Complications of Upper Cervical Spine Trauma in Elderly Subjects. A Systematic Review of The Literature

Orthopaedics & Traumatology: Surgery & Research (2013) 99, S301—S312
Available online at
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ORIGINAL ARTICLE
Complications of upper cervical spine

trauma in elderly subjects. A systematic
review of the literature
P. Jubert , G. Lonjon , C. Garreau de Loubresse ∗ , the Bone and
Joint Trauma Study Group (GETRAUM)1
Service de chirurgie orthopédique, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380

Garches, France
Accepted: 30 April 2013
KEYWORDS Summary The frequency of cervical spine trauma in elderly patients is increasing with most
Spinal injuries; injuries occurring in the upper cervical spine. These fractures are associated with a risk of
Axis; sometimes life-threatening complications, although very few studies have specifically analyzed
Cervical atlas; this. The goal of this study was to identify the incidence of complications in the literature
Complications; (mortality and morbidity) following upper cervical spine trauma in elderly patients.
Systematic review Methods: A systematic search was performed on the MEDLINE database without limiting the
search by language or date to identify all studies reporting the rate of complications after
upper cervical spine trauma in patients over the age of 60.
Results: Twenty-four observational studies were included, four were comparative. These stud-
ies included a total of 857 patients, mean age 76. Nearly all traumas were odontoid process
fractures, and most were treated surgically (57%). The median mortality rate was 9.2% (Q1—Q3:
2.5—19.6) and the median rate of short-term complications was 15.4% (Q1—Q3: 5.8—26.9). The
main late stage complication was nonunion, which developed in a mean 10 to 12% depending
on the type of treatment.
Conclusion: Complications following cervical spine trauma are frequent in elderly patients
whatever the type of treatment. Knowledge of the rate of complications in the literature and
the potential risk factors is essential for the clinician to improve the information provided to
patients and to prevent complications.
Type of Study: Systematic review of the literature. Level of evidence IV.
© 2013 Elsevier Masson SAS. All rights reserved.
∗ Corresponding author. Tel.: +33 01 47 10 77 36.

E-mail address: ch.garreau@rpc.aphp.fr (C. Garreau de Loubresse).
1 56, rue Boissonade, 75014 Paris, France.
1877-0568/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved.
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S302 P. Jubert et al.
Introduction (mortality and morbidity) after treatment of traumatic UCS

