Surgeon Experience Is the Most Important Predictor of Case Failure Rate for Anterior Odontoid Screw Fixation

Abstract

Study Design: Retrospective database analysis. Objective: Determine risk factors and failure rate of anterior odontoid screw fixation surgery. Summary of Background Data: Anterior odontoid screw fixation (AOSF) stabilizes type II dens fractures while preserving cervical motion. Despite having potential advantages, AOSF’s failure rate and factors contributing to failure remain unknown. Materials and Methods: We identified AOSF patients in the national claims database Pearldiver using CPT code 22318. Failure was defined as the requirement of supplementary posterior fusion surgery in the C1–C2 or occiput-C2 region after the AOSF. We considered potential predictors of failure including age, sex, Charlson Comorbidity Index (CCI), surgeon experience, history of osteoporosis, obesity, and tobacco use. Univariate comparison analysis and logistic regression were conducted to identify factors associated with the need for additional posterior surgery. Results: For 2008 identified cases of AOSF, 249 cases (12.4%) required additional posterior fusion. Seventy-one of the 249 cases (28.5%) underwent revision surgery on the same day as the AOSF. Over 86% of revisions (215 cases) occurred within 200 days of the initial procedure. Posterior fusion rates are inversely correlated with surgeon experience, with the most experienced surgeons having a rate of 10.0%, followed by 11.5% for moderately experienced surgeons, and 15.0% for the least experienced surgeons. When comparing moderate and inexperienced surgeons to experienced surgeons, the odds ratios for posterior fusion were 1.18 (P>0.05) and 1.61 (P<0.006), respectively. Logistic regression revealed that both lesser experience (odds ratio=1.50) and osteoporosis (odds ratio=1.44) were the only factors significantly associated with failure (P<0.05). Conclusions: Our findings indicate a correlation between AOSF success and surgeon experience. While currently published results suggest higher success rates, most of this data originates from experienced surgeons and specialized centers, therefore, they may not accurately reflect the failure rate encountered in a more general practice setting. Level of evidence: Level III.