Thanks, Marjorie. Thanks, everybody, for being here so late on the last day. Great. So, yeah, my name is Srini Prasad. I'm one of the neurosurgeons at Jefferson. Here's my disclosures. Probably the pertinent disclosures are a couple. One of them is that I come from an institution. Why is this? I come from an institution that has a pretty strong bias, pro-surgery, for type 2 and onto. It's kind of a dogmatic institution, Jefferson. So a lot of it has to do with some of the characters that are there. But we tend to really be conservative with thoracolumbar fractures, like exquisitely so, and then fairly aggressive with type 2 and onto fractures. So those biases kind of creep into your skin. And so on some level, I think I have those. But I bring that to that. I will tell you, we'll go over some of it. It's tough to go over such a broad and controversial topic. But one of the things I'll say up front is that I'm pretty skeptical of most of the data that's out there. It's changed a lot. There's a fair amount that we'll review. So I'm not going to bore people too much. Talking specifically about geriatrics, the important thing to note is that it's a different mechanism in elderly people. Usually lower energy, lack of associated injury is quite common. It's quite common that it's in male and female preponderance equivalently. So those are probably the biggest distinctions. The biggest thing to say is you have to have a higher level of suspicion because it doesn't require a lot of energy for people to develop these. As I think were pointed out by a few people before, it's clear that we live in an aging population. This is from our institution showing the percentage of spinal cord injuries that are elderly. And you can see it's a growing percentage on top of the fact that spinal cord injury rates are actually going up as well. So this is an increasing problem. Certainly we're seeing more and more of it. That, coupled with the fact that type 2 adenoid fractures are the most common cervical fracture, means this is a problem that we really need a good answer for. I'm not sure if we have a good answer, but I'm going to go through the data on some level and some expert opinions on it and try to make it at least as rational as I can. So this is a case of one of my partners. A 74-year-old female comes to your ER. She's got a chronic type 2 adenoid fracture, increasing neck pain, one millimeter of movement on flexion extension films, neurologically intact. Gives you some story of a motor vehicle accident. Hard to know how significant a contribution that was. And this is her imaging. So everyone can see that okay? Just as a show of hands, how many people are doing nothing for this? And how many people are putting her in a collar or a halo? How many people are operating on it? Okay. All right. Perfect. So we'll go through some stuff and revisit the case at the end. So we're talking specifically about type 2 adenoid. I'm not going to go through the rest of it, but 60% of them represent that. This is just a high level. There's non-surgical and surgical options for managing this. The non-surgical is you can do nothing. Just benign neglect, pretend we never saw it. Honestly, it's probably more common than we think because we've all encountered incidentally identified chronic fractures like that, ladies. So the question is really what's the natural history of it? Nobody really knows what the natural history is. Halos, a variety of different collars, those are all the non-operative options. The operative options are really anterior and posterior. The anterior option is a form of adenoid screws. There's some reports of people doing anterior C1-2 transarticular. I've never done that. A variety of posteriors. C1-2 is probably the most common, you know, the harms technique. So in 2008, so it's only 10 years ago, Cochran view, pretty comprehensive really. The conclusion was that there's no great data on it to suggest either operative or non-operative, much less what the best operative or non-operative technique would be. So it's concerning considering that it's a growing thing and we don't have an answer to it. So I just went through kind of comprehensively. If you don't do anything, this is an old paper from 1985 saying if you do nothing, small numbers, they don't heal. So fine. So this was followed at a non-union rate of 100%. The next question is, so what? Like if it hasn't healed, what's the natural history of fibrous non-union in somebody who maybe is asymptomatic? Now admittedly, if they have neurological symptoms or neck pain, it's a different animal. We're talking about people with just non-healed fractures. What's the relevance of it? Super small paper, but looks at a fairly elderly population to say what happens if you follow these people for five years or four something years. Which is kind of interesting. Not many of these things follow them for a very long time. This group followed them for five years and says, none of them go on to progress to develop neurological symptoms or something else. So maybe there's not a huge risk to non-union. And I think that that, my own personal bias, is there's probably not a huge risk to it. Having said that, there's very little data to corroborate that. And there are four papers, I took them out of this, but four papers that are controversial about, there's two papers that suggest, one from Crocker that suggests that late neurological decline is possible, but in a fairly small subset of people. And then there's another report from India that shows it also to be possible. So I'd say the jury's out on that, but the morbidity of a non-healed is hard to know. So if you look at changing gears then, collars versus halos, and just look at union rate. Let's just look at how likely it is to fuse. What's clear from this, and this is kind of lumped in, if you want to read it, it's all on there, but really the things to highlight are the fact that in the elderly, in every paper, there's a fairly low rate of fusion or healing. And that's important to kind of compare. 