injuries in patients over the age of 60.
The frequency of traumatic cervical spine injuries in
patients over 65 is increasing, while it is decreasing in Materials and methods
younger patients [1—3]. Most injuries occur in the upper cer-
vical spine (UCS) especially in the odontoid process [4—7]. This review was performed according to PRISMA [14] group
Classification of odontoid fractures is based on the location guidelines and was not saved in a database.
of the fracture and the direction of the fracture line. Clas- All studies published on traumatic UCS injuries in patients
sifications by Roy Camille, Anderson and D’Alonzo or Grauer over 60 in English or in French were searched for. Studies
are the most frequently used scores (Fig. 1) [8]. were selected with no time limit, and had to report the
The association of osteoporosis of the UCS and morbidity and mortality of these injuries. The studies could
osteoarthritis of the lower cervical spine (LCS) explains the be randomized trials, cohort studies, case control studies
high frequency of these injuries, which usually occur during or series of cases with at least 10 included patients. Clin-
low energy traumas [4,9—11]. In most cases the neurological ical cases and systematic reviews of the literature were
status of the patient is unaffected and there are very few excluded. Studies that did not report on follow-up were
clinical signs, thus explaining the frequent delay in diag- excluded.
nosis [11]. Two therapeutic strategies are possible. First, A search was performed in the MEDLINE database (last
surgical treatment by anterior or posterior approach to sta- update: September 2012) with an association of words to
bilize the fracture. The other is conservative treatment by identify the elderly population with upper cervical spine
immobilization in an external brace. The goal of both these injury, with no time limitation. The terms searched for in
treatments is to stabilize the injuries to obtain union and Pubmed were ‘‘odontoid process’’ ‘‘axis’’ ‘‘cervical atlas’’
allow patients to rapidly reach the same level of autonomy ‘‘atlato-axial joint’’ (MeSH), ‘‘fracture bone’’ ‘‘spinal
as before the injury. injuries’’ ‘‘spinal fracture’’ ‘‘aged’’ (MeSH) ‘‘elderly’’ and
Unlike fractures of the upper end of the femur (FUEF) ‘‘fracture fixation’’ (text).
in the elderly, which have been the subject of numerous Studies were selected based on the title and the abstract,
studies and guidelines, UCS injuries are associated with a and then two independent readers read the entire arti-
high rate of mortality and morbidity, whose risk factors cle. Moreover, the references of the identified studies
have not yet all been identified. [12,13]. There is no exist- were evaluated to search for missing studies. The follow-
ing consensus on the therapeutic management of traumatic ing descriptive features were extracted from all studies:
UCS injuries. Like FUEF, guidelines could be drafted if the type of study, size of the study sample, characteristics
negative predictive factors of survival in patients with UCS of the population, type of fracture, therapeutic strategy,
injuries were known. length/duration of patient follow-up. The mortality rate was
Thus, the goal of this study was to perform a systematic recorded at 3 months and at the final follow-up. The compli-
study of the literature to evaluate the complication rate cation rate was noted as well as the date this was evaluated.
Figure 1 Types of classification used for odontoid fractures. Anderson and D’Alonzo Classification. (A. type I fracture. B. type II
fracture. C. type III fracture). Raymond Roy Camille Classification. (A. OBAV type fracture [oblique line below and in front]. B. OBAR
type fracture [slanted fracture line below and behind]. C. Fracture de type HTAL [horizontal fracture line]). This figure is taken from:
F. de Peretti, M. Challali. Traumatismes du rachis cervical supérieur. EMC-Appareil locomoteur 2012;7(4):1—8 [Article 15-825-A-10].
Copyright© 2012 Elsevier Masson SAS. All rights reserved.
Upper cervical spine trauma in elderly subjects S303
Because there were no homogenous randomized or non- was the most frequent surgical technique (75%), and a
randomized comparative studies, a meta-analysis could not rigid neck brace was the most frequent type of con-
be performed to compare the two types of treatment. Only servative external immobilization (65%). Fourteen studies
a descriptive analysis of the mortality and morbidity rates reported the treatment choice criteria for surgical versus
could be obtained with this systematic review of the litera- conservative treatment [15,17—20,22,23,25,28—31,37,38].
ture. The three most frequent criteria were the number of co-
morbidities or the ASA status (6/14 studies), the patients
Results and/or the surgeon’s choice (6/14 studies) and the char-
acteristics of the fracture (7/14 studies). In case of surgical
treatment, internal fixation by anterior screw fixation of the
Three hundred thirty three MEDLINE references were iden-
odontoid process was chosen in 75% of cases. In case of con-
tified (Fig. 2). After reading the title and the abstract,
servative treatment a rigid or semi-rigid neck brace was the
47 studies were selected. Twenty-five studies were excluded
most frequently prescribed type of immobilization (84%).
after reading the entire article, leaving 22 studies in the final
analysis. Two studies were added after the bibliographic ref-
erences had been evaluated. Thus a total of 24 studies were Morbidity and mortality
included in this systematic review of the literature.
The median rate of short term complications, all types
of treatment combined was 15.4% (Q1—Q3: 5,8—26,9)
Study characteristics
(Tables 2—4). The main complications of surgical treat-
ment were dysphagia (30/323 patients) and respiratory
All selected studies were retrospective [15—38] and only
problems (27/323 patients). The main complications of
4 were comparative [23,27,34,38] (Table 1). The selected
conservative treatment were local complications (14/372
studies described the management of UCS fractures in
patients) (mobilization or infection of the pin sites of the
857 patients over 60 years old. The mean age in 22/24
halo brace, skin reactions) and respiratory decompensation
studies was 76. The gender ratio based on 20 studies
(7/372 patients).
was 1.2 women/1 man (333 W/274 M). Follow-up was always
Long-term complications were mainly difficulties with
reported.
union and nonunion (Table 3). Twenty-one studies reported
The type of fracture was reported in 23/24 studies
the rate of nonunion in odontoid fractures (768 patients).
(846 patients). Fractures were Anderson and D’Alonzo type II
In the group of surgically treated patients (396 patients),
in 803/846 cases (95%).
nonunion occurred in 49 (12.4%). In the group receiving con-
The mechanism of injury was reported in 16/24 studies
servative treatment (372 patients), nonunion was reported
(415 patients). The mechanism was a low energy trauma
in 40 (10.8%) and only one study reported the treatment
(falling from standing height) in 305/415 patients. The non-
strategy if union was not obtained [18]. Only 4 studies
neurological clinical signs associated with injury were only
reported on whether nonunion should be treated or not when
reported in 1/24 studies and was neck pain in all cases [29].
it was observed [16,23,24,33]. The studies reported a cat-
Nineteen studies (587 patients) reported the presence of
egory of patients in whom stable nonunion developed due
concomitant injuries in 110 patients: 61 injuries of the UCS
to a fibrotic reaction of the fracture site (551 patients).
other than an odontoid process fracture (58 C1 fractures,
This rate of ‘‘stable fibrosis’’ in the surgery group was 12.9%
one C1—C2 dislocation and one C2 lateral mass fracture),
(51/396 patients) and 25.8% in the conservative treatment
nine LCS injuries and 40 extraspinal injuries.
group (40/155 patients).
Nineteen studies reported the initial neurological status
All the studies reported the mortality rate in patients
(726 patients). Only one study had the presence of asso-
with UCS injuries. The median mortality rate three months
ciated neurological symptoms as exclusion criteria. [15]. A
after injury was 9.2% (Q1—Q3: 2.5—19.6), or 120 patients,
total of 692 patients (55 ASIA E, 98 Frankel E, 539 with no
all types of treatment combined. Forty-three of the patients
clinical deficit) had no neurological deficits. A total of only
who died had received surgical treatment (485 patients) and
six patients had tetraparesis [21,23,28,29]. The presence of
77 conservative treatment (372 patients). Fifty-one addi-
secondary cervical myelopathy was reported in 3 patients
tional deaths occurred after 3 months, including seven in
[28,29].
the surgical treatment group and 44 in the conservative
The presence of comorbidities was reported in 14 stud-
treatment group. In the surgical treatment group, mortality
ies (497 patients). Four studies used the ASA score (American
was reported in relation to the type of surgical technique
society of Anesthesiologists) [18,20,26,37], one the Charlson
in certain cases. Twenty-two deaths were reported in the
comorbidity index (CCI) [36] and a Cumulative Illness Rat-
group with odontoid screw fixation (323 patients) and 12 in
ing Scale for Geriatrics (CIRS-G) [30]. Three studies reported
the group that was treated by posterior approach (162
the mean number of comorbidities per patient without using
patients). The main cause of death was cardiopulmonary
a valid score [21,34,38]. The four remaining studies specif-
(68/171patients) occurring less than 3 months after the
ically described the different comorbidities of the patients
trauma in 89.7% of the cases (61/68 patients) (Table 4).
[16,24,32,35]. Finally 1 study reported the presence of
comorbidities in six patients without providing a specific
description [23]. Discussion
The type of treatment was described in all the selected
studies (857 patients) (Table 2). It was surgical in 485 UCS fractures in general and of the odontoid process, in par-
patients and conservative in 372. Anterior screw fixation ticular, are becoming a frequent ‘‘geriatric’’ trauma, and
S304
Table 1 Characteristics of included studies.
Authors, year Type of study Number of patients Mean Force of Neurological Odontoid Associated UCS Treatment Comorbidities
age trauma, n (%) status fracture, n lesion, n (%)
reported (%)
(type)
Hanigan et al., Retrospective 19 > 80 Low, 15 (79) Yes Ot II: 16 No Mixed NA

