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1
Department of Radiology, University of Vienna, Waehringer Guertel 18-20,
A-1090 Vienna, Austria.
2
Department of Radiology, Harborview Medical Center, 325 Ninth Ave., Box
359728, Seattle, WA 98104-2499.
3
Department of Orthopedic Surgery, Harborview Medical Center, Seattle, WA
98104-2499.
Received June 26, 2001;
accepted after revision August 29, 2001.
Address correspondence to C. C. Blackmore.
Abstract
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MATERIALS AND METHODS. The distribution and type of 225 cervical spine injuries in 149 consecutive patients 65 years old and older over a 5-year interval were retrospectively assessed. For each patient, initial admission imaging studies were reviewed, and injuries were classified. Trauma mechanism (falls from standing or seated height vs higher energy mechanisms) and initial clinical and neurologic status were recorded. Data were correlated according to patients' age (65-75 years and >75 years) and causative trauma mechanism.
RESULTS. Ninety-five (64%) of 149 patients had upper cervical spine injuries. Fifty-nine (40%) of 149 patients had multilevel injuries. Main causes for cervical spine injuries were motor vehicle crashes in "young elderly" (65-75 years old; 36/59, 61%) and falls from standing or seated height in "old elderly" (>75 years old; 36/90, 40%). Fracture patterns at risk for neurologic deterioration were common (>50%), even in the absence of acute myelopathy or radiculopathy. Patients older than 75 years, independent of causative mechanism, and patients who fell from standing height, independent of age, were more likely to have injuries of the upper cervical spine (p = 0.026 and p = 0.006, respectively).
CONCLUSION. Cervical spine injuries in elderly patients tend to involve more than one level with consistent clinical instability and commonly occur at the atlantoaxial complex. Old elderly patients and patients who fall from standing height are more prone to injuries of the upper cervical spine.
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A striking feature of older patients is their propensity to suffer major cervical spine injury from seemingly minor trauma (e.g., falling from standing or seated height) [11]. To our knowledge, few reports of associations between trauma mechanism and pattern of cervical spine injury in the elderly are available. Further, on the basis of common practice, the typical elderly population can be divided into "young elderly" (65-75 years old) and "old elderly" (>75 years old) [12, 13]. This distinction reflects observed differences in functional decline [14], trauma mortality rates [15], and osteoporosis [16]. To our knowledge, differences in cervical spine injury patterns between these two age subpopulations have also received little attention in the literature.
The objectives of this study were twofold: to describe patterns of cervical spine fractures in the elderly population, assessing type, distribution, and associated clinical and radiologic findings; and to identify any association in fracture pattern between causative trauma mechanism and patient age.
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We retrospectively identified all patients from our level 1 regional trauma center who had sustained cervical spine fractures and were 65 years old or older from a 5-year period (1996-2000), using our institutional inpatient trauma registry, the orthopedic department case logs, and the radiology information system (n = 162). Patients for whom radiographs were not available were excluded (n = 13).
For each patient, cervical spine studies from the initial workup were reviewed to verify case inclusion, to characterize the spectrum of age-related findings, and to classify the type of fractures in this consecutive elderly population. The imaging studies were retrospectively evaluated by one of two board-certified radiologists with subspecialty experience in emergency radiology who were blinded to clinical information. Available imaging studies included conventional radiography in all patients and CT scans (HiLight Advantage and LightSpeed; General Electric Medical Systems, Milwaukee, WI) in nearly all patients. MR imaging was used in only a minority of patients (1.5- T scanner, General Electric Medical Systems).
The craniocervical to cervicothoracic junctions were assessed for the presence of degenerative changes, multilevel intervertebral fusion, fracture associated paravertebral swelling, and presence of endotracheal intubation. Multilevel intervertebral fusion was defined as fusion of four or more adjacent vertebral bodies from diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, spondylitis deformans, or other causes. Fractures of the upper cervical spine, including the levels C0-C2, were classified according to Harris et al. [17]. Lower cervical spine fractures, including the levels C3-C7, were classified on the basis of a revision of the Orthopedic Trauma Association classification method [18] into six main categories of increasing severity of injury, ranging from clinically stable and relatively unimportant fractures (category 1) to clinically highly unstable and severe fracture—dislocations (category 6).
