14.1%, 25.3%)
    Treatment
      Operative
    6.2% (1.8%, 10.6%)
      Nonoperative
    14.2% (11.2%, 17.2%)
    Age/Treatment*
      65-74/Operative
    0.0% (0.0%, 7.1%)
      65-74/Nonoperative
    10.6% (5.9%, 15.4%)
      75-84/Operative
    2.3% (0.00%, 6.7%)
      75-84/Nonoperative
    12.9% (8.3%, 17.6%)
      85+/Operative
    22.2% (6.5%, 37.9%)
      85+/Nonoperative
    19.3% (13.3%, 25.3%)
    *Breslow-Day p-value for the test of interaction = .02

    Thank you again for highlighting the important contribution of this paper.

    Vafa Rahimi-Movaghar
    Posted on March 14, 2010
    Mortality in Elderly Patients After Cervical Spine Fractures
    Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran

    To the Editor:

    We read with great interest the article by Harris et al. (1). The authors evaluated probable determinants of mortality in elderly patients following cervical spine fracture. Multivariate analysis showed surgery between 65 and 74 years has a Hazard Ratio (HR) of 0.2 with a 95% confidence interval (CI) from 0.2 to 0.8. In fact, the study raises the hypothesis that surgical intervention probably is not as effective as we expect in older patients with cervical spine fractures. The same finding has been reported regarding spinal cord injury in the elderly and some authors failed to show surgery is superior to conservative management in these patients (2). Although the study was not designed to compare the outcome of operative and conservative managements in these patients, the study has several limitations that make it difficult to interpret the results. Harris and colleagues (1) showed that mortality rate was not significantly different between operative and non-operative groups at 3 and 12 months, however, we believe that postoperative-related mortality usually occurs sooner, mainly during the first 30 postoperative days. Thus, reporting the first postoperative month could be more helpful.

    Some existing evidence suggests that patients with spine fractures have a higher relative risk of mortality in the long-term than the general population. Compared with participants who had no fracture during follow-up, those who had a vertebral fracture in the second year were at an increased risk of death (adjusted HR 2.7, 95% CI 1.1–6.6) (3). The higher risk persists after excluding metastatic spine fractures (4), which explains the high mortality rate in patients. In another study, the age standardized mortality ratio for vertebral fractures was 1•66 (1•51–1•80) and 2•38 (2•17–2•59) in women and men, respectively (5).

    The cause of death was not reported in these patients. The fact that in how many cases the cause of death could be explained in the context of pre-existing morbidities was important. The number of cases who had an absolute indication for surgical intervention due to unstable fractures was additional useful data that was not reported.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Harris MB, Reichmann WM, Bono CM, Bouchard K, Corbett KL, Warholic N, Simon JB, Schoenfeld AJ, Maciolek L, Corsello P, Losina E, Katz JN. Mortality in elderly patients after cervical spine fractures. J Bone Joint Surg Am. 2010;92:567-74.

    2. Sokolowski MJ, Jackson AP, Haak MH, Meyer PR Jr, Sokolowski MS. Acute mortality and complications of cervical spine injuries in the elderly at a single tertiary care center. J Spinal Disord Tech. 2007;20:352-6.

    3. Ioannidis G, Papaioannou A, Hopman WM, Akhtar-Danesh N, Anastassiades T, Pickard L, Kennedy CC, Prior JC, Olszynski WP, Davison KS, Goltzman D, Thabane L, Gafni A, Papadimitropoulos EA, Brown JP, Josse RG, Hanley DA, Adachi JD. Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ. 2009;181:265-71.

    4. Puisto V, Rissanen H, Heliövaara M, Knekt P, Helenius I. Mortality in the presence of a vertebral fracture, scoliosis, or Scheuermann's disease in the thoracic spine. Ann Epidemiol. 2008;18:595-601.

    5. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet. 1999;353:878-82.

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