title: Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture.
abstract: BACKGROUND
  Dens fractures are relatively common in the elderly. The treatment of Type-II dens fractures remains controversial. The aim of this multicenter prospective cohort study was to compare outcomes (assessed with use of validated clinical measures) and complications of nonsurgical and surgical treatment of Type-II dens fractures in patients sixty-five years of age or older.
  
  
  METHODS
  One hundred and fifty-nine patients with a Type-II dens fracture were enrolled in a multicenter prospective study. Subjects were treated either surgically (n = 101) or nonsurgically (n = 58) as determined by the treatment preferences of the treating physicians and the patients. The subjects were followed at six and twelve months with validated outcome measures, including the Neck Disability Index (NDI) and Short Form-36v2 (SF-36v2). Treatment complications were prospectively recorded. Statistical analysis was performed to compare outcome measures before and after adjustment for confounding variables.
  
  
  RESULTS
  The two groups were similar with regard to baseline characteristics. The most common surgical treatment was posterior C1-C2 arthrodesis (eighty of 101, or 79%) while the most common nonsurgical treatment was immobilization with use of a hard collar (forty-seven of fifty-eight, or 81%). The overall mortality rate was 18% over the twelve-month follow-up period. At twelve months, the NDI had increased (worsened) by 14.7 points in the nonsurgical cohort (p < 0.0001) compared with a nonsignificant increase (worsening) of 5.7 points in the surgical group (p = 0.0555). The surgical group had significantly better outcomes as measured by the NDI and SF-36v2 Bodily Pain dimension compared with the nonsurgical group, and these differences persisted after adjustment. There was no difference in the overall rate of complications, but the surgical group had a significantly lower rate of nonunion (5% versus 21% in the nonsurgical group; p = 0.0033). Mortality was higher in the nonsurgical group compared with the surgical group (annual mortality rates of 26% and 14%, respectively; p = 0.059).
  
  
  CONCLUSIONS
  We demonstrated a significant benefit with surgical treatment of dens fractures as measured by the NDI, a disease-specific functional outcome measure. As a result of the nonrandomized nature of the study, the results are vulnerable to the effects of possible residual confounding. We recommend that elderly patients with a Type-II dens fracture who are healthy enough for general anesthesia be considered for surgical stabilization to improve functional outcome as well as the union and fusion rates.
authors.affiliation: Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA. alexvaccaro3@aol.com
authors.forename: Alexander R
authors.initials: AR
authors.lastname: Vaccaro
authors.forename: Christopher K
authors.initials: CK
authors.lastname: Kepler
authors.forename: Branko
authors.initials: B
authors.lastname: Kopjar
authors.forename: Jens
authors.initials: J
authors.lastname: Chapman
authors.forename: Christopher
authors.initials: C
authors.lastname: Shaffrey
authors.forename: Paul
authors.initials: P
authors.lastname: Arnold
authors.forename: Ziya
authors.initials: Z
authors.lastname: Gokaslan
authors.forename: Darrel
authors.initials: D
authors.lastname: Brodke
authors.forename: John
authors.initials: J
authors.lastname: France
authors.forename: Mark
authors.initials: M
authors.lastname: Dekutoski
authors.forename: Rick
authors.initials: R
authors.lastname: Sasso
authors.forename: S Tim
authors.initials: ST
authors.lastname: Yoon
authors.forename: Christopher
authors.initials: C
authors.lastname: Bono
authors.forename: James
authors.initials: J
authors.lastname: Harrop
authors.forename: Michael G
authors.initials: MG
authors.lastname: Fehlings
mesh_terms: D000367:Age Factors; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007103:Immobilization; D008297:Male; D009809:Odontoid Process / Q000293:injuries*; D011788:Quality of Life; D020127:Recovery of Function / Q000502:physiology*; D016103:Spinal Fractures / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D013123:Spinal Fusion; D016896:Treatment Outcome