RESUMEN

To investigate the relationship between preoperative blood glucose levels and long-term all-cause mortality in patients with osteoporotic vertebral compression fractures (OVCF) who underwent percutaneous vertebroplasty (VP). This single-center retrospective study involved a chart review of patients admitted for VP to treat OVCF between 2013 and 2020. Patients with pathological or multiple fractures or those who did not undergo bone mineral density assessment were excluded. All relevant information was collected from electronic medical records. The survival status of all patients was confirmed at the end of March 2021. Cox proportional hazard models with multivariate adjustments were used to examine the effects of blood glucose levels on all-cause mortality. Overall, 131 patients were retrospectively analyzed (mean age: 75.8 ± 9.3 years, male patients: 26.7%) with a median follow-up period of 2.1 years. Preoperative hyperglycemia (hazard ratio: 2.668, 95% confidence interval [CI] 1.064, 6.689; p = 0.036) and glucose levels (hazard ratio: 1.007, 95% CI 1.002-1.012; p = 0.006) were found to be independently associated with a higher risk of all-cause mortality. This correlation remained significant even after adjusting for age and sex, and other factors and comorbidities that might affect outcomes (hazard ratio: 2.708, 95% CI 1.047, 7.003, p = 0.040 and 1.007; 95% CI 1.001, 1.013, p = 0.016, respectively). Furthermore, a history of diabetes mellitus was not a significant factor influencing long-term all-cause mortality. Preoperative glucose levels were found to be independently associated with survival outcomes in patients with OVCF who underwent VP. Conversely, diabetes mellitus was not associated with long-term all-cause mortality. Our findings highlight that preoperative hyperglycemia is a risk factor for long-term mortality in this aging surgical population.

Asunto(s)

Glucemia , Fracturas por Compresión , Fracturas Osteoporóticas , Fracturas de la Columna Vertebral , Vertebroplastia , Humanos , Masculino , Anciano , Femenino , Fracturas por Compresión/cirugía , Fracturas por Compresión/mortalidad , Fracturas Osteoporóticas/cirugía , Fracturas Osteoporóticas/mortalidad , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/cirugía , Fracturas de la Columna Vertebral/etiología , Glucemia/análisis , Glucemia/metabolismo , Estudios Retrospectivos , Anciano de 80 o más Años , Periodo Preoperatorio , Factores de Riesgo , Modelos de Riesgos Proporcionales , Hiperglucemia/mortalidad , Hiperglucemia/complicaciones , Hiperglucemia/etiología

RESUMEN

BACKGROUND: Vertebral compression fractures (VCFs) in older adults cause considerable health and socioeconomic burdens due to worsening ability to perform activities of daily living. The long-term effects of VCFs on patient outcomes, particularly prolonged analgesic use and functional decline, remain unknown. The aims of this study were to examine long-term clinical outcomes and to determine the risk factors for persistent pain and functional disability after VCFs. METHODS: This retrospective cohort study evaluated mortality, duration of analgesic use, and changes in care requirements in older adults with VCFs using claims data from a suburban prefecture in the Greater Tokyo Area. Patients were included if they were ≥65 years of age and had been diagnosed with a VCF between June 2014 and February 2019, as determined on the basis of International Classification of Diseases, Tenth Revision (ICD-10) codes; we also used claims data that could determine whether the patients underwent imaging examinations. Patients who discontinued outpatient visits within 1 month after the VCF diagnosis were excluded. RESULTS: We included 18,392 patients with VCFs and a mean age of 80 years. Seventy-six percent of patients were women, and the median follow-up period was 670 days. At the index VCF diagnosis, 3,631 patients (19.7%) were care-dependent. Overall, 968 patients (5.3%) died within 1 year. Among the 8,375 patients who received analgesics, 22% required analgesics for >4 months. Factors associated with prolonged analgesic use for >1 year were female sex (odds ratio [OR], 1.39 [95% confidence interval (CI), 1.16 to 1.65]) and VCFs in the thoracolumbar region (OR, 1.95 [95% CI, 1.50 to 2.55]) or lumbar region (OR, 1.59 [95% CI, 1.23 to 2.04]) (the reference was the thoracic region). The care needs of 1,510 patients (8.2%) increased within 1 year. Patients with a preexisting care dependency had a 10 times higher risk of increased care need (30.2% [1,060 of 3,509]) than those who had been independent at the time of the index diagnosis (3.0% [450 of 14,761]) (p < 0.001). CONCLUSIONS: Individuals with preexisting care dependency were more likely to experience functional decline following VCFs than those who were independent, which underscores the need for intensive and appropriate allocation of health-care resources to care-dependent patients. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Asunto(s)

Analgésicos , Fracturas por Compresión , Fracturas de la Columna Vertebral , Humanos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Anciano de 80 o más Años , Fracturas por Compresión/terapia , Fracturas de la Columna Vertebral/terapia , Fracturas de la Columna Vertebral/mortalidad , Analgésicos/uso terapéutico , Actividades Cotidianas , Factores de Riesgo

RESUMEN

Introduction: The most prevalent type of fragility fractures is osteoporotic vertebral fractures (OVFs). However, only a few studies have examined the relationship between anti-osteoporosis treatments and malignancy-related mortality following an OVF. The goal of this study is to determine the effect of anti-osteoporosis therapy on mortality in OVF patients with and without cancer. Method: Data from older people over the age of 65 who were hospitalised for OVFs between 1 January 2003 and 31 December 2018 were analysed retrospectively. A total of 6139 persons getting osteoporosis treatment and 28,950 who did not receive treatment were analysed, together with 2 sets of patients, comprising cancer patients (794) and cancer-free patients (5342), using anti-osteoporosis medication or not, in 1:1 propensity score-matched analyses. The hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Results: In all, 35,089 patients with OVFs were included in the population; 29,931 people (85.3%) were women, and the mean (standard deviation) age was 78.13 (9.27) years. Overall survival was considerably higher in those undergoing osteoporosis therapy. This was true both for those without cancer (adjusted HR 0.55; 95% CI 0.51-0.59; P<.0001) as well as those with cancer (adjusted HR 0.72; 95% CI 0.62-0.84; P<.0001). Even among cancer patients, those who received anti-osteoporotic drugs had a lower mortality rate than those who did not. Conclusion: Our findings suggest that anti-osteoporosis therapy should be initiated regardless of the presence of cancer in the elderly, as it increases survival following OVFs.