1993 [15] (84.2), Ot
III: 3 (15.8)
Berleman and Retrospective 19 75 Low, 19 (100) Yes Ot II: 19 Fr. C1: 4 (21) Surg. 3 patients with
Schwarzenbach, (100) comorbidities
1997 [16]
Müller et al., 1999 Retrospective 23 80.9 Low, 21 (91) Yes Ot II: 22 Fr. C1: 13 (56.5) Mixed NA
[17] and (Frankel) (95.7), Ot
comparative III: 1 (4.3)
Andersson et al., Retrospective 29 78 Low, 19 (65.5) Yes Ot II: 24 Fr.C1: 3 (10) Mixed ASA Score I: 4 II: 20 III:
2000 [18] (Frankel) (82.8), Ot 5
III: 5 (17.2)
Harrop et al., Retrospective 10 80 Low, 8 (80) Yes (ASIA) Ot II: 10 Fr.C1: 4 (40) Surg. NA
2000 [19] (100)
Börm et al., 2003 Retrospective 15 81 NA Yes Ot II: 15 0 Surg. ASA Score mean: 3
[20] and (Frankel) (100)
comparative
Tashjian et al., Retrospective 78 80.7 NA Yes Ot II: 60 Fr.C1: 10 (12.8) Mixed Mean number: 2.1
2006 [21] (77), Ot III:
18 (23)
Frangen et al., Retrospective 27 85.5 Low, 27 (100) Yes Ot IIB: 27 0 (exclusion Surg. NA
2007 [22] (100) criteria)
Platzer et al., Retrospective 41 71 Low, 33 (80) Yes Ot II: 41 NA Surg. 6 patients with
2007 [23] et (100) comorbidities
comparative
Collins et al., 2008 Retrospective 15 69 Low, 9 (60) Yes Ot IIB: 15 No Surg. 8 patients with
[24] (100) comorbidities
Koech et al., 2008 Retrospective 42 80 Low, 23 (55) No Ot II: 42 No Ortho. NA
[25] (100)
Smith et al., 2008 Retrospective 72 > 80 NA Yes Ot II: 72 No Mixed Mean ASA score: 2,3
[26] (100) and 2 (Ortho. and
Surg.)
P. Jubert et al.
Daentzer et Retrospective 11 75.4 Low, 5 (45) No UCS NA Ortho. NA
Flörkemeier, and
2009 [27] comparative
Upper cervical spine trauma in elderly subjects

