The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 8

Scientific Articles | August 01, 2007

Surgical Treatment of Dens Fractures in Elderly Patients

Patrick Platzer, MD¹; Gerhild Thalhammer, MD¹; Gerhard Oberleitner, MD¹; Rupert Schuster, MD¹; Vilmos Vécsei, MD¹; Christian Gaebler, MD¹

¹ Department for Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria. E-mail address for P. Platzer: patrick.platzer@gmx.at

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Disclosure: 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. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department for Traumatology, Medical University of Vienna, Vienna, Austria

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Aug 01;89(8):1716-1722. doi: 10.2106/JBJS.F.00968

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Abstract

Background: A dens fracture is the most common cervical fracture in elderly patients. The purposes of this study were to analyze the functional and radiographic results after surgical treatment of dens fractures in patients over sixty-five years of age and to compare the two methods that were used for operative treatment.

Methods: We reviewed the cases of fifty-six patients, with an average age of 71.4 years at the time of surgery, who had undergone surgical treatment of a dens fracture from 1988 to 2002. Thirty-seven fractures were stabilized with anterior screw fixation, and nineteen fractures had posterior cervical arthrodesis.

Results: Forty-five patients returned to their preinjury activity level and were satisfied with their treatment. Thirty-five patients had a full range of neck movement, and forty-seven patients were free of pain. Technical failures occurred in eight patients. The thirty-seven patients treated with anterior screw fixation had a good clinical outcome, with fracture-healing in thirty-three patients (89%) and technical failure in five patients (14%). All nineteen patients treated with posterior cervical arthrodesis had fracture union, with technical failure in three patients, but the functional results were worse than those after anterior screw fixation. With the inclusion of the six patients who had been excluded from the clinical and radiographic review, the overall morbidity rate was 16% (ten of sixty-two patients) and the overall mortality rate was 6% (four of sixty-two patients).

Conclusions: A satisfactory outcome can be achieved with surgical treatment of a dens fracture in geriatric patients. It appears that anterior screw fixation may maintain better mobility of the cervical spine, but it appears to be associated with a higher rate of fracture nonunion and a greater potential for reoperation.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Dens fractures account for 5% to 15% of all cervical spine injuries, with an increasing rate in elderly patients^1-3. In persons who are more than sixty-five years old, these injuries comprise the majority of cervical spine fractures^1,3,4. Although dens fractures have been the subject of many investigations, few studies have focused on geriatric patients.

There is a lack of agreement on the best treatment of these fractures, particularly in older patients^1,3. Immobilization for several weeks with use of a halo-vest or a rigid cervical collar has been reported to be an acceptable approach, but it is associated with a high risk of nonunion^5-7. Surgical treatment either by anterior screw fixation or posterior cervical (C1-C2) arthrodesis has a high success rate in younger patients^8-14. However, there have been concerns with regard to increased morbidity and mortality in geriatric patients following surgical treatment^2,15.

The purposes of this study were to determine the long-term functional and radiographic results in patients over sixty-five years of age after surgical stabilization of dens fractures and to analyze the two methods (anterior screw fixation and posterior cervical arthrodesis) that were used for the operative treatment in these patients.

Materials and Methods

Materials and Methods | Results | Discussion | References

We reviewed the clinical records and trauma database of Vienna General Hospital, Medical University of Vienna, and identified 233 trauma patients with dens fractures who were admitted to this level-I trauma center from 1988 to 2002. Patients who had had surgical treatment of a dens fracture were selected, and their clinical records were examined for completeness and accuracy. Those with complete sets of clinical records and who were over sixty-five years of age at the time of injury were enrolled in this study. Exclusion criteria were patients with incomplete records as well as patients with a penetrating mechanism of injury or a congenital cervical spine anomaly. From a database of 233 trauma patients with a dens fracture, we identified 139 who underwent surgical treatment of the fracture. Sixty-two of these patients were older than sixty-five years of age. Of those, fifty-six patients (thirty-one women and twenty-five men with an average age at the time of surgery of 71.4 years; range, sixty-six to eighty-three years) met the criteria for inclusion and were enrolled in this study. Six patients were excluded from the clinical and radiographic analysis as relevant data were missing. Four of them had died within one to thirty-two days after surgery, and the other two were lost during the follow-up period. However, these six patients were included in the morbidity and mortality analysis. The study was approved by the internal review board of our institution, and patients gave their consent to participate in the study after receiving appropriate information.