20 percent, 22 percent, 32 percent, 14 percent, to the distinction of the younger populations. The younger populations tend to heal pretty well, as a general rule. On top of that, I think halos, how many people use halos for this? Type 2 odontoid fractures, anybody putting people still in a halo? Right, I think it's pretty much, I can't remember the last time we put a type 2 odontoid fracture in somebody older than like 50 in a halo. But there's a fair amount of literature, and I think everybody must be aware of that then, showing striking mortality, striking morbidity, to taking some 78-year-old frail person and putting them in a halo. It's like a death sentence. So then, this is the last slide to kind of outline conclusions for nonoperative management. What's clear with that is that it's a much more complicated situation. Nonoperative, a bracing carries significant morbidity, whether it's a halo or a collar in the elderly population. And here's the numbers. Significant rates of nonunion, significant rates of morbidity, and fairly significant rates of mortality with particularly halos. So overall, a fairly high failure rate with nonoperative management if failure is defined to be nonhealing of the fracture. So surgical options, we'll go through anterior versus posterior. So the anterior option is really a odontoid fixation, one or two screws. The benefits of it are that it's short. As a procedure, they're pretty quick. People can get very facile with them. Supine positioning, it spares the C1-2 articulation. So it's a great technique, particularly in younger people. I think it's an awesome technique. Yeah, the union rates are, you know, approach 100%. The problems in the elderly are a few things. One of them is that the trabeculae at the C2 base of the dens, significantly more rarefied. And so there's a fairly lower rate of fusion on those patients. The other thing is that they really can't take a joke. And it's mostly the hypopharyngeal and parapharyngeal plexus. Like you can't, even a little bit of manipulation of those, they develop these apraxias, dysphagia, swallowing troubles, et cetera, aspiratory airway issues. And those are real, and those affect older people certainly much more for a variety of reasons. Posterior, this is like a video that I got from somebody that I like, so I kind of kept it playing. But there's a variety of ways of doing it. You could imagine that wiring, kind of established, Galley-Brooks, those, they're great. Old school, certainly when I started my training, that was still pretty common. We take iliac crest autograft on most patients. For whatever reason, one of the distinctions between, we're talking about old people here, elderly, young people really don't tolerate iliac crest autograft very well. And they really don't tolerate C1-2s very well. Elderly people, for whatever reason, seem to tolerate it better. It doesn't seem to bother them as much. They tolerate iliac crest autograft. So we do take quite a bit of iliac crest autograft for that. It's not the way I was trained. It's certainly a thing at my institution, but it's something to mention. But C1-2 transarticular screws, which were just shown, C1-C2 kind of harms technique, lateral mass at C1, C2, pick your poison pars, pedicle, laminar. The benefits of this are that biomechanically it's very robust. It's a very definitive treatment. We put people in a soft collar or nothing. Usually the soft collar is for comfort for a couple days and they go home. Very high fusion rates, very low rates of dysphagia. And probably the biggest benefit of it, this is kind of editorial, but probably the biggest benefit of it is really the fact that the messaging to their nursing home, their home, their family, is that this has been a fixed problem. People mobilize them quickly. They get them eating quickly. They're walking quickly. And I think that probably has a greater impact than how people do in the long term anyway. Like our emphasis is if we do a C1-2 on somebody with a type 2 odontoid fracture who's older than 70, we get them standing that day, like walking, out of bed, eating. We get them moving along and try to get them out of the hospital ASAP. And I think that probably it's more of a messaging thing. So this is a quick overview of the same. These are the posterior typical things. That video had shown a lot of them. The common ones, again, are C1-2 transarticular fixation. We don't do as many. I don't do as many of these. If I do do them, I use navigation. The anatomy has to be quite favorable, and I'll leave it at that. The C1-2s, the thing to emphasize, I think most people are familiar with how to put C1 lateral mass screws in. The C2, there's a variety, pedicle, PARs, laminar. And I think there's advantages to both. Particularly in osteoporotic people, there's some advantages to laminar screws. The big downside, no risk to the verte. So somebody with an anomalous verte architecture or something, this is a nice technique. The big problem is they tend to be pretty proud, and elderly, frail people especially can really be prominent and painful. So something else to consider. I'd say the lion's share of what we do are PARs. The second would be laminar, and I do fairly uncommonly, I'll do a pedicle screw. So now when you look at, we'll switch gears a little bit. We'll talk about some of the evidence for it. Some of the evidence is