Table 1 (Continued)
Authors, year Type of study Number of patients Mean Force of Neurological Odontoid Associated UCS Treatment Comorbidities
age trauma, n (%) status fracture, n lesion, n (%)
reported (%)
(type)
Omeis et al., 2009 Retrospective 29 80 Low, 24 (82.8) Yes Ot II: 29 Fr.C1: 5 (17.2) Surg. NA
[28] (100)
Lefranc et al., Retrospective 27 80.7 Low, 20 (74) Yes Ot II: 18 Fr.C1: 3 (11.1), Mixed NA
2009 [29] (66.7), Ot Fr.C2: 2 (7.4),
III: 9 (33.3) ldislocation
C1C2: 1 (3.7)
Chaudhary et al., Retrospective 20 > 70 Low, 16 (80) Yes Ot II: 20 0 (exclusion Mixed NA
2010 [30] (100) criteria)
Dailey et al., 2011 Retrospective 57 81.2 Low, 36 (63) Yes Ot II: 54 Fr.C1: 11 (19) Surg. NA
[31] (95), Ot III: Fr.C2: 1 (2)
3 (5)
Hou et al., 2011 Retrospective 43 80.6 NA Yes Ot II: 43 NA Surg. 17 patients with
[32] (Frankel) (100) comorbidities
Mayer et al., 2011 Retrospective 18 78 NA No Ot II: 14 Fr.C1: 2 (11) Surg. NA
[33] (77.8), Ot
III: 4 (22.2)
Molinari et al., Retrospective 34 84 NA No Ot II: 34 NA Ortho. 10 patients avec
2011 [34] and (100) comorbidités
comparative
Osti et al., 2011 Retrospective 35 79.6 Low, 26 (74) Yes (ASIA) Ot II: 35 No Surg. 15 patients
[35] (100) withcomorbidities
Schoenfel, 2011 Retrospective 156 82 NA Yes Ot II: 156 NA Mixed NA
(100)
Hénaux et al., Retrospective 11 85.4 Low, 11 (100) Yes (ASIA) Ot IIB: 11 Fr.C1: 3 (27) Surg. Score ASA I: 0 II: 5 III: 6
2012 [37] (100)
Molinari et al., Retrospective 26 79 NA No Ot II: 26 NA Surg. 10 patients with
2012 [38] and (100) comorbidities
comparative
Ot II/III: ondontoid fracture type II/III from Anderson and D’Alonzo Classification; Ot IIB: odontoid fracture type IIB, Grauer classification; UCS: upper cervical spine; Fr.: fracture; Surg.:
surgical treatment; Ortho.: conservative treatment; Mixed: conservative OR surgical treatment.
S305
S306
Table 2 Rate of complications in relation to type of treatment.
Authors, Year Number of Number of Number of Number of complications Number of Total Overall CI 95%
patients patients patients after surgical treatment complications incidence
treated treated con- (type) after conservative %
surgically servatively treatment (type)
(type) (type)
Hanigan et al., 19 5 (posterior route) 14 (2 halo brace, 11 0 0 0 0.0 [0—20.9]