Mechanism of Injury, Fracture Types, and Initial Displacement

Several mechanisms of injury were identified. The injuries resulted from high-energy accidents in thirty-seven patients (66%) and from low-energy trauma in nineteen (34%) (Table I). The fractures were classified with use of the systems of Anderson and D'Alonzo and of Roy-Camille et al.^15,16 (Table II). Initial displacement of the dens was measured on a cervical computer tomography scan, which was acquired routinely before surgery. Forty-one patients with a nondisplaced or slightly displaced (<2 mm) fracture of the dens were identified, and fifteen patients demonstrated greater displacement of the fracture on the initial computed tomography scan. The average displacement for all dens fractures was 3.8 mm (range, 0 to 8 mm).

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TABLE I Mechanism of Injury and Initial Fracture Displacement

	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
Mechanism of injury
Motor-vehicle and pedestrian accidents	16	10
Falls from a considerable height or downstairs	5	4
Sports activities	2	0
Falls from a standing position or from a chair	14	5
Initial displacement
No or slight displacement	27	14
Displacement of >2 mm
Anterior	1	1
Posterior	5	4
Lateral	1	2
More than one plane	0	1

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TABLE I Mechanism of Injury and Initial Fracture Displacement

	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
Mechanism of injury
Motor-vehicle and pedestrian accidents	16	10
Falls from a considerable height or downstairs	5	4
Sports activities	2	0
Falls from a standing position or from a chair	14	5
Initial displacement
No or slight displacement	27	14
Displacement of >2 mm
Anterior	1	1
Posterior	5	4
Lateral	1	2
More than one plane	0	1

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TABLE II Fracture Classification According to the Systems of Anderson and D'Alonzo and Roy-Camille et al.

Fracture Classification	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
System of Anderson and D'Alonzo¹⁵
Type I	0	0
Type II	37	11
Type III	0	8
System of Roy-Camille et al.¹⁶
Anterior oblique	0	7
Posterior oblique	14	2
Horizontal	23	10
Others	0	0

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TABLE II Fracture Classification According to the Systems of Anderson and D'Alonzo and Roy-Camille et al.

Fracture Classification	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
System of Anderson and D'Alonzo¹⁵
Type I	0	0
Type II	37	11
Type III	0	8
System of Roy-Camille et al.¹⁶
Anterior oblique	0	7
Posterior oblique	14	2
Horizontal	23	10
Others	0	0

Associated Injuries, Neurological Deficits, and Risks Factors for Surgery

Major associated injuries were noted in twelve patients, whereas forty-four had isolated injuries of the dens. The average Injury Severity Score (ISS) for these twelve patients with a dens fracture and major concomitant injuries was 25 points¹⁷. None of these patients had an ISS of >40. Neurological deficits related to the dens fracture were present in nine patients. The severity of the spinal cord injury and the impairment of neurological function were classified according to the American Spinal Injury Association (ASIA) grades¹⁸. The deficits were graded as ASIA D (useful motor function) in six patients and as ASIA C (some sensory and motor preservation) in three patients¹⁸. Two patients had notable cardiac or pulmonary disease. The average American Society of Anesthesiologists (ASA) score, which was assessed preoperatively as a measure of anesthetic risk, was 2.2 in our series¹⁹. No patient with an ASA grade of 4 or 5 was treated surgically.