Records of initial emergency department evaluation of study patients were reviewed to extract clinical information. This review focused on notes written by the emergency department physician and the consulting orthopedic surgeon and neurosurgeon. Additionally, an electronic database of procedure reports, hospital discharge summary reports, and outpatient evaluation reports was reviewed to supplement and confirm the findings noted in the emergency department records. The reviewer extracting clinical data, a board-certified orthopedic surgeon specializing in spinal disorders, was blinded to the radiologic fracture-pattern data. Abstracted clinical information included the documented mechanism of injury; reported symptoms of pain, numbness, and weakness; and reported findings of neurologic status.
According to the mechanism of injury, the patients were separated into two groups: low-energy injuries were those that occurred from falls of standing or seated height, whereas high-energy injuries included those occurring from falls from greater than standing height, crashes of motor vehicles, pedestrains struck by cars, or other mechanisms consistent with high-energy deposition. Further, the study population was prospectively divided into two age groups. Patients from 65 to 75 years formed the group of young elderly, and patients older than 75 years formed the group of old elderly [12, 13].
Comparisons between groups (including injury types in patients with different trauma mechanisms and injury types in different age groups) were made using the chi-square statistic. To avoid confounding by inclusion of multiple fractures in the same patient, we performed all statistical analyses with the patient as the unit of analysis, classified by the level with the most severe injury. Graphs of fracture frequency used each fracture as the unit of analysis, with multiple fractures from the same patients included. In addition, we modeled for independence of age (young elderly vs old elderly) and mechanism of injury (low- vs high-energy) as predictors of injury patterns, using multiple logistic regression. Correction for multiple comparisons used the Bonferroni method.
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At the time of initial imaging, 41 patients (28%) had undergone intubation, whereas 108 patients (72%) had not undergone intubation. Of patients treated with intubation, 27 (66%) had injuries of the upper cervical spine (C0-C2), and 14 patients (34%) had injuries of the lower cervical spine (C3-C7). Of the patients not undergoing intubation, 63 (58%) had injuries of their upper cervical spine, and 45 patients (42%) had injuries of the lower cervical vertebrae. Prevertebral soft-tissue swelling in patients not undergoing intubation was shown by conventional radiographs in 83% of patients with injuries to the upper and in 60% of patients with injuries to the lower cervical spine (p = 0.009). Degenerative osseous changes were present in almost all patients (99%). Multilevel intervertebral fusion was present in a minority of patients.
As a result of multilevel injuries, 225 vertebrae in the 149 patients were fractured or dislocated. On the basis of these injuries, frequency of involvement of each vertebra was evaluated. C2 was the most commonly injured vertebra, with 91 (40%) of 225 cervical spine injuries occurring at this level (in 61% of patients). Thirty-two (14%) of 225 injuries were fractures of the atlas, and five (2%) of 225 injuries were fractures of the occipital condyles. In the lower cervical spine, the C5 and C6 vertebrae were most commonly injured, with equal frequency (each in 12% [26/225] of all injuries). The C3, C4, and C5 vertebrae were less frequently injured, in 11 (5%), 19 (8%), and 15 (7%) of 225 injuries, respectively.
In 90 patients (60%), only a single level in the cervical spine was injured. In 44 patients (29%), injuries to two adjacent vertebrae were depicted, of which two patients also had an associated fracture in a more noncontiguous cervical vertebra. Eleven patients (7%) had an injury to three adjacent vertebrae. and one patient (1%), to four adjacent vertebrae. Another four patients (3%) fractured two distant cervical vertebrae. Frequency and distribution of injuries to adjacent levels were evaluated. Most of these multilevel injuries involved the C1-C2 motion segment (40%). In the lower cervical spine, the C5-C6 level (20%) was most frequently affected (20% of all multilevel injuries). The other motion segments were less frequently involved (C0-C1, 6%; C2-C3, 6%; C3-C4, 7%; C4-C5, 8%; C6-C7, 13%).