1993 [15] neck braces, 1
traction)
Berleman and 19 19 (anterior route) 5 (3 respiratory failure, 5 26.3 [10.1—51.4]
Schwarzenbach, 1 urinary infection, 1
1997 [16] hematoma)
Müller et al., 1999 23 5 (anterior route) 18 (13 halo brace, 5 0 4 (loss of 4 17.4 [5.7—39.5]
[17] neck braces) reduction)
Andersson et al., 29 18 (11 anterior route, 11 (1 halo brace, 10 1 (MCI) 1 (bedsore) 2 6.9 [1.2—24.2]
2000 [18] 7 posterior route) neck braces)
Harrop et al., 10 10 (anterior route) 2 (1 pneumopathy, 1 MCI) 2 20.0 [3.5—55.7]
2000 [19]
Börm et al., 2003 15 15 (anterior route) 2 (respiratory failure) 2 13.3 [2.3—41.6]
[20]
Tashjian et al., 78 13 (NA) 65 (38 halo brace, 27 Details Chir. et Ortho. 72 92.3 [83.4—96.8]
2006 [21] neck braces) Not given (16
pneumopathy, 12 ACR, 3
DVT/PE, 40 urinary
infection)
Frangen et al., 27 27 (posterior route) NA
2007 [22]
Platzer et al., 41 41 (anterior route) 10 (2 cardiac failure, 3 10 24.4 [12.9—40.6]
2007 [23] respiratory failure 3
pneumopathy, 1 severe
infection, 1 DVT)
Collins et al., 2008 15 15 (anterior route) 0 0 0.0 [0—25.3]
[24]
Koech et al., 2008 42 42 (32 halo brace, 10 4 (3 bedsores, 1 4 9.5 [3—23.5]
[25] neck brace) pin mobilization)
Smith et al., 2008 72 32 (10 anterior route, 40 (16 halo brace, 24 20 (10 respiratory 12 (7 respiratory 32 44.4 [32.8—56.5]
P. Jubert et al.
[26] 22 posterior route) neck brace) failure, 10 dysphagia) failure, 5 urinary
infections)
Upper cervical spine trauma in elderly subjects