Asunto(s)

Conservadores de la Densidad Ósea , Neoplasias , Osteoporosis , Fracturas Osteoporóticas , Fracturas de la Columna Vertebral , Humanos , Anciano , Femenino , Masculino , Fracturas de la Columna Vertebral/mortalidad , Neoplasias/mortalidad , Neoplasias/tratamiento farmacológico , Neoplasias/complicaciones , Anciano de 80 o más Años , Fracturas Osteoporóticas/mortalidad , Fracturas Osteoporóticas/prevención & control , Estudios Retrospectivos , Conservadores de la Densidad Ósea/uso terapéutico , Osteoporosis/tratamiento farmacológico , Osteoporosis/mortalidad , Singapur/epidemiología , Modelos de Riesgos Proporcionales , Puntaje de Propensión , Estudios de Cohortes

RESUMEN

OBJECTIVES: The modified 5-item frailty index (mFI-5) is a comorbidity-based risk stratification tool to predict adverse events following various neurologic surgeries. This study aims to quantify the association between increased mFI-5 and postoperative complications and mortality following surgical fixation of traumatic thoracolumbar fractures. METHODS: The 2011-2021 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing fusion surgeries for thoracolumbar spine fractures. The mFI-5 score was calculated based on the presence of 5 major comorbidities: congestive heart failure within 30 days before surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, partially dependent or totally dependent functional health status at the time of surgery, and hypertension requiring medication. Multivariate analysis assessed the independent impact of increasing mFI-5 scores on postoperative 30-day morbidity and mortality while controlling for baseline clinical characteristics. RESULTS: A total of 66,904 patients were included in our analysis (54.2% female, mean age 62.27 ± 12.93 years). On univariate analysis, higher mFI-5 score was significantly associated with increased risks of superficial surgical site infection, deep surgical site infection, wound dehiscence, unplanned reoperation, pneumonia, unplanned intubation, postoperative ventilator use, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, myocardial infarction, cardiac arrest, pulmonary embolism, deep vein thrombosis, bleeding requiring transfusion, sepsis, septic shock, and longer hospital length of stay (LOS). On multivariate logistic regression, increasing mFI-5 score versus a mFI-5 score of zero was associated with higher odds of overall complications (mFI-5 ≥2: odds ratio [OR] 1.38 CI: 1.24-1.54, P < 0.001; mFI-5 = 1: OR 1.18 CI: 1.11-1.24, P < 0.001) and 30-day mortality (mFI-5 ≥2: OR 2.33 CI: 1.60-3.38, P < 0.001). CONCLUSION: This study demonstrates that frailty, when measured using the mFI-5, independently predicts postoperative complications, hospital LOS, and 30-day mortality after surgical repair of thoracolumbar fractures. These findings are important for risk stratification in patients undergoing thoracolumbar fusion surgery and for standardization in reporting outcomes after those procedures.

Asunto(s)

Fragilidad , Vértebras Lumbares , Complicaciones Posoperatorias , Fracturas de la Columna Vertebral , Vértebras Torácicas , Humanos , Femenino , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Vértebras Torácicas/cirugía , Vértebras Torácicas/lesiones , Fracturas de la Columna Vertebral/cirugía , Fracturas de la Columna Vertebral/mortalidad , Anciano , Vértebras Lumbares/cirugía , Fragilidad/complicaciones , Fusión Vertebral/efectos adversos , Fusión Vertebral/métodos

RESUMEN

There is imminent refracture risk in elderly individuals for up to six years, with a decline thereafter except in women below 75 who face a constant elevated risk. Elderly men with fractures face the highest mortality risk, particularly those with hip and vertebral fractures. Targeted monitoring and treatment strategies are recommended. PURPOSE: Current management and interventions for osteoporotic fractures typically focus on bone mineral density loss, resulting in suboptimal evaluation of fracture risk. The aim of the study is to understand the progression of fractures to refractures and mortality in the elderly using multi-state models to better target those at risk. METHODS: This prospective, observational study analysed data from the AGES-Reykjavik cohort of Icelandic elderly, using multi-state models to analyse the evolution of fractures into refractures and mortality, and to estimate the probability of future events in subjects based on prognostic factors. RESULTS: At baseline, 4778 older individuals aged 65 years and older were included. Elderly men, and elderly women above 80 years of age, had a distinct imminent refracture risk that lasted between 2-6 years, followed by a sharp decline. However, elderly women below 75 continued to maintain a nearly constant refracture risk profile for ten years. Hip (30-63%) and vertebral (24-55%) fractures carried the highest 5-year mortality burden for elderly men and women, regardless of age, and for elderly men over 80, lower leg fractures also posed a significant mortality risk. CONCLUSION: The risk of refracture significantly increases in the first six years following the initial fracture. Elderly women, who experience fractures at a younger age, should be closely monitored to address their long-term elevated refracture risk. Elderly men, especially those with hip and vertebral fractures, face substantial mortality risk and require prioritized monitoring and treatment.