Frequencies of injury type by vertebral level are shown in Table 2 for the upper cervical spine and in Figure 1 for the lower cervical spine. In the upper cervical spine, the most frequently occurring fracture types were odontoid fractures, with "high" (Anderson-D' Alonzo type II) odontoid fractures occurring in 33 (22%) of 149 patients and "low" (Anderson-D' Alonzo type III) odontoid in 35 (23%) of 149 patients [19, 20]. Of type II dens fractures, 56% occurred in combination with fractures of Cl, whereas only 20% of type III dens fractures were associated with fractures of the atlas. In our patient population, no Anderson-D' Alonzo type I odontoid fracture occurred.
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In the lower cervical spine, approximately one third of injuries (37%) were clinically stable minor disruptions, including isolated spinous process, laminar, and transverse process fractures or anterior compression fractures. Even in the absence of myelopathy or radiculopathy, most lower cervical spine fractures (63%) in the elderly were classified as potentially unstable, including either uni- or bilateral injury to the facet joints (mainly due to hyperflexion mechanism), burst fractures, and, in a large proportion, hyperextension fracture dislocation injuries.
At time of injury, 59 (40%) of the 149 patients were 65-75 years, forming the group of young elderly. Ninety patients (60%) were over the age of 75 years, representing the old elderly. Old elderly patients with a fracture were significantly more likely to have sustained upper cervical spine injuries than patients between 65 and 75 years (p = 0.003), as shown in Figure 2.
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Forty-five patients (30%) were admitted to the hospital because of falls from standing or seated height, considered as injuries of low energy. One hundred four patients (70%) had a history of trauma considered high-energy injury, including falls from greater than standing height and motor vehicle collisions (Table 1). The comparison in distribution of injured level in patients with high- and low-energy injury mechanisms showed that patients with low-energy mechanism (fall from standing or seated height) were significantly more likely to sustain upper cervical spine injuries than patients with a high-energy mechanism (p = 0.001) (Fig. 3).
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Multiple logistic regression analysis showed that the associations of age and mechanism with fracture distribution were independent. Older elderly patients were more likely to have fractures of the upper cervical spine, independent of mechanism (odds ratio = 2.2, 95% confidence interval [CI]: 1.1-4.5, p = 0.026), and patients with low-energy mechanism were more likely to have injuries of the upper cervical spine independent of age (odds ratio = 3.3, 95% CI: 1.4-7.6, p = 0.006).
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A striking feature in the elderly population is that patients with histories of falls from standing or seated heights are more likely to injure their upper cervical spine in contrast to patients who are involved in high-energy injuries, such as motor vehicle crashes or falls from greater than standing height. The old elderly patients, compared with young elderly patients, are more likely to sustain cervicocranial injuries, regardless of the mechanism.
Degenerative osseous changes are known to influence the site of cervical spine injuries and were shown in almost all patients (99%). Under normal circumstances in the younger individual, the most mobile motion segments are C4-C7. Not surprisingly, most fractures in younger patients occur at these levels [1]. With degenerative changes, these same segments become less mobile, and the C1-C2 motion segment becomes the most mobile portion [3]. The higher incidence of upper cervical injury in the elderly population may be due to the stiffening effect of aging on the vertebral column. Injury distribution in our consecutive study population supports this stiffening thesis, with the C2 vertebra as most frequently injured, followed by the C1 level in the upper and C5 and C6 levels in the lower cervical spine. These findings are in agreement with previous studies, which indicate a high frequency of upper cervical spine injury, particularly odontoid fractures and injuries involving the atlantoaxial complex in elderly patients [4,5,6,7,8,9].
