Time from injury to acute surgery for patients with traumatic cervical spinal cord injury in South-East Norway.

Background: The recommended treatment for cervical spinal cord injury (cSCI) is surgical decompression and stabilization within 24 h after injury. The aims of the study were to estimate our institutional compliance with this recommendation and identify potential factors associated with surgical delay. Methods: Population-based retrospective database study of patients operated for cSCI in 2015-2022 within the South-East Norway Health Region (3.1 million inhabitants). Data extracted were demographics, injury description, management timeline, place of primary triage [local hospital (LH) or neurotrauma center (NTC)]. Main outcome variables were: (1) time from injury to surgery at NTC, (2) time from injury to admission NTC, and (3) time from admission NTC to surgery. Results: We found 243 cSCI patients having acute neck surgery. Their median age was 63 years (IQR 47-74 years), 77% were male, 48% were ≥65 years old. Primary triage at an LH occurred in 150/243 (62%). The median time from injury to acute surgery was 27.8 h (IQR 15.4-61.9 h), and 47% had surgery within 24 h. The median time from injury to NTC admission was 5.6 h (IQR 1.9-19.4 h), and 67% of the patients were admitted to the NTC within 12 h. Significant factors associated with increased time from injury to NTC admission were transfer via LH, severe preinjury comorbidities, less severe cSCI, time of injury other than night, absence of multiple injuries. The median time from NTC admission to surgery was 16.7 h (IQR 9.5-31.0 h), and 70% had surgery within 24 h. Significant factors associated with increased time from NTC admission to surgery were increasing age and non-translational injury morphology. Conclusion: Less than half of the patients with cSCI were operated on within the recommended 24 h time frame after injury. To increase the fraction of early surgery, we suggest the following: (1) patients with clinical suspicion of cSCI should be transported directly to the NTC from the scene of the accident, (2) MRI should be performed only at the NTC, (3) at the NTC, surgery should commence on the same calendar day as arrival or as the first operation the following day.

Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients.

BACKGROUND CONTEXT: The recommended primary treatment for type III odontoid fractures (OFx) is external immobilization, except for patients having major displacement of the odontoid fragment. The bony fusion rate of type III OFx has been reported to be >85%. High compliance to treatment recommendations is favorable only if the treatment leads to a good outcome. PURPOSE: The primary aim of this study was to determine the long-term outcome after conservative and surgical treatment of type III OFx and to reaffirm that primary external immobilization is the best treatment for most type III fractures. STUDY DESIGN/SETTING: Retrospective study based on a prospective database. PATIENT SAMPLE: Two hundred twelve consecutive patients with type III OFx treated at Oslo University Hospital over an 8-year period (2009-2017). OUTCOME MEASURES: Long-term rates of bony fusion, crossover from primary conservative treatment to surgical fixation, new onset spinal cord injury (SCI), severe persistent neck pain (visual analogue scale - VAS), and persistent disability measured with Neck Disability index (NDI). METHODS: The present study was based on data extracted from our quality control database for acute cervical spine fractures from a general population. During the years 2018 to 2019 long-term follow-up of alive patients was performed (median follow-up time was 38.0 months; range 3.0-108.0 months). The follow-up included neurological examination, radiological examination and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new onset SCI, neck pain, and Neck Disability Index (NDI score). RESULTS: In this consecutive series of 212 patients with type III acute OFx, median patient age was 72 years, 56% had severe preinjury comorbidities (ASA score ≥3) and 22% lived dependently. Severe comorbidities and dependent living were significantly associated with increasing age (p<.001). The trauma mechanism was fall injury in 82%. The median age of patients injured by falls was significantly higher than in patients with a nonfall injury (p<.001). At the time of diagnosis, 4% had an OFx related SCI. Primary treatment was external immobilization alone in 95.3% and open surgical fixation in 4.7%. Patients treated with primary external immobilization alone presented with significantly less translation of the odontoid fragment (p<.001) and less angulation of the odontoid fragment (p=.025) than patients treated with primary surgery. Subsequent crossover to surgical fixation was performed in 5.4%. At long-term follow-up, 95.7% of patients had bony fusion of the OFx, 80.5% had minimal/no neck pain, and none developed new onset SCI. There was no significant difference in long-term follow-up VAS (p=.444) or NDI (p=.562) between the primary external immobilization group and the primary surgical group. CONCLUSION: This study reaffirms that nonsurgical treatment remains the preferable option in the majority of patients with type III OFx.

Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients.

BACKGROUND CONTEXT: The surgical fixation rate of type II odontoid fracture (OFx) in the elderly (≥65 years) is much lower than expected if the treatment adheres to current general treatment recommendations. Outcome data after conservative treatment for elderly patients with these fractures are sparse. PURPOSE: The main aim of this study was to determine the long-term outcome after conservative and surgical treatments of type II OFx (all age-groups) to evaluate whether nonoperative treatment yields an acceptable outcome. STUDY DESIGN/SETTING: Retrospective study based on a prospective database. PATIENT SAMPLE: Two hundred eighty-two consecutive patients with type II OFx treated at Oslo University Hospital over an 8-year period. OUTCOME MEASURES: Long-term rates of bony fusion, fibrous union, pseudarthrosis, crossover from primary conservative treatment to surgical fixation, new-onset spinal cord injury (SCI), and neck pain were the outcome measures used. METHODS: The present study was based on data extracted from our quality control database for acute cervical spine fractures. All ages were included. In addition, long-term follow-up of alive patients was performed during the years 2018-2019. The follow-up included neurological examination, radiological examination, and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new-onset SCI, neck pain, and Neck Disability Index (NDI score). Data are described by counts, percentages, medians, means, ranges and standard deviations where appropriate. For statistical analyses the Mann-Whitney U test, Wilcoxon signed-rank test, and t tests were used. RESULTS: During the eight-year study period, we registered 282 consecutive patients with type II OFx; 54% were males, patient age ranged from 15 to 101 years, 84% were ≥65 years of age (WHO definition of elderly), and 51% were ≥80 years of age. Severe comorbidities (American Society of Anesthesiologists, ASA ≥3) were seen in 67%, whereas nonindependent living was registered in 32%. Severe comorbidities and nonindependent living were significantly associated with increasing age (p<.001). SCI secondary to the OFx was seen in 5.3%. Primary treatment of the OFx was conservative (external immobilization alone) in 193 patients (68.4%), open surgical fixation in 87 patients (30.9%), and no treatment in two critically injured patients. At the time of long-term follow-up, 125 patients had died, nine patients declined the invitation to follow-up, and five patients did not respond. Thus, 143 patients were available for follow-up with a median follow-up time of 39 months (range 5-115 months). At long-term follow-up, the fusion status was bony fusion in 39.2% of patients, fibrous union in 57.3%, and pseudarthrosis in 3.5%. The proportion of bony fusion was significantly higher in the primary surgical fixation group (p=.005). No patients had new-onset SCI presenting after the start of primary treatment. The proportion of crossover from primary external immobilization to surgery was 14.4%, whereas proportion of revision surgery in the primary surgical group was 9.5%. There was no significant difference between the primary surgical fixation group and the primary conservative treatment group at long-term follow-up with respect to the proportion of pseudarthrosis and degree of neck pain. CONCLUSIONS: Primary conservative treatment of elderly patients with type II OFx appears to be safe and should be regarded a viable treatment option.

Odontoid fractures: impact of age and comorbidities on surgical decision making.