Methods of Operative Treatment and Indications

Thirty-seven patients (66%) were treated with anterior screw fixation, and nineteen patients (34%) underwent posterior cervical arthrodesis of C1-C2. Anterior screw fixation, originally described by Böhler¹⁰, was performed with use of a two-screw system. Posterior cervical arthrodesis was performed with a modification of the technique of posterior wiring and bone-grafting originally described by Brooks and Jenkins^10,20. For the technique of anterior screw fixation, the patient was placed in the supine position with the head slightly extended and secured by tongs. After closed reduction of the dens in patients with displacement, an anterior cervical approach with use of biplanar fluoroscopic guidance was performed. After a horizontal incision of the skin and platysma at the level of C5-C6, the anterior cervical spine was approached by dissecting through the cervical fascia. The C2-C3 disc space was identified, and the desired entry point at the inferior end plate of C2 was determined. Two Kirschner wires were inserted under biplanar fluoroscopic control across the fracture line into the apical cortical surface of the dens and then were replaced by two cannulated small-fragment AO screws (Arbeitsgemeinschaft für Osteosynthesefragen; Synthes, Davos, Switzerland) of an appropriate length to compress the fracture fragments. For posterior cervical arthrodesis of C1-C2, the patient was placed in the prone position with the cervical spine maintained in a slight amount of flexion. Tongs were used for traction to achieve a closed reduction of the displaced fractures. All procedures were performed under biplanar fluoroscopic visualization. After a vertical skin incision and dissection of the dorsal fascia longitudinally down to the spinous processes of the upper cervical spine, the posterior arches of C1 and C2 were identified. Two autogenous corticocancellous bone grafts were harvested from the iliac crest and wedged in between the C1 and C2 lamina on each side of the midline. The grafts were secured by sublaminar cerclage wires that passed on each side of the midline under both the laminated C1 and C2 arches and wrapped around each bone graft respectively.

Surgical treatment was performed within twenty-four hours after the injury in nine patients, within three days in seventeen patients, and within a week in twenty-seven patients. Three additional patients were initially treated with use of a halo-thoracic vest, but they did not tolerate the external immobilization and underwent surgery within three weeks of injury. The mean interval between fracture and surgery was six days. All operative procedures were performed with the patient under general anesthesia. The duration of surgery averaged 140 minutes (range, seventy to 340 minutes). Postoperative immobilization was routinely provided by a soft or a hard collar, depending on the preference of the surgeon, for a minimum of six weeks.

Anterior screw fixation was usually performed in patients with a type-II dens fracture that allowed interfragmentary fracture compression, such as fractures with horizontal or posterior oblique fracture lines. Indications for posterior cervical arthrodesis were a type-II fracture with anterior oblique fracture lines, a type-III fracture with comminution or major displacement, a pathological fracture, and a fracture with comminution of the atlantoaxial joints.

Clinical and Radiographic Follow-up Monitoring

Follow-up included clinical and radiographic examination of the patients before hospital discharge; at six, twelve, and twenty-four weeks postoperatively; and at twelve and twenty-four months postoperatively. All surviving patients were monitored for a period of two years. Radiographic assessment consisted of a three-view cervical spine series (anteroposterior, lateral, and open-mouth) at each follow-up visit and additional flexion-extension radiographs were made between three and twelve months after surgery. Fine-cut computed tomography scans with helical reconstruction were routinely acquired twelve months after surgery or earlier, if the adequacy of fusion could not be determined on the standard radiographs. Clinical examination included an assessment of the range of motion of the cervical spine, local pain, and activities of daily living. The range of motion was determined by evaluation of the flexion-extension, lateral inclination, and rotation of the cervical spine with use of a goniometer. To quantify the clinical results, the patients were asked to grade the functional outcome according to the Smiley-Webster scale as excellent, good, fair, or poor (Table III). For evaluation of neurological function, patients were additionally assessed by a neurological consultant. The ASIA grades were used to quantify the severity of neurological deficits. In addition, measurements of cervical spine movement and the scores of the Smiley-Webster scale were analyzed statistically with use of the Student t test²¹. The level of significance was defined as p < 0.05.