Asunto(s)

Fracturas de Cadera , Fracturas Osteoporóticas , Recurrencia , Fracturas de la Columna Vertebral , Humanos , Fracturas Osteoporóticas/mortalidad , Anciano , Masculino , Femenino , Islandia/epidemiología , Anciano de 80 o más Años , Fracturas de Cadera/mortalidad , Fracturas de la Columna Vertebral/mortalidad , Estudios Prospectivos , Medición de Riesgo/métodos , Progresión de la Enfermedad , Densidad Ósea/fisiología , Pronóstico

RESUMEN

INTRODUCTION: Treatment of spine fractures may require periods of prolonged immobilization which prevents effective pulmonary toileting. We hypothesized that patients with longer time to mobilization, as measured by time to first physical therapy (PT) session, would have higher pulmonary complications. METHODS: We performed a retrospective review of all trauma patients with cervical and thoracolumbar spinal fractures admitted to a level 1 trauma center over a 12-month period. Demographic data collection included age, gender, BMI, pulmonary comorbidities, concomitant rib fractures, admission GCS, Injury Severity Score (ISS), GCS at 24 h, treatment with cervical or thoracolumbar immobilization, and time to first PT evaluation. The primary outcome was the presence of any one of the following complications: unplanned intubation, pneumonia, or mortality at 30 days. Multivariable logistic regression analysis was used to assess significant predictors of pulmonary complication. RESULTS: In total, 491 patients were identified. In terms of overall pulmonary complications, 10% developed pneumonia, 13% had unplanned intubation, and 6% died within 30 days. In total, 19% developed one or more complication. Overall, 25% of patients were seen by PT <48 h, 33% between 48 and 96 h, 19% at 96 h to 1 week, and 7% > 1 week. Multivariable logistic regression analysis showed that time to PT session (OR 1.010, 95% CI 1.005-1.016) and ISS (OR 1.063, 95% CI 1.026-1.102) were independently associated with pulmonary complication. CONCLUSION: Time to mobility is independently associated with pulmonary complications in patients with spine fractures.

Asunto(s)

Fracturas de la Columna Vertebral , Humanos , Femenino , Masculino , Estudios Retrospectivos , Fracturas de la Columna Vertebral/complicaciones , Fracturas de la Columna Vertebral/terapia , Fracturas de la Columna Vertebral/mortalidad , Persona de Mediana Edad , Adulto , Factores de Tiempo , Anciano , Neumonía/etiología , Vértebras Torácicas/lesiones , Puntaje de Gravedad del Traumatismo , Vértebras Cervicales/lesiones , Modalidades de Fisioterapia , Enfermedades Pulmonares/etiología , Vértebras Lumbares/lesiones , Inmovilización , Factores de Riesgo

RESUMEN

BACKGROUND: Rib fixation for traumatic rib fractures is advocated to decrease morbidity and mortality in select patient populations. We intended to investigate the effect of combination osseous thoracic injuries on mortality with the hypothesis that combination injuries will worsen overall mortality and that SSRF will improve outcomes in combination injuries and in high-risk patients. METHODS: Patients with rib fractures were identified from the Trauma Quality Improvement Project registry from 2019. Patients were then divided into rib fracture(s) alone or in combination with sternal, thoracic vertebra, or scapula fracture. Patients were also categorized into those with COPD and smokers. Patients with AIS >3 outside of thorax were excluded. Patients were subcategorized into those who had rib fixation verse nonoperative management for all subgroups. Analysis was performed to evaluate the efficacy of rib fixation. RESULTS: A total of 111,066 patients were included for analysis. The overall mortality was 1.4%. Patients with COPD had over double the mortality risk, with an overall mortality of 3.4%. Combination injuries did not appear to increase mortality. SSRF did not decrease mortality; however, the number of patients in this group was too small to complete statistical analysis. The overall complication rate was 0.43%. There was a trend towards an increase in extrapulmonary complications in the group that underwent surgical fixation. DISCUSSION: Mortality from rib fractures with concomitant osseous thoracic fracture appears to be low. However, mortality is increased in patients with COPD regardless of rib fracture pattern. The number of patients who underwent SSRF was too small to make a statistical comparison.

Asunto(s)

Enfermedad Pulmonar Obstructiva Crónica , Fracturas de las Costillas , Humanos , Fracturas de las Costillas/mortalidad , Fracturas de las Costillas/cirugía , Fracturas de las Costillas/complicaciones , Masculino , Femenino , Persona de Mediana Edad , Factores de Riesgo , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Anciano , Adulto , Estudios Retrospectivos , Vértebras Torácicas/lesiones , Vértebras Torácicas/cirugía , Escápula/lesiones , Escápula/cirugía , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/mortalidad , Esternón/lesiones , Esternón/cirugía , Sistema de Registros , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/epidemiología , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/cirugía , Fracturas Múltiples/cirugía , Fracturas Múltiples/mortalidad , Fracturas Múltiples/complicaciones , Resultado del Tratamiento