Table 2 (Continued)
Authors, Year Number of Number of Number of Number of complications Number of Total Overall CI 95%
patients patients patients after surgical treatment complications incidence
treated treated con- (type) after conservative %
surgically servatively treatment (type)
(type) (type)
Daentzer et 11 11 (halo brace) 8 (4 pin site 8 72.7 [39.3—92.6]

Flörkemeier, infection, 1
2009 [27] bedsore, 3
problem with
material)
Lefranc et al., 27 11 (8 anterior route, 16 (neck brace) 0 0 0 0.0 [0—15.5]
2009 [29] 3 posterior route)
Omeis et al., 2009 29 29 (15 anterior route, 2 (1 Preoperative CRF, 1 2 6.9 [1.2—24.2]
[28] 14 posterior route) respiratory failure)
Chaudhary et al., 20 11 (anterior route) 9 (neck brace) NA NA
2010 [30]
Dailey et al., 2011 57 57 (anterior route) 34 (20 dysphagia, 11 34 59.6 [45.8—72.1]
[31] pneumopathies, 3 MCI)
Hou et al., 2011 43 43 (42 anterior route, NA
[32] 1 posterior route)
Osti et al., 2011 35 35 (anterior route) 10 (Cardiorespiratory 10 28.6 [15.2—46.5]
[35] distress, pneumopathy,
kidney failure: no
details)
Mayer et al., 2011 18 18 (anterior route) 1 (Postoperative 1 5.6 [0.2—29.3]
[33] gastrointestinal
hemorrhage)
Molinari et al., 34 34 (neck brace) 2 (bedsore) 2 5.9 [1—21.1]
2011 [34]
Schoenfeld et al., 156 44 (NA) 112 (NA) NA NA
2011 [36]
Hénaux et al., 11 11 (anterior route) 0 0 0.0 [0—32.1]
2012 [37]
Molinari et al., 26 26 (posterior route) 5 (1 worsening of 5 19.2 [7.3—39.9]
2012 [38] neurological status, 1
dural breach, 1
respiratory failure, 2
dysphagia)
MDI: myocardial infarction; CRF: cardiorespiratory failure; DVT/PE: deep vein thrombosis, pulmonary embolism; Surg.: surgical treatment; Ortho.: conservative treatment.
S307
Figure 2 Flow diagram of article selection.
studies on this topic are increasing in the literature [39—42]. The studies included in this review of the literature
Paradoxically, available published studies often lack statis- have different methodologies, study populations, types of
tical power even though the number of recently published treatment and reported follow-up. Moreover, there were no
studies is a sign of the growing interest in this subject prospective studies. Many of the series in the review include
[31—33,36—38,42]. at least 20 patients [16,20,24,37]. Often, information such
Table 3 Rate of nonunion in relation to type of treatment.
Surgery Conservative
Anterior route Posterior route
Number of patients 323 105 372