old, and the last five years is really when there's been the emergence of the most data, which I'll try to spend a bit more time on. This is the one paper I could find that looked at collar versus anterior versus posterior. And it's pretty long follow-up. I mean, four-year follow-up. These numbers, you know, 100%, C1-2, anterior screw strikingly low. I don't understand how an anterior screw has significantly lower fusion rate than nothing at all. But, you know, with a grain of salt, it seems like it suggests that there's some advantages to posterior surgery. We change gears a little bit and talk about anterior versus posterior alone. This paper also, all of these papers are retrospective, which I find very striking in terms of how you can interpret them. But the things to note on them, on this conclusion from this paper, it's fairly small, is that really anterior and posterior are both reasonable, reasonable techniques for it and roughly equivalent. There are a few meta-analyses that are the last slide that I'll get into that will kind of dwell on that a touch more on the anterior versus posterior. So two things, the one thing I would say is that at our institution, we have noticed an increase in the incidence of this. We encounter it much more frequently. And this is like a 20-, 30-year trend at Jefferson. We also notice that we've been operating on more of them over time. So the gray, darker gray, the top part of this represents surgical. And, of course, the bottom one is a non-surgical. So you see two things on this slide. One is that it's been growing at least in our population, and we've been incrementally operating on more of them. That's certainly been the trend for a variety of reasons in our institution. So there are a few papers. This is a busy one. I tried to kind of distill it down a little bit, and I'll just kind of emphasize the important things. This is three different institutions, all level I trauma centers, collected over six years. Fairly large number, 320, and fairly balanced, you know, 150-something, 160-something. It is retrospective, which implicitly means that it was surgeons' choice about how to manage them. So you'd have to argue there may well be some distinctions between or differences in the populations. But the things to take away from this are a couple. One of them, the mortality rate is significantly higher in the non-operative group than the operative. Longer hospital stay, longer ICU stay. The hospital stay struck me as unusual. Longer ICU stay, they're almost equivalent, 1.5 versus 1.1. And the conclusion from this is that there is a survival advantage to surgical management to them. The challenge or the criticism being, of course, there may be different populations. Certainly at our institution, for us not to operate on a type 2 odontoid fracture, somebody has to be pretty sick. So I'm not sure what the implication of that is. So then this is another paper. What I thought was interesting about this paper, again, it's a large paper. It's a fairly long horizon with pretty good follow-up. And this organization, this institution, appeared to have a bit more of a bias towards non-operative management, at least if this is any reflection on how they managed this 150-something patients. Having said that, I almost found this more credible. The operative mortality rate was 25% as opposed to 45%, which is, again, a pretty striking difference. I think it is important to recognize that surgical management could well have a lower mortality rate as borne out by a variety of different studies than conservative management. I think that's important. When you drill down, another kind of thing to mention, which I didn't put into this, but to mention when you look at the studies on it is that when that happens tends to also be different. When you operate on somebody, their highest risk of mortality is like the first seven days, where when you don't operate on them, it's the spread-out mortality over three months. So it's important to kind of recognize that getting them out of the hospital is important, and once they hit the one-week mark, they're kind of home free. There are a couple. This is an important paper only because it's a prospective study. But one of the things to say is the treatment preference in these 159 patients really is up to the surgeon. You can kind of use the fact that 100 versus 60 is a reflection of maybe the leanings of the group. The posterior C.1.2 was the posterior fusion of choice, and 80 percent basically in the non-surgical treatment was mostly hard collars, just so you kind of know. So this looks at functional and quality of life outcomes in people. So I'll just say quickly, the NDI scores were worse in the non-surgical group. No real difference in complication rates. The non-union rate was significantly higher in the non-surgical group. The fusion rate was much higher in the surgical group. I think those are the important takeaways. Once again, the mortality is almost twice as high in the non-surgical group. So there are a couple more slides to go through that I think are relevant. This is a follow-up on the same study, a second paper on it, that basically looks at risk factors for poor outcome, poor outcome being death, NDI of greater than 9.5 or a major complication. And the things to really notice are these three, that conservative management has a threefold or an odds ratio of three for a poor outcome. Another thing about it, even though it's a one-to-one male-to-female ratio, four times more likely, if you're a male, to have a problem in that group. So this paper is a meta-analysis one of my colleagues did, 21 articles, 1,200 patients looking at a variety of things. They distilled it down to