RESUMEN

BACKGROUND AND OBJECTIVES: Nearly 30% of older adults presenting with isolated spine fractures will die within 1 year. Attempts to ameliorate this alarming statistic are hindered by our inability to identify relevant risk factors. The primary objective of this study was to develop a prediction model that identifies feasible targets to limit 1-year mortality. METHODS: This retrospective cohort study included 703 older adults (65 years or older) admitted to a level I trauma center with isolated spine fractures, without neural deficit, from January 2013 to January 2018. Multivariable analysis was used to select for independently significant patient demographics, frailty variables, injury metrics, and management decisions to incorporate into distinct logistic regression models predicting 1-year mortality. Variables were considered significant, if P < .05. RESULTS: Of the 703 older adults, 199 (28.3%) died after hospital discharge, but within 1 year of index trauma. Risk Analysis Index (RAI; odds ratio [OR]: 1.116; 95% CI: 1.087-1.149; P < .001) and ambulation requiring a cane (OR: 2.601; 95% CI: 1.151-5.799; P = .02) or walker (OR: 4.942; 95% CI: 2.698-9.196; P < .001), ie, frailty variables, were associated with increased odds of 1-year mortality. Spine trauma scales were not associated with 1-year mortality. Longer hospital stays (OR: 1.112; 95% CI: 1.034-1.196; P = .004) and nursing home discharge (OR: 3.881; 95% CI: 2.070-7.378; P < .001) were associated with increased odds, while discharge to rehab (OR: 0.361; 95% CI: 0.155-0.799; P = .014) decreased 1-year mortality odds. A "preinjury" regression model incorporating Risk Analysis Index and ambulation status resulted in an area under receiver operating characteristic curve (AUROCC) of 0.914 (95% CI: 0.863-0.965). A "postinjury" model incorporating Glasgow Coma Scale, hospital stay duration, and discharge disposition resulted in AUROCC of 0.746 (95% CI: 0.642-0.849). Combining elements of the preinjury and postinjury models into an "integrated model" produced an AUROCC of 0.908 (95% CI: 0.852-0.965). CONCLUSION: Preinjury frailty measures are most strongly associated with 1-year mortality outcomes in older adults with isolated spine fractures. Incorporating injury metrics or management decisions did not enhance predictive accuracy. Further work is needed to understand how targeting frailty may reduce mortality.

Asunto(s)

Fragilidad , Fracturas de la Columna Vertebral , Humanos , Femenino , Anciano , Masculino , Fragilidad/mortalidad , Fracturas de la Columna Vertebral/mortalidad , Estudios Retrospectivos , Anciano de 80 o más Años , Estudios de Cohortes , Factores de Riesgo

RESUMEN

BACKGROUND: Hyponatremia is implicated in pathological bone resorption and has been identified as a risk factor for bone fracture in the general population. However, there are limited data on the association between serum sodium levels and fracture risk in patients undergoing hemodialysis (HD). METHODS: We analyzed a historical cohort of 2220 maintenance HD patients to examine the association between serum sodium levels and the risk of fracture and mortality. We also examined the association between serum sodium levels and osteoporosis, based on metacarpal bone mineral density, in a subcohort of 455 patients with available data. In addition, we examined the association between serum sodium levels and bone turnover markers in a separate cross-sectional cohort of 654 maintenance HD patients. RESULTS: During a median follow-up of 5.4 years, 712 patients died, 113 experienced clinical fractures, and 64 experienced asymptomatic vertebral fractures. Lower serum sodium levels were associated with an increased risk of mortality (HR 1.06 per 1 mEq/L decrease; 95% CI 1.03-1.09) but not with the risk of clinical fracture (HR 1.04 per 1 mEq/L decrease; 95% CI 0.97-1.11). A similar lack of association was observed for asymptomatic vertebral fracture and any fracture. Serum sodium levels were also not associated with osteoporosis in a subcohort with available data (n = 455) or with bone alkaline phosphatase or tartrate-resistant acid phosphatase-5b in a separate cross-sectional cohort. CONCLUSION: Serum sodium levels were associated with mortality but not with fracture risk, osteoporosis, or bone turnover markers in maintenance HD patients.

Asunto(s)

Biomarcadores , Densidad Ósea , Diálisis Renal , Sodio , Fosfatasa Ácida Tartratorresistente , Humanos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Estudios Transversales , Sodio/sangre , Fosfatasa Ácida Tartratorresistente/sangre , Factores de Riesgo , Biomarcadores/sangre , Fosfatasa Alcalina/sangre , Fracturas Óseas/sangre , Fracturas Óseas/mortalidad , Fracturas Óseas/etiología , Hiponatremia/sangre , Hiponatremia/mortalidad , Osteoporosis/sangre , Fracturas de la Columna Vertebral/sangre , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/etiología , Remodelación Ósea , Fosfatasa Ácida/sangre , Isoenzimas/sangre , Fracturas Osteoporóticas/sangre , Fracturas Osteoporóticas/mortalidad , Fracturas Osteoporóticas/etiología , Factores de Tiempo , Osteocalcina

RESUMEN

BACKGROUND: The thoracic cage is an anatomical entity formed by the thoracic spine, ribs, and sternum. As part of this osteoligamentous complex, the sternum contributes substantially to the stability of the thoracic spine. This study investigates the influence of a concomitant sternal fracture (SF) on the treatment and hospital course of pediatric patients with a thoracic vertebral fracture (TVF). METHODS: The Trauma Quality Improvement Program data sets from 2016 to 2020 were reviewed. Patients aged 0 year to 19 years with TVF with or without SF following blunt trauma were identified using the Abbreviated Injury Scale codes and selected for further data collection. Patients with transverse or spinous process fractures or incomplete data were excluded. Data collected included demographics, mechanisms of injury, clinical variables, procedures, intensive care unit admission and length of stay, total length of stay and in-hospital mortality. Continuous variables were analyzed with Wilcoxon rank sum test, categorical variables with χ 2 test. RESULTS: A total of 13,434 patients were identified, of which 10,292 had isolated TVF (TVF), 788 TVF and concomitant SF (TVF + SF), 2,225 isolated SF (excluded), and 126 incomplete data (excluded). Motor vehicle collisions were the most common mechanism of injury in both groups (TVF, 75%; TVF + SF, 88%), followed by falls (TVF: 23%, TVF + SF: 12%). Spinal cord injuries were more common among TVF + SF patients (6.4% vs. 4%). Median injury severity score (17 vs. 12), age (17 vs. 15 years), LOS (5 vs. 3 days), and mortality (5.6% vs. 2.3%) were significantly higher and the need for operative treatment (69% vs. 56%) and ICU admission (53% vs. 36%) significantly more frequent in patients with TVF + SF. CONCLUSION: Concomitant SF occur in 7% of all pediatric patients with TVF and are associated with increased morbidity and mortality. This combination of injuries is likely the result of greater energy transmission and injury potential. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Asunto(s)