Number of patients with information 313 83 155
Union 202 (64.5%) 43 (51.8%) 53 (34.2%)
Nonunion 35 (11.2%) 14 (16.8%) 40 (25.8%)
Stable fibrosis 37 (11.8%) 14 (16.8%) 40 (25.8%)
Death 22 (7%) 12 (14.6%) 19 (12.2%)
Lost to follow-up 17 (5.5%) 0 (0%) 3 (2%)
as the initial neurological status, comorbidities, associated The presence of a secondary neurological deficit could
injuries and the level of autonomy before injury was not also be considered a risk factor of mortality even if the
reported [25,27,33,36,38]. association of a neurological deficit and UCS injury is rare
Many of these studies confirmed that the most frequent [3,6,10]. Decompensation of a cervical myelopathy with a
injuries of the UCS were type II odontoid process fractures motor deficit after a low energy trauma has been shown
and that there were two peaks in the frequency of this to increase the mortality rate in elderly subjects [3,11]. In
entity. The first was at 30 years old and the other around 75 the same way, the mortality rate in elderly subjects with a
[34]. Moreover, the category ‘‘elderly subjects’’ includes, cervical spine fracture and a neurological deficit increased
in fact, two subcategories, less than and more than 74 years at 3 months and 1 year of follow-up [10]. In this review
old, with different characteristics in each. UCS injuries of the literature, the post-traumatic neurological status
were more frequent and the mortality rate was higher in was reported in 85% of the studies but the description was
patients over 74 [4,7,15,36]. The studies in this analysis not homogenous. Certain studies used scores with detailed
observed that modified anatomical structures (osteoporo- scales (ASIA, Frankel) while others indicated the results of
sis, osteoarthritis) were responsible for the traumatic injury clinical examinations that nevertheless made it impossible
associated with a low energy trauma, like most other trau- to compare the different series. A UCS fracture was asso-
matic injuries in the elderly. [3,6,7,10,43]. ciated with a neurological deficit in less than 5% of cases
Despite their frequency, these injuries often go unnoticed and with tetraparesia in less than 1% in all the studies in
resulting in delayed treatment [5,33,35,37]. Nevertheless, this review. This percentage seems low compared to results
two North American studies, the National Emergency X published in certain studies. Patel recently found neurologi-
radiography Utilization Study (NEXUS) and the Canadian C- cal deficits in 9.6% of odontoid fractures, all ages combined
Spine Rule Study have described clinical criteria to prevent (42—89 years old) with a high mortality rate because 50% of
a delayed diagnosis and guidelines in the prescription of cer- these patients died within 3 months after injury [50].
vical spine X-rays following trauma [44,45]. More recently, An analysis of the literature showed that 57% of the
the validity of these criteria has been questioned, in partic- patients received surgical management and 43% conser-
ular in elderly subjects. Systematic CT Scan of the neck is vative treatment. Treatment selection criteria were not
recommended in these cases [46,47]. clearly defined but were based on the patient’s pre-existing
The type of treatment was often the only cause of condition, comorbidities, the characteristics of the frac-
mortality mentioned, while comorbidities and the patients ture as well as the surgeon’s and patient’s preferences.
pre-existing condition were not always described, even Odontoid screw fixation was the most frequent surgical
though they have been identified as a risk factor in other technique. There were no studies showing that this tech-
traumatic injuries in the elderly [20,21,48]. Only 58% of the nique was better than others. Moreover, there are numerous
studies in this review reported comorbidites and only 17% surgical techniques by posterior approach (C1—C2 arthrode-
defined them. This lack of information as well as number of sis with or without a graft, wiring) that are difficult to
different scores used (ASA, CCI, CIRS-G) made it difficult to compare.
perform a statistical analysis of the risk factors of mortality External immobilization with a rigid neck brace was used
and morbidity. in most cases (65%) of conservative treatment. The mean
The most frequent negative predictive factors in geriatric duration of immobilization with a neck brace or a halo corset
traumatology are comorbidities and injuries concomitant to was often long, sometimes as long as 24 weeks all [25,27,34].
the initial trauma [49]. Like comorbidities, these concomi- This long immobilization and its effect on autonomy can
tant injuries were only reported in 62.5% of the studies. seem surprising in a population of elderly patients.
Thus, there were concomitant C1 injuries in 10% of cases, In the surgery group union was obtained in 62% of patients
LCS injuries in only 1.5% and extraspinal injuries in 6.8%. compared to only 34% in the conservative treatment group.
Patients with concomitant injuries were excluded in certain The rate of ‘‘stable fibrosis’’ was twice as high in the conser-
studies such as Chaudhary et al. [30] and Frangen et al. [22]. vative treatment group as in the ‘‘surgical treatment’’ group
Except in the study by Lefranc, the exact type of concomi- (25.8% and 12.9% respectively), which can explain why dif-
tant injuries were usually not described, whether they were ference in the rate of nonunion was low between the two
of the cervical spine or peripheral injuries [29]. groups. Stability of the fracture site provided by the fibrous
S310
Table 4 Rate of mortality and causes of death.
Authors, year Number of Mean duration Number of Mortality rate Confidence Number of additional Cause of death
Patients of follow-up deaths at at 3 months interval 95% deaths at the final
(months) 3 months follow-up
Hanigan et al., 1993 [15] 19 28 5 26.3 [10.12—51.42] 0 5 cardiopulomonary