The prevalence of cervical spine fractures among elderly patients is greater than that among all other age groups [21]. This distribution has been attributed to the propensity of the elderly to sustain falls, a greater per mile risk for motor vehicle crashes, and the biomechanical attrition associated with senile osteopenia. Not surprisingly, the prevalence of spinal fractures increases with increasing age [1, 22,23,24], and age-related increases in trauma mortality are evident by the fifth decade [25]. However, most publications dealing with cervical spine injuries simply define "elderly" as age 65 years and older [26]. On the basis of the broader context of aging and illness, the typical elderly population may be subdivided into young elderly (65-75 years) and old elderly (>75 years) [12,13,14,15,16]. These groups differ, and these differences suggest that the propensity of old elderly for fractures of the upper cervical spine may reflect accelerated age-related changes in the senescent spine.
Regarding the mechanism of injury, events leading to cervical spine fractures in the elderly are commonly considered as trivial mechanisms in young adults. Falls, usually from standing or seated height, are the most frequent causative mechanism for cervical spine injury in patients older than 65 years [4,5,6]. Comparing the trauma mechanism that led to cervical spine fractures in our age-based subpopulations, we found that most young elderly were injured as drivers or passengers of motor vehicles involved in crashes, whereas the majority of old elderly sustained their cervical spine injuries in falls from standing or seated height. This difference suggests that apparently low-energy injury mechanisms in the old elderly should be considered high risk for cervical spine fracture. In addition, this propensity for injury with low-energy mechanisms will likely become increasingly significant as the population of superannuated individuals increases.
Development of optimal cervical spine imaging protocols in the elderly should reflect both the higher prevalence of injury and the lower energy of mechanisms. CT is the most cost-effective screening technique for patients at high probability of injury [27]. In the elderly, the injury distribution, frequency, and mechanism support a lower threshold for use of CT. In addition, decreased mental status in traumatized elderly patients and senescent changes of the bony anatomy may make it more difficult to ensure proper patient positioning for obtaining diagnostic radiographs and may radiographically obscure cervical spine fractures [28]. Our results suggest that CT may be appropriate as the primary cervical spine imaging modality for all trauma patients over the age of 75. However, we believe that further research is necessary to define the diagnostic yield in patients over age 75 and to determine if this, in fact, is a high-risk group. Quality radiographs, including an open-mouth dens view, remain valuable as screening tools for low-injury probability in young elderly patients or when CT is not available.
Prevertebral soft-tissue swelling due to hemorrhage was present in a large proportion of elderly patients with injuries in the upper cervical spine but was absent or inconspicuous frequently (in 17% in the upper cervical spine and in 40% in the lower cervical spine). Therefore, we do not consider prevertebral soft-tissue swelling a reliable indirect sign of injury in the lower cervical spine for this population. Prevertebral soft-tissue swelling was not assessed in patients treated with intubation, because prior endotracheal intubation severely limits visualization of the cervicocranial prevertebral soft tissue on lateral radiographs [29].
A potential limitation of our study is that cases were culled retrospectively from a single institution. The retrospective extraction of clinical data from the medical record, as performed in this study, is subject to limitations. For example, the presence of posterior midline neck pain or tenderness, valuable information for clinical decision rules to exclude patients at low risk for cervical spine fractures, was either not assessed or not recorded in a large proportion of the patients. The information concerning a patient's trauma history and neurologic status at the time of admission was, however, available in all patients. Whereas this circumstance may limit the consistency and thoroughness of clinical data, these are not the principal data for this study. On the other hand, because of the structure of our level 1 trauma center, the admitted patients represent all social, age-, and trauma-related stages affecting the general population, and we are unlikely to have failed to identify a meaningful number of clinically important cervical spine injuries.
In summary, as has been shown previously, there is a preponderance of upper cervical spine fractures in elderly blunt trauma patients. We showed that old elderly patients and patients who fall from standing or seated height are more prone to injuries of the upper cervical spine compared with young elderly or patients involved in high-energy trauma. Independent of age or causative trauma mechanism, cervical spine fractures often involve more than one level and are, in a large proportion, severe and highly unstable.
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