Fracturas de la Columna Vertebral , Esternón , Vértebras Torácicas , Humanos , Estudios Retrospectivos , Niño , Masculino , Femenino , Esternón/lesiones , Adolescente , Preescolar , Fracturas de la Columna Vertebral/mortalidad , Vértebras Torácicas/lesiones , Lactante , Tiempo de Internación/estadística & datos numéricos , Mortalidad Hospitalaria , Bases de Datos Factuales , Adulto Joven , Heridas no Penetrantes/mortalidad , Heridas no Penetrantes/diagnóstico , Recién Nacido , Escala Resumida de Traumatismos , Accidentes de Tránsito/estadística & datos numéricos

RESUMEN

BACKGROUND: Clinical guidelines recommend low-molecular-weight heparin for thromboprophylaxis in patients with fractures, but trials of its effectiveness as compared with aspirin are lacking. METHODS: In this pragmatic, multicenter, randomized, noninferiority trial, we enrolled patients 18 years of age or older who had a fracture of an extremity (anywhere from hip to midfoot or shoulder to wrist) that had been treated operatively or who had any pelvic or acetabular fracture. Patients were randomly assigned to receive low-molecular-weight heparin (enoxaparin) at a dose of 30 mg twice daily or aspirin at a dose of 81 mg twice daily while they were in the hospital. After hospital discharge, the patients continued to receive thromboprophylaxis according to the clinical protocols of each hospital. The primary outcome was death from any cause at 90 days. Secondary outcomes were nonfatal pulmonary embolism, deep-vein thrombosis, and bleeding complications. RESULTS: A total of 12,211 patients were randomly assigned to receive aspirin (6101 patients) or low-molecular-weight heparin (6110 patients). Patients had a mean (±SD) age of 44.6±17.8 years, 0.7% had a history of venous thromboembolism, and 2.5% had a history of cancer. Patients received a mean of 8.8±10.6 in-hospital thromboprophylaxis doses and were prescribed a median 21-day supply of thromboprophylaxis at discharge. Death occurred in 47 patients (0.78%) in the aspirin group and in 45 patients (0.73%) in the low-molecular-weight-heparin group (difference, 0.05 percentage points; 96.2% confidence interval, -0.27 to 0.38; P<0.001 for a noninferiority margin of 0.75 percentage points). Deep-vein thrombosis occurred in 2.51% of patients in the aspirin group and 1.71% in the low-molecular-weight-heparin group (difference, 0.80 percentage points; 95% CI, 0.28 to 1.31). The incidence of pulmonary embolism (1.49% in each group), bleeding complications, and other serious adverse events were similar in the two groups. CONCLUSIONS: In patients with extremity fractures that had been treated operatively or with any pelvic or acetabular fracture, thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin in preventing death and was associated with low incidences of deep-vein thrombosis and pulmonary embolism and low 90-day mortality. (Funded by the Patient-Centered Outcomes Research Institute; PREVENT CLOT ClinicalTrials.gov number, NCT02984384.).

Asunto(s)

Anticoagulantes , Aspirina , Quimioprevención , Fracturas Óseas , Heparina de Bajo-Peso-Molecular , Adulto , Humanos , Persona de Mediana Edad , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Aspirina/efectos adversos , Aspirina/uso terapéutico , Quimioprevención/métodos , Extremidades/lesiones , Fracturas Óseas/complicaciones , Fracturas Óseas/mortalidad , Hemorragia/etiología , Heparina de Bajo-Peso-Molecular/efectos adversos , Heparina de Bajo-Peso-Molecular/uso terapéutico , Fracturas de Cadera/complicaciones , Fracturas de Cadera/mortalidad , Huesos Pélvicos/lesiones , Ensayos Clínicos Pragmáticos como Asunto , Embolia Pulmonar/etiología , Embolia Pulmonar/prevención & control , Fracturas de la Columna Vertebral/complicaciones , Fracturas de la Columna Vertebral/mortalidad , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/tratamiento farmacológico , Trombosis de la Vena/etiología , Trombosis de la Vena/prevención & control

RESUMEN

BACKGROUND: Although the mortality related to hip fracture and osteoporotic vertebral fracture have been reported, few studies have examined the mortality related to atlas and/or axis fractures. The aim of this study was to assess the association between mortality and atlas and/or axis fractures retrospectively and to elucidate the efficacy of surgical treatment. METHODS: A total of 33 elderly patients who were treated for atlas and/or axis fractures at our institution between January 2012 and December 2018 were included in this study. These patients were divided into two groups: surgical treatment and conservative treatment. Fracture types, comorbidities, neurological status, treatment types, and walking ability at follow-up were reviewed. Mortality was assessed using medical records or via phone interviews. RESULTS: The mean age at injury was 79.9 ± 8.0 years, and the mean follow-up period was 2.3 years. The overall mortality rates at 1 and 5 years were 21.4% and 48.4%, respectively. During the observation period, 12 (36%) patients died. Twenty-two patients were treated conservatively (14 were treated with a cervical collar, 8 were treated with a halo vest). Surgical procedures included occipital-cervical fixation, osteosynthesis of C2 fractures, C1-2 fixation, and C1-4 fixation using a posterior approach. Surgical treatment correlated with better survival rates. There was no significant difference between the two groups in terms of ambulatory ability and functional recovery. CONCLUSION: Upper cervical spine fractures appear to have a worse prognosis compared to hip and osteoporotic vertebral fractures. This study indicates the efficacy of surgical treatment for upper cervical spine fractures in the elderly for improving survival prognosis.