Berleman and 19 54 1 5.3 [0.28—28.11] 1
Schwarzenbach, 1997
[16]
Müller et al., 1999 [17] 23 44.3 8 34.8 [17.19—57.18] 0 7 cardiopulmonary,
head trauma
Harrop et al., 2000 [19] 10 10 1 10.0 [0.52—45.88] 1 1 cardiopulmonary,
1 NA
Andersson et al., 2000 29 51 0 0.0 [0—14.56] 10 NA
[18]
Borm. 2003 15 16.6 1 6.7 [0.35—33.97] 1 1 cardiopulmonary,
1 NA
Tashjian et al., 2006 [21] 78 NA 24 30.8 [21.08—42.38] NA 24 cardiopulmonary
Platzer et al., 2007 [23] 41 > 24 4 9.8 [3.17—24.06] NA NA
Frangen et al., 2007 [22] 27 3 6 22.2 [9.38—42.73] NA 6 cardiopulmonary
Smith et al., 2008 [26] 72 NA 10 13.9 [7.22—24.52] NA NA
Collins et al., 2008 [24] 15 18 0 0.0 [0—25.35] 0
Koech et al., 2008 [25] 42 24 0 0.0 [0—10.44] 0
Daentzer et Flörkemeier, 11 6.6 0 0.0 [0—32.14] 0
2009 [27]
Lefranc et al., 2009 [29] 27 12 5 18.5 [7.03—38.75] 0 NA
Omeis et al., 2009 [28] 29 13.5 1 3.4 [0.18—19.63] 0 1 cardiopulmonary
Chaudhary et al., 2010 20 >3 4 20.0 [6.61—44.27] 0 4 cardiopulmonary
[30]
Dailey et al., 2011 [31] 57 15 5 8.8 [3.27—20.04] 0 4 cardiopulmonary,
1 systemic
Osti et al., 2011 [35] 35 74 3 8.6 [2.24—24.19] 0 3 cardiopulmonary
Schoenfeld et al., 2011 156 36 33 21.2 [15.2—28.56] 28 NA
[36]
Hou et al., 2011 [32] 43 21.3 0 0.0 [0—10.21] 8 7 cardiopulmonary,
1 systemic
Mayer et al., 2011 [33] 18 75.7 0 0.0 [0—21.88] 0
Molinari et al., 2011 [34] 34 3 2 5.9 [1.03—21.06] 2 NA
P. Jubert et al.
Hénaux et al., 2012 [37] 11 34 2 18.2 [3.21—52.25] 0 NA
Molinari et al., 2012 [38] 26 13.7 5 19.2 [7.31—39.98] 0 5 cardiopulmonary
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Orthopaedics & Traumatology: Surgery & Research (2013) 99, S301—S312

Complications of upper cervical spine

Service de chirurgie orthopédique, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380

Accepted: 30 April 2013

∗ Corresponding author. Tel.: +33 01 47 10 77 36.

Introduction (mortality and morbidity) after treatment of traumatic UCS

Table 1 Characteristics of included studies.

Hanigan et al., Retrospective 19 > 80 Low, 15 (79) Yes Ot II: 16 No Mixed NA

Upper cervical spine trauma in elderly subjects

Table 2 Rate of complications in relation to type of treatment.

Hanigan et al., 19 5 (posterior route) 14 (2 halo brace, 11 0 0 0 0.0 [0—20.9]

Upper cervical spine trauma in elderly subjects

Daentzer et 11 11 (halo brace) 8 (4 pin site 8 72.7 [39.3—92.6]

Figure 2 Flow diagram of article selection.

Table 3 Rate of nonunion in relation to type of treatment.

Anterior route Posterior route

Number of patients 323 105 372

Table 4 Rate of mortality and causes of death.

Hanigan et al., 1993 [15] 19 28 5 26.3 [10.12—51.42] 0 5 cardiopulomonary

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