Mom is 65 and in the hospital for a work-up of her neck fracture. I guess there's a knob at top of her neck that has broken off. We could see it on the X-ray where they shoot the picture with her mouth open. There's been a lot of discussion about which way to go: bracing with a halo vest or surgery to pin the bone together and fuse the spine. Can you give us some of the pros and cons for each?
A fracture of the odontoid process (dens) is the most common type of fracture in the upper cervical spine. Just as you described, the odontoid process is a knob of bone attached to the second cervical vertebra. It pokes up through the hole formed by the first cervical vertebra. Together, these two cervical vertebrae (C1 and C2) form a stable based for the head to sit upon. They allow the head to flex, extend, tilt, turn, and shift without falling off. Of course, a series of ligaments and muscles help hold everything together and in place.
You can see why a fracture at this site can create instability of the head on the spine. A type II odontoid fracture extends through the base of the dens. Without treatment, pressure on the spinal cord can cause serious neurologic damage (e.g., paralysis and even death). It's clear that some type of treatment is required.
What's the best way to secure this broken bone? There are two basic choices: a rigid neck brace that holds the spine still until the fracture heals or surgical fixation. Surgical fixation means that screws are used to hold everything together while the bone knits itself back together.
The bracing option is really more for the younger crowd (50 years old and younger). Studies have shown that the complication rate is so high for older adults treated this way, it's just not worth it. So that leaves surgical fixation as the best practice for older adults (over age 70). As you have discovered, patients in the between ages (50 to 70) may have to consider the pros and cons of both when deciding.
Here are some things to think about. The fusion rate in older adults using external bracing with the halo vest is much lower than in younger folks. Poor fusion can mean an unstable spine. Patients 65 and older seem to have a much higher death rate when placed in this type of brace compared with younger patients. Cardiac complications, pneumonia, and respiratory arrest are a few of the potential hazards of bracing in older adults. That's why surgical stabilization is often the recommended course of action.
Surgery can be done from the front of the spine (the anterior approach) or from the back of the spine (the posterior approach). The anterior approach is often preferred by surgeons because it helps preserve neck motion. It also decreases the amount of trauma to the surrounding soft-tissues and doesn't require bone grafting to provide the stability needed. This approach reduces the time it takes to perform the operation and that's important for the older age group. There is also less risk of damage to the nerves and blood vessels compared with the posterior approach.
There are two major downsides to an anterior spinal procedure. And that's the fact that the patient can end up with difficulty swallowing called dysphagia. Dysphagia can lead to aspiration. Aspiration refers to inhaling food into the lungs. The result of aspiration can be pneumonia, a potentially life-threatening complication in this age group. All of that sounds rather dire when in fact, the surgery can, and often does, go well.
But you aren't left alone in making this decision. Your surgeon will be able to advise you based on the specifics of your mother's condition. Having some idea of the potential pitfalls will give you some idea what questions to ask. You want to feel confident that the best decision has been made based on all factors including age, severity of the fracture, your mother's general health, the presence of other health concerns, and so forth.
Andrew T. Dailey, MD, et al. Anterior Fixation of Odontoid Fractures in an Elderly Population. In Journal of Neurosurgery. January 2010. Vol. 12. No. 1. Pp. 1-8.
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