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World Neurosurgery Mar 2020Instability of the craniovertebral junction (CVJ) following odontoidectomy is relatively common. Traditionally, separate stage posterior atlantoaxial ± occipitocervical...
Instability of the craniovertebral junction (CVJ) following odontoidectomy is relatively common. Traditionally, separate stage posterior atlantoaxial ± occipitocervical fusion is used for treatment. A transmucosal approach using a clean-contaminated route is associated with hypothetical risks of infectious complications. There is a paucity of information in the literature assessing the risk of surgical site infection (SSI) using the transmucosal approach for hardware placement. The authors conducted a literature search through PubMed identifying patients with pathology requiring transmucosal (i.e., transnasal or transoral) CVJ fixation. Studies that described 1) cases requiring a transmucosal approach and 2) associated infectious complications were included. Rates of SSIs, device removal, unplanned reoperation, and hardware failures were analyzed. Descriptive statistics and odds ratios (ORs) were used to compare complications. Nine studies with a total of 431 patients were identified. There were 4 (0.93%) superficial SSIs and 4 (0.93%) deep SSIs. In total, 1.86% of patients experienced SSI. There were 18 (4.18%) cases of unplanned reoperation, 4 (0.93%) related to SSI. Five (1.16%) patients required removal of their anterior fixation device, 4 (0.93%) related to SSI. ORs comparing our results with Medvedev et al's retrospective National Surgical Quality Improvement Program study assessing the risk associated with posterior cervical fixation showed no statistical difference between postoperative infection rates (OR = 0.72, P = 0.36). An extensive review of the literature found no evidence to suggest placement of spinal hardware via transmucosal corridor is associated with an increased risk of SSI.
Topics: Atlanto-Axial Joint; Atlanto-Occipital Joint; Device Removal; Humans; Mouth Mucosa; Nasal Mucosa; Odontoid Process; Reoperation; Spinal Cord Compression; Spinal Fusion; Surgical Wound Infection
PubMed: 31811965
DOI: 10.1016/j.wneu.2019.11.168 -
Journal of Neurosurgery. Spine Jan 2024Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the inherently increased surgical risks in older patients. The objective of this study was to compare fusion rates and outcomes between operative and nonoperative treatments of type II odontoid fractures in the older population.
METHODS
A systematic literature review was performed to identify studies reporting the management of type II odontoid fractures in patients older than 65 years from database inception to September 2022. A meta-analysis was performed to compare rates of fusion, stable and unstable nonunion, mortality, and complication.
RESULTS
Forty-six articles were included in the final review. There were 2822 patients included in the different studies (48.9% female, 51.1% male), with a mean ± SD age of 81.5 ± 3.6 years. Patients in the operative group were significantly younger than patients in the nonoperative group (81.5 ± 3.5 vs 83.4 ± 2.5 years, p < 0.001). The overall (operative and nonoperative patients) fusion rate was 52.9% (720/1361). The fusion rate was higher in patients who underwent surgery (74.3%) than in those who underwent nonoperative management (40.3%) (OR 4.27, 95% CI 3.36-5.44). The likelihood of stable or unstable nonunion was lower in patients who underwent surgery (OR 0.37, 95% CI 0.28-0.49 vs OR 0.32, 95% CI 0.22-0.47). Overall, 4.8% (46/964) of nonoperatively managed patients subsequently required surgery due to treatment failure. Patient mortality across all studies was 16.6% (452/2721), lower in the operative cohort (13.2%) than the nonoperative cohort (19.0%) (OR 0.64, 95% CI 0.52-0.80). Complications were more likely in patients who underwent surgery (26.0% vs 18.5%) (OR 1.55, 95% CI 1.23-1.95). Length of stay was also higher with surgery (13.6 ± 3.8 vs 8.1 ± 1.9 days, p < 0.001).
CONCLUSIONS
Patients older than 65 years of age with type II odontoid fractures had higher fusion rates when treated with surgery and higher stable nonunion rates when managed nonoperatively. Complications and length of stay were higher in the surgical cohort. Mortality rates were lower in patients managed with surgery, but this phenomenon could be related to surgical selection bias. Fewer than 5% of patients who underwent nonoperative treatment required revision surgery due to treatment failure, suggesting that stable nonunion is an acceptable treatment goal.
Topics: Humans; Male; Female; Aged; Aged, 80 and over; Spinal Fractures; Odontoid Process; Fractures, Bone; Treatment Failure; Treatment Outcome; Retrospective Studies
PubMed: 37877937
DOI: 10.3171/2023.6.SPINE22920