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TABLE III Functional Results After Anterior Screw Fixation and Posterior Cervical Arthrodesis According to the Smiley-Webster Scale

Grade	Description	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
I. Excellent	Patient returned to full-time work and/or activity as before onset of symptoms; no pain medication required	27	5
II. Good	Patient returned to full-time work and/or activity; occasional consumption of pain medication	8	4
III. Fair	Patient not able to return to former level of work and/or activity; occasional pain medication; improved over preoperative status	2	8
IV. Poor	Patient not able to return to work and/or former activity level; regular consumption of pain medication	0	2

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TABLE III Functional Results After Anterior Screw Fixation and Posterior Cervical Arthrodesis According to the Smiley-Webster Scale

Grade	Description	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
I. Excellent	Patient returned to full-time work and/or activity as before onset of symptoms; no pain medication required	27	5
II. Good	Patient returned to full-time work and/or activity; occasional consumption of pain medication	8	4
III. Fair	Patient not able to return to former level of work and/or activity; occasional pain medication; improved over preoperative status	2	8
IV. Poor	Patient not able to return to work and/or former activity level; regular consumption of pain medication	0	2

Results

Materials and Methods | Results | Discussion | References

Radiographic Results

Fracture-healing was achieved in fifty-two patients (93%). In four patients, all of whom had a type-II dens fracture, nonunion was diagnosed by a computed tomography scan of the cervical spine between six and twelve months after surgery. The fracture-healing rate was 92% (forty-four of forty-eight patients) for type-II fractures, and all type-III fractures healed. All four patients with nonunion had undergone anterior screw fixation, leading to a pseudarthrosis rate of 11% associated with this surgical technique. In all four patients, we noted an original fracture displacement of >2 mm. In the posterior cervical arthrodesis group, all nineteen fractures healed. Technical failures of reduction and fixation were noted in eight patients (14%). Five of these patients were treated by anterior screw fixation, and three had undergone posterior cervical arthrodesis. In the anterior screw fixation group, we failed to achieve correct anatomical reduction of the dens intraoperatively in three patients (Fig. 1), one patient had malpositioning of the implants, and another patient had secondary loss of reduction and cut-out of the screws. In the posterior cervical arthrodesis group, two patients had loss of reduction (Fig. 2) and one patient had malpositioning of the cerclage wire and insufficient fixation of the bone grafts between C1 and C2.

Clinical Results

Forty-five of the fifty-six patients returned to their preinjury activity level one year after surgery and were satisfied with the result of their treatment. Eleven patients (20%) reported certain limitations in the activities of daily living with occasional or chronic pain symptoms and a decrease of cervical spine motion. Thirty-five patients had a full range of neck movement. The Smiley-Webster scale showed a mean overall functional outcome score of 1.68 (Table III). Patients with anterior screw fixation of the dens fracture had, on the average, an excellent-to-good outcome (average score, 1.32), and patients after posterior cervical arthrodesis had good-to-fair results (average score, 2.37), which represents a significant difference between the two treatment groups (p = 0.021). Clinical characteristics, including presence and severity of pain, as well as activities of daily living, are presented in Table IV. Neurological deficits were present after surgery in three patients (5%). The neurological deficits were diagnosed following anterior screw fixation in two patients and after posterior cervical arthrodesis in the third patient. All patients with preoperative neurological deficits recovered fully after surgery. We did not find a notable difference with regard to the clinical results of patients with neurological deficits compared with those without deficits.

