The March 16, 2016 JBJS includes a careful incidence, treatment, and outcome analysis by Pearson et al. of CMS data regarding C2 cervical-spine fractures that occurred in the Medicare population from 2000 to 2011. The study’s methodological quality comes as no surprise, as the group hails from Dartmouth, the home of the renowned Dartmouth Atlas of Health Care, which has posed many vexing clinical and cost questions for the orthopaedic community.
Pearson et al. found that while the incidence of C2 fractures in the elderly increased 135% from 2000 to 2011, the rate of surgical treatment for this injury remained essentially unchanged. I find that static rate of surgical treatment troubling, because, after controlling for potential confounders, the authors found that surgical treatment was associated with a nearly 50% decrease in 30-day mortality and a 37% decrease in one-year mortality, relative to nonoperative approaches.
I believe that our apparent reluctance to perform surgery in these cases is due to the underlying belief that upper C-spine fixation/fusion in the elderly presents a prohibitively high risk. I question that general proposition because we think quite the opposite nowadays when managing hip fractures and many other metaphyseal fractures with high complication profiles in older people. Certainly, the major risks with upper C-spine surgery are potentially fatal neurologic and vascular injuries, but this well-done analysis demonstrates that the mortality outcomes are markedly better with surgery. In addition, JBJS recently published a paper by Joestl et al. on the outcomes of C2 fusions in geriatric patients with a dens fracture nonunion, which confirmed good outcomes and a favorable risk profile (see related OrthoBuzz post).
I think it is time for the orthopaedic, neurological-spine, and rehabilitation communities to seriously reconsider our approach to elders with C2 fractures. As Pearson et al. conclude, until an RCT is performed on this question (if ever), “surgeons and patients should use the available data in a shared decision-making model to choose the treatment consistent with an individual patient’s values.”
Marc Swiontkowski, MD