simple questions, which may be like the most value of a meta-analysis of this size. The left one shows operative versus non-operative, and it suggests that mortality favors operative, short-term and long-term mortality favor it, and complications are roughly equivalent between operative and non-operative. And the second column shows anterior versus posterior, which basically shows it's roughly the same, except fusion is favored in the posterior, so slightly higher fusion rate posteriorly than anteriorly. But complications, mortality, morbidity, on this pretty large meta-analysis there. So this is a paper that Jim Harrop, one of my colleagues, had written. It's really just expert review, but sampling a number of people. And there's some important questions that kind of conclude this. So the optimal management for a type 2 odontoid fracture in the elderly patients, looking at the literature, very low-quality literature, a weak recommendation for operative stabilization. And I think that the data that I showed today kind of reinforces that. The optimal non-operative treatment for type 2 odontoid fractures, if you're going to do anything, it's a hard collar and not a halo. And I think that's been borne out kind of time and again, and I think it's based, again, on reasonable, though low-quality, consistent data. And the last thing is, what's the optimal operative treatment? And the literature is pretty low-quality as well, with a preference or a recommendation for posterior fixation as the fixation of choice. So you revisit this patient, which is unusual. I mean, we see so many typical fractures. This is one that I thought was kind of interesting. So one of my colleagues managed this person in a collar for two months. I'm not sure why. Presented with neck pain. If you looked at the MRI, maybe there's some stir signal within the adjacent marrow, but it's clearly a corticated, maybe some irritation of an old fracture. She stops wearing it at four months, kind of goes about life, feels fine. Five years later, five years later, presents to our institution with slow progression of myelopathy that she reports on history, fell and had a pretty bad spinal cord injury with the center cord syndrome. So, not without, I mean, obviously this is a zebra case. I mean, she went on to have a posterior C1-2. I think the people that said in the room that they would have C1-2'd it up front I think is probably reasonable, might have been right in this. This is a fairly rare event, but it's how this one ended, and it's part of the reason we put it in. So, in summary, I would say a few things. One is that it's increasingly common. We're all encountering them a lot as it is. It's only going to be a growing problem. Halovestin mobilization is really just a no-go at this point, and it sounds like everyone in the room knows that. Anterior approaches do carry a higher complication risk based on a few of the papers, not every, and not that meta-analysis, particularly dysphagia, swallowing trouble, et cetera. So, many of our patients already have those problems when you ask about it. Something to be sensitive about. And they also have lower fusion rates than posterior. And then optimal management really is controversial and has to be based on discussions, people's level of frailty, et cetera. Thank you. Do you treat for osteoporosis as well? After you fuse, do you use Forteo or anything? When I encounter type 2 endotractures? Yeah. Is that what you mean? Yeah, so I do. We get Texas scans quite routinely, or I talk to them, but when I started practice like 10 years ago, I really felt like I wanted to learn everything about osteoporosis management because it was such an important thing. Now if I see someone with a compression fracture or type 2 endotracture, I'll use it to trigger getting a DEXA scan and then involving them with our endocrinologist or their primary care doctor, but kind of enlisting the help of them to have that discussion with them. Not just, 82-year-old patients with type 2 endotractures, what do you offer? Healthy otherwise. Fairly active healthy. Yeah, yeah, yeah. So in somebody who's otherwise fairly active, I mean it's a function of the social context, but I'll tell you in the absence of a significant medical contraindication, we've fused those 100 out of 100 times at Jeff. No, I think it's okay. I mean I think you can put them in a collar, you can counsel them about nonunion, you see them back at six weeks, get them out, maybe flex X them. I mean the risk really is neck pain. This is not that common, right? It's really just ongoing neck pain down the road, and I guess that could be managed if people want it, but somebody who's turning it down in the acute setting is probably not going to want surgery anyway. So I think you're very much in bounds to manage it nonoperatively. And there are situations. Believe it or not, Alex Vaccaro is so aggressive. Like the fellows will discharge people if they're like, oh, we discharged a 104-year-old because otherwise if he came in on Monday morning, he would have fused it. You know? So it's something that's like we, you know, it's a bit extreme, like the way we manage some of the type 2 odontoid fractures. There's a paper coming out of the Toronto Group now that says that if they look at the quality of life impact and the cost per QALY, that the calculation is that beyond the age of something ridiculous, like 94, I just saw in the manuscript, like beyond the age of 94, it doesn't make sense. But below that, it's acceptable and cost effective. It's kind of striking. Any other questions? Okay, great. Thank you. All right.

type 2 odontoid fractures

elderly patients

management

surgical approaches

non-surgical approaches