Asunto(s)

Fracturas Osteoporóticas , Fracturas de la Columna Vertebral , Anciano , Vértebras Cervicales/cirugía , Fijación Interna de Fracturas/métodos , Humanos , Fracturas Osteoporóticas/diagnóstico por imagen , Fracturas Osteoporóticas/mortalidad , Fracturas Osteoporóticas/cirugía , Estudios Retrospectivos , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/cirugía , Resultado del Tratamiento

RESUMEN

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: To identify nationwide temporal trends in management of geriatric odontoid fractures and to compare comorbidities, inpatient complications, hospital characteristics, and cost between patients receiving operative versus nonoperative management. SUMMARY OF BACKGROUND DATA: The treatment of geriatric odontoid fractures remains controversial with some studies demonstrating decreased mortality and improved functional outcomes associated with operative management and significant morbidity associated with halo devices during nonoperative management. METHODS: Patients between ages 65 to 90 years with odontoid fractures who underwent operative or nonoperative management between the years 2003 and 2017 were identified in the National Inpatient Sample (NIS) database. Year of injury, demographic variables, comorbidities, inpatient complications, mortality, length of stay, inpatient cost, and hospital characteristics were compared between operative and nonoperative treatment groups. RESULTS: Thirty two thousand four hundred nineteen patients (average age 77 yr, 54% female) were included in the final analysis. Operative treatment occurred in 21,954 (67%) patients and nonoperative treatment occurred in 10,465 (32%). In 2003, operative treatment occurred in 46% of patients and nearly doubled to 86% in 2017, with an average increase of 3.7% per year (P < 0.001). Patients undergoing operative management had a lower prevalence of at least one major medical comorbidity (76% vs. 83%, P < 0.001). Patients undergoing operative treatment demonstrated higher odds of developing most complications, particularly pulmonary, gastrointestinal, and renal (P < 0.01). Inpatient mortality was 3.6% in patients receiving operative treatment and 5.9% in patients receiving nonoperative treatment (P < 0.001). Average cost per episode of care during the study period was $131,855 for operative treatment and $65,374 for nonoperative treatment (P < 0.001). CONCLUSION: This study demonstrates a clear national paradigm shift in the management of geriatric odontoid fractures, wherein operative management nearly doubled from 46% in 2003 to 86% in 2017.Level of Evidence: 3.

Asunto(s)

Apófisis Odontoides , Fracturas de la Columna Vertebral/complicaciones , Fracturas de la Columna Vertebral/mortalidad , Anciano , Anciano de 80 o más Años , Comorbilidad , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Estudios Retrospectivos , Fracturas de la Columna Vertebral/economía , Fracturas de la Columna Vertebral/cirugía

RESUMEN

Patients admitted with a cervical fracture are twice as likely to die within 30 days of injury than those with a hip fracture. However, guidelines for the management of cervical fractures are less available than for hip fractures. We hypothesise that outcomes may differ between these types of fractures. We analysed 1359 patients (406 men, 953 women) with mean age of 83.8 years (standard deviation = 8.7) admitted to a National Health Service hospital in 2013-2019 with a cervical (7.5%) or hip fracture (92.5%) of similar age. The association of cervical fracture (hip fracture as reference), hospital length of stay (LOS), co-morbidities, age and sex with outcomes (acute delirium, new pressure ulcer, and discharge to residential/nursing care) was assessed by stepwise multivariate logistic regression. Acute delirium without history of dementia was increased with cervical fractures: odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.3-4.7, age ≥ 80 years: OR = 3.5 (95% CI = 1.9-6.4), history of stroke: OR = 1.8 (95% CI = 1.0-3.1) and ischaemic heart disease: OR = 1.9 (95% CI = 1.1-3.6); pressure ulcers was increased with cervical fractures: OR = 10.9 (95% CI = 5.3-22.7), LOS of 2-3 weeks: OR = 3.0 (95% CI = 1.2-7.5) and LOS of ≥ 3 weeks: OR = 4.9, 95% CI = 2.2-11.0; and discharge to residential/nursing care was increased with cervical fractures: OR = 3.2 (95% CI = 1.4-7.0), LOS of ≥ 3 weeks: OR = 4.4 (95% CI = 2.5-7.6), dementia: OR = 2.7 (95% CI = 1.6-4.7), Parkinson's disease: OR = 3.4 (95% CI = 1.3-8.8), and age ≥ 80 years: OR = 2.7 (95% CI = 1.3-5.6). In conclusion, compared with hip fracture, cervical fracture is more likely to associate with acute delirium and pressure ulcers, and for discharge to residency of high level of care, independent of established risk factors.

