Surgical Management of Type II Displaced Dens Fractures Improves One-year Mortality in Elderly Patients

Study Design. Retrospective cross-sectional analysis of US national data collected by PearlDiver Inc. database. Objective. To determine the rates of surgical/nonsurgical treatments and associated one-year mortality for displaced type II dens fractures without neurological deficit. Summary of Background Data. Existing literature on dens fractures includes small series of patients with highly variable surgical rates. These studies contain insufficient data to determine the benefits of surgical or nonsurgical treatment as surgeon bias in treatment and selection of patients have significant effects on the results. Materials and Methods. Displaced type II dens fractures and upper cervical surgeries were identified using their respective International Classification of Diseases, 10th Revision (ICD-10) diagnosis and Current Procedural Terminology (CPT) codes. Inclusion criteria included patients older than 65, diagnosed with a displaced type II dens fracture, absent neurological damage, during the years 2015 to 2018. Age, sex, ICD-10 diagnosis codes, CPT codes, displacement type, and Elixhauser Comorbidity Index scores were obtained through the PearlDiver database. Patient-related variables and one-year mortality associated with surgical versus nonsurgical treatment were compared using univariate χ²analysis, odds ratios, and multivariate logistic regression analysis. Results. Among the 5300 patients who met our inclusion criteria, 59% (n=3108) were female, the mean age was 76.6 (±3.9) years old, and the average Elixhauser Comorbidity Index was 7.1 (±4.0). Only 8.3% (n=437) had surgical treatment for the displaced dens fracture. Multivariate logistic regression analysis for one-year mortality showed surgery was associated with decreased one-year mortality in all patients (z=-6.26; P<0.001), patients between the ages of 65 and 74 (z=-2.53; P=0.012), and patients over the age of 75 (z=-5.81; P<0.001). Conclusion. Despite surgery improving survival in elderly patients with type II dens fractures, surgical management is rarely pursued. Factors that independently increase the likelihood of surgery include younger age, male sex, and posterior displacement. Level of Evidence. 4.