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TABLE IV Activities of Daily Living and Pain

	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
Activities of daily living
No impairments	26	0
Limitations in certain activities	11	14
Limitations in (nearly) all activities	0	5
Pain
Presence of pain
No pain	33	14
Occasional pain	3	3
Regular pain	1	2
Severity of pain
Mild symptoms	3	4
Severe symptoms	1	1

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TABLE IV Activities of Daily Living and Pain

	Patients Who Had Anterior Screw Fixation (N = 37)	Patients Who Had Posterior Cervical Arthrodesis (N = 19)
Activities of daily living
No impairments	26	0
Limitations in certain activities	11	14
Limitations in (nearly) all activities	0	5
Pain
Presence of pain
No pain	33	14
Occasional pain	3	3
Regular pain	1	2
Severity of pain
Mild symptoms	3	4
Severe symptoms	1	1

Morbidity, Mortality, and Complications

To determine the overall morbidity and mortality associated with the surgical procedures, we included in the analysis the six patients who had been excluded from the clinical and radiographic review. General intraoperative or postoperative complications occurred in ten of these sixty-two patients, leading to an overall morbidity rate of 16%. The complications were distributed similarly between the two treatment groups (Table V). No reoperation was necessary secondary to a general complication in any patient. Four patients died and their deaths were related to surgery, leading to a mortality rate of 6%. One patient died of a cardiac arrest, two patients died because of severe pneumonia with respiratory insufficiency, and the fourth patient died of a pulmonary embolism. The deaths occurred one to thirty-two days after the operation. Complications specific to the surgical procedures were noted in nine (16%) of the fifty-six patients. Reoperations relating to specific complications after surgical procedures were necessary in three patients (5%).

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TABLE V General and Specific Complications Following Anterior Screw Fixation and Posterior Cervical Arthrodesis

	Patients Who Had Anterior Screw Fixation	Patients Who Had Posterior Cervical Arthrodesis
Specific complications
Nonunion	4	0
Incorrect reduction	3	0
Secondary loss of reduction	0	2
Malpositioning of implants	1	1
Implant loosening and/or cut-out	1	0
Reoperations	3	0
General complications
Cardiac failure	1	0
Respiratory failure	1	1
Pneumonia	2	2
Severe infection	0	1
Thromboembolism	1	1
Death	3	1

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TABLE V General and Specific Complications Following Anterior Screw Fixation and Posterior Cervical Arthrodesis

	Patients Who Had Anterior Screw Fixation	Patients Who Had Posterior Cervical Arthrodesis
Specific complications
Nonunion	4	0
Incorrect reduction	3	0
Secondary loss of reduction	0	2
Malpositioning of implants	1	1
Implant loosening and/or cut-out	1	0
Reoperations	3	0
General complications
Cardiac failure	1	0
Respiratory failure	1	1
Pneumonia	2	2
Severe infection	0	1
Thromboembolism	1	1
Death	3	1

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Fig. 1: A seventy-two-year-old man sustained an isolated dens fracture after falling from a considerable height. The patient underwent anterior screw fixation. Note the slight overcorrection and distraction of the dens. Fracture-healing was achieved three months after surgery.

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Fig. 2: A seventy-five-year-old woman sustained an isolated dens fracture following a motor-vehicle accident. She was treated with posterior cervical arthrodesis. Note the slight secondary loss of reduction of the dens fracture. Fracture-healing was achieved four months after surgery.

Discussion

Materials and Methods | Results | Discussion | References

The population is getting older, and dens fractures are becoming more frequent^1,3. In recent years, several authors have proposed the surgical treatment of dens fractures in elderly patients, even though the anesthesia risk is greater in elderly patients^3,22-24. Despite this increasing tendency toward operative treatment, few investigations have addressed this issue and presented reliable long-term results^1,3. Our study shows that good results with relatively low complication rates can be achieved by surgical treatment of dens fractures in elderly individuals. Patients who had undergone anterior screw fixation of the dens fracture had a high rate of fracture union (89%) and encouraging functional results. Other authors have reported lower fracture-healing rates, ranging from 70% to 85%, with use of the same surgical techniques in elderly patients^1,25,26. Nonunion after anterior screw fixation was noted in four patients in our series. All of them had a displaced dens fracture, indicating a possible relationship between the development of nonunion and initial displacement. With regard to the clinical outcome, several authors have also reported good functional results following anterior stabilization of the dens^8-10,12-14. Particularly in younger patients, this method has shown promising results, as it preserves cervical spine motion including axial rotation^9,10,13,25.