Asunto(s)

Fracturas de Cadera/complicaciones , Fracturas de la Columna Vertebral/complicaciones , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/lesiones , Vértebras Cervicales/fisiopatología , Distribución de Chi-Cuadrado , Estudios Transversales , Femenino , Fracturas de Cadera/epidemiología , Fracturas de Cadera/mortalidad , Hospitalización/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Calidad de la Atención de Salud/normas , Calidad de la Atención de Salud/estadística & datos numéricos , Factores de Riesgo , Fracturas de la Columna Vertebral/epidemiología , Fracturas de la Columna Vertebral/mortalidad

RESUMEN

BACKGROUND: The surgical treatment of osteoporotic vertebral fractures (OVF) is generally associated with a high risk of complications due to an aging population with osteoporosis; however, the detailed risk factors for systemic complications and mortality have not been clarified. We evaluated the risk factors for systemic complications and mortality in surgically treated OVF patients using a large national inpatient database. METHODS: Patients over 65 years old who were diagnosed with OVF and received either anterior fusion (AF) or posterior fusion (PF), from 2012 to 2016, were extracted from the diagnosis procedure combination (DPC) database. In each of the perioperative systemic complications (+) or (-) group, and the in-hospital death (+) or (-) group, we surveyed the various risk factors related to perioperative systemic complications and in-hospital death. RESULTS: The significant factors associated with systemic complications were older age (OR 1.38, 95% CI 1.09-1.74), a lower activity of daily living score upon admission (OR 1.52, 95%CI 1.19-1.94), atrial fibrillation (OR 2.14, 95%CI 1.25-3.65), renal failure (OR 2.29, 95%CI 1.25-4.20), and surgical procedure (AF, OR 1.73, 95%CI 1.35-2.22). The significant explanatory variables for in-hospital death were revealed to be male sex (OR 3.26, 95%CI 1.20-8.87), a lower body mass index (OR 3.97, 95%CI 1.23-12.86), unscheduled admission (OR 3.52, 95%CI 1.17-10.63), atrial fibrillation (OR 8.31, 95%CI 2.25-30.70), renal failure (OR 7.15, 95%CI 1.32-38.77), and schizophrenia (OR 8.23, 95%CI 1.66-42.02). CONCLUSIONS: Atrial fibrillation and renal failure as preoperative comorbidities were common factors between perioperative systemic complications and mortality in elderly patients for OVF.

Asunto(s)

Bases de Datos Factuales , Pacientes Internos , Osteoporosis/complicaciones , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral/métodos , Actividades Cotidianas , Factores de Edad , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/epidemiología , Índice de Masa Corporal , Comorbilidad , Femenino , Mortalidad Hospitalaria , Humanos , Japón/epidemiología , Masculino , Periodo Perioperatorio , Insuficiencia Renal/epidemiología , Factores de Riesgo , Factores Sexuales , Fracturas de la Columna Vertebral/epidemiología , Fracturas de la Columna Vertebral/etiología

RESUMEN

BACKGROUND: Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries. METHODS: Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012-2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital's data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P <.05 significant. RESULTS: Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01). CONCLUSION: Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

Asunto(s)

Vértebras Cervicales/lesiones , Traumatismos Vertebrales/diagnóstico por imagen , Traumatismos Vertebrales/etiología , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nevada/epidemiología , Sistema de Registros , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/etiología , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/terapia , Traumatismos Vertebrales/mortalidad , Traumatismos Vertebrales/terapia , Intento de Suicidio , Centros Traumatológicos , Estados Unidos/epidemiología , Heridas por Arma de Fuego/mortalidad , Heridas por Arma de Fuego/terapia

RESUMEN

BACKGROUND: Traumatic cervical spinal cord injuries (SCIs) can be lethal and are especially dangerous for older adults. Falls from standing and risk factors for a cervical fracture and spinal cord injury increase with age. This study estimates the 1-year mortality for patients with a cervical fracture and resultant SCI and compares the mortality rate with that from an isolated cervical fracture. METHODS: We performed a retrospective cohort study of U.S. Medicare patients older than 65 years of age. International Classification of Diseases (ICD)-9 codes were used to identify patients with a cervical fracture without SCI and patients with a cervical fracture with SCI between 2007 and 2014. Our primary outcome was 1-year mortality cumulative incidence rate; our secondary outcome was the cumulative incidence rate of surgical intervention. Propensity weighted analysis was performed to balance covariates between the groups. RESULTS: The SCI cohort had a 1-year mortality of 36.5%, compared with 31.1% in patients with an isolated cervical fracture (risk difference 5.4% (2.9%-7.9%)). Patients with an SCI were also more likely to undergo surgical intervention compared with those without a SCI (23.1% and 10.3%, respectively; risk difference 12.8% (10.8%-14.9%)). CONCLUSIONS: Using well-adjusted population-level data in older adults, this study estimates the 1-year mortality after SCI in older adults to be 36.5%. The mortality after a cervical fracture with SCI was 5 percentage points higher than in patients without SCI, and this difference is smaller than one might expect, likely representing the frailty of this population and unmeasured covariates.

