Introduction: Evidence, that conservative therapy for unstable odontoid fractures in the elderly has higher morbidity and mortality than operative therapy has emerged. Anterior and posterior operative strategies for unstable odontoid fractures in this population coexist. While there are some reports about morbidity and mortality for posterior operations, there is a relative paucity of data about anterior procedures. In our department we applied a modified anterior transarticular C1/2 fixation with lesser need for pharyngeal mobilization than the standard anterior tripple or quadruppel osteosynthesis as the most common operative strategy used for treatment of these fractures in the elderly.
Material/Methods: Between Juli 2010 and February 2018, 36 patients underwent a modified anterior transarticular C1/2 fixation with additional single odontoid screw through a right-sided Smith-Robinson-approach with a short and steep screw trajectory for the right and long trajectory for the left side. We included in this retrospective analysis odontoid fracture patients who were 75 years or older at the time of surgery (29 patients, 8 male/21 female). All patients suffered odontoid fractures type II, some of them with additional ligamentous injuries or atlas fractures.
Results: The mean operating time was 55.8 minutes. The mean age was 82.6 years (75-95y). Mean Age-Adjusted Charlson Comorbidity Index (CCI) was 5.3 points (range 3-12), and mean ASA score was 2.9 points (range 2-4). There were no intraoperative complications and blood loss was minimal in all cases. One patient with delayed swallowing problems had low grade infectious implant loosening and dislocation, he underwent implant removal and long term antibiotic drug therapy. The most common medical complication were aspiration pneumonia (24.1%, n=7), altered mental status (17.2%, n=5) and cardiac decompensation (6.9%, n=2). The 30-day mortality rate in this group of patients is 13.8% (4 patients), while the 1-year mortality rate was 27.6% (8 patients).
Conclusion: Although the modified version of anterior transarticular C1/2 fixation and odontoid fixation allowed less pharyngeal mobilization and required a relatively short operative time, the procedure was associated with a significant amount of postoperative Dysphagia, which in some cases lead to aspiration and death. Despite the theoretical advantages of supine positioning and short operative time, and also little intraoperative complications, dysphagia and aspiration seem to be the major problem in the elderly especially if comorbidities exist like dementia or parkinsonism. Estimation of the risk factors for such complications should play a role in the decision making process and a posterior approach or conservative therapy should be considered for patients at high risk.
|