Our patients also appeared to benefit from this surgical technique, as more than two-thirds in the anterior screw fixation group had no limitations in activities of daily living and were free of pain. Technical failures related to anterior screw fixation occurred in five patients (14%). The literature dealing with technical failures and surgical complications after anterior stabilization in the elderly is scarce and controversial^1,25,26. Andersson et al., for example, reported a high rate of technical failures in geriatric patients treated with anterior screw fixation, whereas other authors have shown acceptable results with only a few complications^1,25,27. A 14% rate of technical failures in our series might be considered relatively high, but as only three of these patients required reoperation, we believe the results are satisfactory.

Patients who were treated with posterior arthrodesis of C1 and C2 had a fracture union rate of 100% but had worse functional results. The rates of successful atlantoaxial arthrodesis reported in the literature are similarly high, ranging from 85% to 100%^15,20,28-31. Some might argue that the high rate of fracture-healing following posterior cervical arthrodesis in our series might be influenced by the fact that nearly half of the patients had a type-III fracture, which is known to have a much higher union rate than a type-II fracture. However, the inclusion of type-III fractures in our study did not increase the healing rate in either group compared with the healing of type-II fractures alone. Decreased functional results with considerable impairment in cervical spine motion and chronic pain symptoms have been reported by a number of authors following posterior arthrodesis^25,28,30. In particular, axial rotation of the cervical spine is often severely limited after arthrodesis of C1 and C2, as 50% of the rotation at the cervical spine typically occurs at the atlantoaxial joint^5,25,31. Recently, a few authors have reported on the relative tolerance of the resulting limitations in range of motion among elderly patients, but in our series nearly half of the patients in the posterior cervical arthrodesis group had subjectively and objectively unsatisfactory functional results^5,7,20. Alternative techniques for posterior fixation (such as transarticular screw fixation of C1-C2) might be considered as a more contemporary and reasonable method for posterior arthrodesis, requiring less stringent immobilization.

In our study, the rates of technical failure and specific complications in the anterior screw fixation group were similar to those in the posterior arthrodesis group. However, most authors have reported fewer complications and technical problems associated with posterior arthrodesis than with anterior screw fixation^1,5,22,32. The similar rates in our series might be attributed to the fact that we had a smaller number of patients within the posterior arthrodesis group. But, in contrast to the anterior screw fixation group, no reoperation was necessary in any of these patients, which may indicate that anterior screw fixation is more likely to result in the need for additional surgery than is posterior arthrodesis.

With regard to morbidity and mortality, we believe we had a satisfactory outcome. A morbidity rate of 16% might be considered to be relatively high, but previous works have shown that the morbidity rate in elderly patients following nonoperative treatment of these fractures ranges between 10% and 25%^{6,7,22-24,33,34}. The overall in-hospital mortality rate in our series was 6%, as four of sixty-two patients died. The reported primary in-hospital mortality for elderly patients following surgical treatment of dens fractures has varied from 0% to 30%^{1,6,7,22,25,26}. Concomitant illness and enhanced preoperative risk have been regarded as relevant factors in determining early postoperative mortality^3,4. In our series, two of the patients who died during the postoperative period had major comorbidities with an increased anesthesia risk. ?

References

Materials and Methods | Results | Discussion | References

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Topics

fracture ; bone screws ; morbidity ; odontoid fracture ; elderly ; cervical arthrodesis

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Patrick Platzer, Gerhild Thalhammer, Gerhard Oberleitner, Rupert Schuster, Vilmos Vécsei, Christian Gaebler; Surgical Treatment of Dens Fractures in Elderly Patients. The Journal of Bone & Joint Surgery. 2007 Aug;89(8):1716-1722.

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