Asunto(s)

Traumatismos de la Médula Espinal/mortalidad , Traumatismos de la Médula Espinal/cirugía , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/cirugía , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/lesiones , Vértebras Cervicales/cirugía , Estudios de Cohortes , Humanos , Incidencia , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos

RESUMEN

OBJECTIVES: To understand the prognostic value of laboratory markers at presentation on post-treatment survival of patients 50 and older following cervical spine fracture. PATIENTS AND METHODS: We obtained clinical data on patients 50 and older treated for cervical spine fracture in a single healthcare system (2006-2016). Our primary outcome consisted of 1-year mortality, with mortality within 3-months of presentation considered secondarily. Our primary predictors included serum glucose, serum creatinine, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) at presentation. We used multivariable logistic regression to adjust for confounding from sociodemographic and clinical characteristics. Point estimates and 95 % confidence intervals (CI) from the final model were refined using Bayesian regression techniques. RESULTS: We included 1781 patients in this analysis, with an average age of 75.3 (SD 12.0). The mortality rate at 3-months was 12 % and 17 % at 1-year. In multivariable testing, neither elevated PLR or NLR were significant predictors of 1-year mortality. Elevated serum creatinine was associated with increased mortality at 1-year (OR 1.89; 95 % CI 1.30, 2.74), as was hyperglycemia (OR 1.50; 95 % CI 1.06, 2.13). Elevated serum creatinine remained influential (OR 1.64; 95 % CI 1.06, 2.54) on mortality at 3-months. CONCLUSIONS: This is the first study to evaluate laboratory values at presentation in conjunction with survival following cervical fractures. The results can be used to help forecast natural history and in expectation management. They may also help formulate treatment plans, especially when the need for surgical intervention is not clearly defined.

Asunto(s)

Fracturas de la Columna Vertebral/mortalidad , Anciano , Anciano de 80 o más Años , Glucemia/análisis , Vértebras Cervicales/lesiones , Creatinina/sangre , Femenino , Humanos , Hiperglucemia/complicaciones , Hiperglucemia/mortalidad , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Factores Socioeconómicos , Análisis de Supervivencia , Resultado del Tratamiento

RESUMEN

OBJECTIVE: The aim to evaluate central sarcopenia, as measured by psoas cross-sectional area on admission imaging, is associated with outcomes in patients with vertebral compression fractures (VCFs) treated with percutaneous vertebral augmentation treatment. METHODS: We evaluated the records of patients aged >60 years treated with vertebroplasty or kyphoplasty between 2009 and 2018 for osteoporotic VCFs. The Social Security Death Index was used to determine death. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. A multivariate Cox algorithm was applied to recognize factors independently associated with survival. RESULTS: A total of 103 patients were included with an average age of 72.3 years. During the study period, 22 (21.4%) patients were deceased, whereas 81 (78.6%) were alive. The survival rates at 1 month, 6 months, and 1 year after surgery were 99%, 94.1%, and 88.4%, respectively. PLVI measurements ranged from 0.24-1.19 with a mean of 0.59 ± 0.17 and a median of 0.603. A total of 51 patients with a median value of 0.603 were defined as low PLVI group, and 52 patients with a median value of ≥0.603 were defined as the high PLVI group. PLVI was significantly low in patients who died. Age, American Society of Anesthesiologists score, and PLVI value were independently associated with a poor overall survival. CONCLUSIONS: There is a significant correlation between sarcopenia and postoperative mortality after vertebral augmentation procedure in patients with VCFs.

Asunto(s)

Fracturas Osteoporóticas/complicaciones , Fracturas Osteoporóticas/cirugía , Sarcopenia/complicaciones , Fracturas de la Columna Vertebral/complicaciones , Fracturas de la Columna Vertebral/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Fracturas por Compresión/complicaciones , Fracturas por Compresión/mortalidad , Fracturas por Compresión/cirugía , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Fracturas Osteoporóticas/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Fracturas de la Columna Vertebral/mortalidad , Resultado del Tratamiento , Vertebroplastia/métodos

RESUMEN

Background Osteoporotic vertebral compression fractures (OVCFs) are prevalent, with associated morbidity and mortality. Vertebral augmentation (VA), defined as either vertebroplasty and/or balloon kyphoplasty (BKP), is a minimally invasive surgical treatment to reduce pain and further collapse and/or renew vertebral body height by introducing bone cement into fractured vertebrae. Nonsurgical management (NSM) for OVCF carries inherent risks. Purpose To summarize the literature and perform a meta-analysis on the mortality outcomes of patients with OVCF treated with VA compared with those in patients treated with NSM. Materials and Methods A single researcher performed a systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines. Online scientific databases were searched in April 2018 for English-language publications. Included studies investigated mortality in patients with OVCF with VA as the primary intervention and NSM as the comparator. A meta-analysis was performed for studies that reported hazard ratios (HRs) and 95% confidence intervals (CIs). HR was used as a summary statistic and was random-effect-models tested. The χ2 test was used to study heterogeneity between trials, and the I2 statistic was calculated to estimate variation across studies. Results Of the 16 included studies, eight reported mortality benefits in VA, seven reported no mortality difference, and one reported mixed results. Seven studies were included in a meta-analysis examining findings in more than 2 million patients with OVCF (VA = 382 070, NSM = 1 707 874). The pooled HR comparing VA to NSM was 0.78 (95% CI: 0.66, 0.92; P = .003), with mortality benefits across 2- and 5-year periods (HR = 0.70, 95% CI: 0.69, 0.71, P < .001; and HR = 0.79, 95% CI: 0.62, 0.9999, P = .05; respectively). Balloon kyphoplasty provided mortality benefits over vertebroplasty, with HRs of 0.77 (95% CI: 0.77, 0.78; P < .001) and 0.87 (95% CI: 0.87, 0.88; P < .001), respectively. Conclusion In a meta-analysis of more than 2 million patients, those with osteoporotic vertebral compression fractures who underwent vertebral augmentation were 22% less likely to die at up to 10 years after treatment than those who received nonsurgical treatment. © RSNA, 2020 See also the editorial by Jennings in this issue.

Asunto(s)

Fracturas por Compresión/mortalidad , Fracturas por Compresión/cirugía , Fracturas Osteoporóticas/mortalidad , Fracturas Osteoporóticas/cirugía , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/cirugía , Vertebroplastia , Humanos , Cifoplastia