BACKGROUND: Surgical fixation is recommended for type II and III odontoid fractures (OFx) with major translation of the odontoid fragment, regardless of the patient's age, and for all type II OFx in patients aged ≥50 years. The level of compliance with this recommendation is unknown, and our hypothesis is that open surgical fixation is less frequently performed than recommended. We suspect that this discrepancy might be due to the older age and comorbidities among patients with OFx. METHODS: We present a prospective observational cohort study of all patients in the southeastern Norwegian population (3.0 million) diagnosed with a traumatic OFx in the period from 2015 to 2018. RESULTS: Three hundred thirty-six patients with an OFx were diagnosed, resulting in an overall incidence of 2.8/100000 persons/year. The median age of the patients was 80 years, and 45% were females. According to the Anderson and D'Alonzo classification, the OFx were type II in 199 patients (59%) and type III in 137 patients (41%). The primary fracture treatment was rigid collar alone in 79% of patients and open surgical fixation in 21%. In the multivariate analysis, the following parameters were significantly associated with surgery as the primary treatment: independent living, less serious comorbidities prior to the injury, type II OFx and major sagittal translation of the odontoid fragment. Conversion from external immobilization alone to subsequent open surgical fixation was performed in 10% of patients. Significant differences the in conversion rate were not observed between patients with type II and III fractures. The level of compliance with the treatment recommendations for OFx was low. The main deviation was the underuse of primary surgical fixation for type II OFx. The most common reasons listed for choosing primary external immobilization instead of primary surgical fixation were an older age and comorbidities. CONCLUSION: Major comorbidities and an older age appear to be significant factors contributing to physicians' decision to refrain from the surgical fixation of OFx. Hence, comorbidities and age should be considered for inclusion in the decision tree for the choice of treatment for OFx in future guidelines.

Complications and long-term outcomes after open surgery for traumatic subaxial cervical spine fractures: a consecutive series of 303 patients.

BACKGROUND: Patient selection for surgical treatment of subaxial cervical spine fractures (S-CS-fx) may be challenging and is dependent on fracture morphology, the integrity of the discoligamentous complex, neurological status, comorbidity, risks of surgery and the expected long-term outcomes. The purpose of this study is to evaluate complications and long-term outcomes in a consecutive series of 303 patients with S-CS-fx treated with open surgical fixation. METHODS: Medical charts were retrospectively reviewed. The surviving patients participated in a prospective long-term follow-up, including clinical history, physical examination and updated cervical CT. Patients with ankylosing spondylitis were excluded from this study. RESULTS: The median patient age was 48 years (range 14.7-93.9), and 74 % were males. Preoperatively, 43 % had spinal cord injury (SCI), and 27 % exhibited isolated radiculopathy. The median time from injury to surgery was 2 days (range 0-136). The risks of SCI deterioration and new-onset radiculopathy after surgery were 2.0 % and 1.3 %, respectively. Surgical mortality (death within 30 days after surgery) was 2.3 %. The reoperation rate was 7.3 %. At the long-term follow-up conducted a median of 2.6 years after trauma (range 0.5-9.1), 256 (99.2 %) of the patients who had survived and were living in Norway participated. Of the patients with American Injury Severity Scale (AIS) A-D at presentation, 51 % had improved one or more AIS grades. At the time of follow-up, 89 % of the patients with preoperative radiculopathy were without symptoms. Furthermore, 11 % of the patients reported severe neck stiffness, 5 % reported severe neck pain (Visual Analog Scale (VAS) ≥7), 6 % reported hoarseness, and 9 % reported dysphagia at the follow-up. The stable fusion rate, as evaluated using cervical-CT, was 98 %. CONCLUSIONS: In this large consecutive series of patients with S-CS-fx treated with open surgical fixation, the surgical mortality was 2.3 %, the risk of neurological deterioration was 3.3 % and the reoperation rate (any cause) was 7.3 %. The neurological long-term results were good, with 51 % improvement in AIS grade and resolution of radiculopathy in 89 % of the patients. Stable fusion was excellent and was achieved in 98 % of the follow-up group.

The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway.

