Analysis was performed relative to gender. Of male patients (n = 22), the 3-month, 1-year, and 2-year survival rates were 72.7%, 72.7%, and 62.7%, respectively. Among women (n = 23), the 3-month, 1-year, and 2-year survival rates were 95.7%, 91.3%, and 82.6%, respectively.
Figure 3 shows the Kaplan-Meier survival curves of the older patients with odontoid fractures. A comparison of the curves for each gender showed no significant disparities between the male and female survival (Figure 3A, P = .124). Compared with age-matched male counterparts, the survival of male subjects with odontoid fractures was significantly worse (Figure 3B, P < .001). Men experienced an initial acute decline in survival, with the remainder of the survival curve matching that of the general male population. In contrast, odontoid fractures did not adversely affect female survival compared with the matched population (Figure 3C, P = .568).
The 2-year SMR of 2.98 for men showed that odontoid fractures led to greater mortality compared with a sex- and age-matched population. This means that men older than 50 years who sustained an odontoid fracture had nearly 3 times the mortality rate after 2 years compared with a normal, matched population; this increase is attributed to the 3-month time point that subsequently normalized. The female rate was 1.33 times that of a matched population, a difference that is not statistically significant.
Subaxial Fracture Patients
Of the 91 patients older than 50 years with subaxial fractures, 3-month, 1-year, and 2-year survival rates were 87.9%, 85.7%, and 85.7%, respectively. Figure 4 shows the 1- and 2-year follow-up data by age group.
Gender-specific analysis was performed. For men (n = 58), the 3-month, 1-year, and 2-year survival rates were 87.9%, 84.5%, and 84.5%, respectively. Among women (n = 33), 4 deaths were recorded at all time points (87.9% survival).
Figure 5 shows Kaplan-Meier survival curves for the older population with subaxial fractures. A comparison of the curves between genders again showed no significant differences between male and female survival (P = .683, Figure 5A). Compared with age- and gender-matched counterparts, men showed decreased relative survival (P < .0001, Figure 5B), whereas subaxial fractures did not decrease female survival (P = .554, Figure 5C).
The 2-year SMR of 2.90 for men showed higher mortality rates relative to sex- and age-matched controls. Men who were both 50 years old and sustained a subaxial fracture were 2.9 times as likely to die within 2 years of follow-up compared with their counterparts. Similar to odontoid fractures, this increase occurred by the 3-month time point and subsequently normalized. The female rate, which was 1.34 times that of the uninjured population, was not statistically significant.
Comparison of Odontoid and Subaxial Fracture Patients
The survival of subaxial injuries was not significantly different from that of odontoid fractures (P = .113, Figure 6A). When analyzed by gender and controlled for age, the rates in both male (P = .347, Figure 6B) and female (P = .643, Figure 6C) patients did not differ between fracture types.
Discussion
The US population is aging rapidly, with the demographic older than 65 years predicted to more than double in size between 2010 and 2050.47 As our elderly population grows, the incidence of age-related injuries will rise accordingly. An understanding of mortality risks associated with different fractures will not only assist practitioners in advising patients regarding prognosis but may also lead to improvements in clinical care.19,48-50 While we know cervical spine trauma is associated with significant morbidity,29-31 little is known about associated moderate-term mortality rates that can be compared with other known injury patterns, such as hip fractures or osteoporotic compression fractures.
An interesting finding of the present study is the bimodal age distribution of the 59 odontoid fractures (Figure 2). The 14 patients younger than 50 years included 3 individuals who died, all within days of their presentation from severe multisystem trauma. This is consistent with the determination that high-energy forces are required to fracture the odontoid process in younger individuals.38,45,46,51,52 Given the severity of their nonspinal injuries, the cause of death was likely not primarily related to their odontoid fractures. Also in line with previous studies, the majority (76%) of odontoid fractures were documented in subjects older than 50 years.32,53,54 Within our cohort older than 50 years, the deaths appear to be spread evenly across age groups and do not seem to be skewed by the oldest portion of the population (Figure 2).
