The old man and the C-spine fracture

BACKGROUND: Placement of a halo vest for cervical spine fractures is presumed to be less morbid than operative fixation. However, restrictions imposed by the halo vest can be detrimental, especially in older patients. The purpose of this study was to evaluate the impact of halo vest placement on outcomes by age in patients with cervical spine fractures without spinal cord injury. METHODS: All patients with blunt cervical spine fractures managed over an 18-year period were identified. Those with spinal cord injury and severe traumatic brain injury were excluded. Patients were stratified by age, sex, halo vest, injury severity, and severity of shock. Outcomes included intensive care unit length of stay, ventilator days, ventilator-associated pneumonia, functional status, and mortality. Multivariable logistic regression was performed to determine whether halo vest was an independent predictor of mortality in older patients. RESULTS: A total of 3,457 patients were identified: 69% were male, with a mean Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score of 19 and 13, respectively. Overall mortality was 5.3%. One hundred seventy-nine patients were managed with a halo vest, 133 of those 54 years and older and 46 of those younger than 54 years. Both mortality (13% vs. 0%, p < 0.001) and intensive care unit length of stay (4 days vs. 2 days, p = 0.02) were significantly increased in older patients despite less severe injury (admission GCS score of 15 vs. 14 and ISS of 14 vs. 17, p = 0.03). Multivariable logistic regression identified halo vest as an independent predictor of mortality after adjusting for injury severity and severity of shock (odds ratio, 2.629; 95% confidence interval, 1.056-6.543) in older patients. CONCLUSION: The potential risk of operative stabilization must be weighed against that of halo vest placement for older patients with cervical spine fractures following blunt trauma. Patient age should be strongly considered before placement of a halo vest for cervical spine stabilization. LEVEL OF EVIDENCE: Therapeutic study, level IV.