AIM: The aim of this study was to estimate the incidence of traumatic cervical spine fractures (CS-fx) in a general population. BACKGROUND: The incidence of CS-fx in the general population is largely unknown. METHODS: All CS-fx (C0/C1 to C7/Th1) patients diagnosed with cervical-CT in Southeast Norway (2.7 million inhabitants) during the time period from April 27, 2010-April 26, 2011 were prospectively registered in this observational cohort study. RESULTS: Over a one-year period, 319 patients with CS-fx at one or more levels were registered, constituting an estimated incidence of 11.8/100,000/year. The median age of the patients was 56 years (range 4-101 years), and 68% were males. The relative incidence of CS-fx increased significantly with age. The trauma mechanisms were falls in 60%, motorized vehicle accidents in 21%, bicycling in 8%, diving in 4% and others in 7% of patients. Neurological status was normal in 79%, 5% had a radiculopathy, 8% had an incomplete spinal cord injury (SCI), 2% had a complete SCI, and neurological function could not be determined in 6%. The mortality rates after 1 and 3 months were 7 and 9%, respectively. Among 319 patients, 26.6% were treated with open surgery, 68.7% were treated with external immobilization with a stiff collar and 4.7% were considered stable and not in need of any specific treatment. The estimated incidence of surgically treated CS-fx in our population was 3.1/100,000/year. CONCLUSIONS: This study estimates the incidence of traumatic CS-fx in a general Norwegian population to be 11.8/100,000/year. A male predominance was observed and the incidence increased with increasing age. Falls were the most common trauma mechanism, and SCI was observed in 10%. The 1- and 3-month mortality rates were 7 and 9%, respectively. The incidence of open surgery for the fixation of CS-fx in this population was 3.1/100,000/year. LEVEL OF EVIDENCE: This is a prospective observational cohort study and level II-2 according to US Preventive Services Task Force.

Surgical management of acute odontoid fractures: surgery-related complications and long-term outcomes in a consecutive series of 97 patients.

BACKGROUND: The purpose of this study was to determine the incidence of surgery for odontoid fractures and to study surgical mortality, surgical morbidity, and long-term outcome in a large, contemporary, consecutive, single-institution, surgical series of odontoid fractures. METHODS: This is a retrospective study of all odontoid fractures treated by open surgery at our hospital during 2002 to 2009. The fractures were classified according to Grauer. Follow-up data, clinical examinations, and cervical computed tomographies were collected in 2010. RESULTS: This study included 97 consecutive patients with a median age of 73.0 years. The incidence of open fixation of odontoid fractures in this population was 0.45 per 100,000, and the incidence increased with age. The fractures were classified as type IIA in 3 patients, type IIB in 63 patients, type IIC in 8 patients, and type III in 23 patients. Anterior fixation and posterior fixation were performed in 41 and 56 patients, respectively. Immediate postoperative neurologic status was unchanged or improved in 97% of the patients. None of the patients developed postoperative hematoma, wound infection, deep venous thrombosis, or pulmonary embolism. Eleven patients underwent resurgery during the follow-up period; five had suboptimal reposition after the first surgery, one had suboptimal position of an anterior odontoid screw, two had rupture of fixation materials, and three developed pseudarthrosis. Overall survival (OS) rates after 1, 12, and 24 months were 96%, 84%, and 75%, respectively. Fifty-seven patients were available for follow-up evaluation with a mean time of 37 months. Radiologic follow-up showed definite bony fusion in 82% of the patients and uncertain bony fusion in 18% of the patients. Flexion-extension radiographs were obtained in 6 of the 10 patients with uncertain bony fusion; 5 of these were defined as stable (fibrous union) and 1 was unstable. Multivariate logistic regression demonstrated increased odds of nonbony fusion in more displaced fractures (OR, 1.44; 95% CI, 1.04-2.16; p = 0.04) and when using the anterior fusion technique (OR, 0.17; 95% CI, 0.03-0.75; p = 0.02). There was no significant association between neck pain and fusion method (Mann-Whitney U test, p = 0.86). Patients treated with a posterior fusion approach had significantly more neck stiffness than patients who underwent fusion with an anterior odontoid screw (Fisher's exact test, p = 0.04). CONCLUSIONS: The annual incidence of open fixation of odontoid fractures was 0.45 per 100,000 inhabitants, and the incidence increased with age. The median age at time of surgery was 73.0 years, and the surgical mortality was 4%. Increased odds of nonbony fusion were observed in more displaced fractures and after anterior screw fixations. There were no significant differences between patients treated with anterior screw fixation versus posterior wiring with respect to neck pain, but patients fused with a posterior approach reported significantly more neck stiffness.