Background for Fast Fact #505     Cervical fractures in older adults are common and can occur with minor trauma, such as a ground-level fall. These fractures can be very morbid and increase the risk of mortality dramatically. This Fast Fact reviews the epidemiology and prognosis of cervical fractures in older adults. The next Fast Fact will discuss management, including the use of soft and hard collars.

Epidemiology     Falls are the leading causes of injury-related deaths in older adults and rates for death from falls have been increasing in the last two decades (1). Older adults are more likely to sustain upper cervical fractures than younger adults (2). The most frequent mechanism for cervical spine fracture in older adults is a ground level fall (54%) – that is falling to the ground from a standing position because of stumbling, tripping, or losing postural tone (2). Cervical fractures range in severity in terms of both structural and neurological injury. The most common cervical fracture in older adults affects C2, specifically the odontoid process or dens (3). Risk factors include advanced age, preexisting cervical spondylosis, osteoporosis, frequent falls, and higher frailty scores (4).

Types of injuries  

• Cervical spinal injuries are classified by location (C1, C2, and sub-axial spine (C3-C7), involvement of vertebral body or bony projection like the spinous process, mechanism of injury (e.g. compression, flexion, compression), and stability of injury.
• Respiratory muscle weakness, often leading to respiratory impairment and weak cough, generally occurs in high cervical injuries (C1-C4) (5).
• Unstable fractures allow for excessive motion between the vertebrae which can allow damage to spinal nerves or the spinal cord.
• Stable fractures are unlikely to move or further compromise neurologic structures.
• There are more than 20 subtypes of cervical fractures. Completeness of spinal cord injury (SCI) is an important factor for long-term functional prognosis. The American Spinal Injury Association Impairment Scale (AIS) score is a standardized neurologic examination that assesses the sensory and motor levels affected. AIS Grade A and B are considered motor complete, AIS Grade C and D are motor incomplete, and AIS Grade E is normal function (6). Individuals who improve to an AIS Grade D or better are more likely to reach functional independence at 1 year follow up (7).

Mortality     One-year mortality is 36.5% in older adults with cervical spine fracture with SCI and 31% without SCI (8). This surpasses the well-documented mortality following hip fracture in older adults (8,9). Older adults with cervical fractures and complete SCI have a poorer prognosis, regardless of treatment (9,10).  Risk factors for mortality include type of cervical fracture sustained, polytrauma, neurological deficits from injury, comorbidities such as heart failure and dementia, baseline functional dependence, and development of delirium during hospitalization (8,10). There are no definitive trials clarifying how operative management affects survival. Some observational studies did not find a statistical difference in mortality between operative and non-operative management, others found a mortality benefit with operative intervention (10-13).

Functional recovery depends on baseline functional status, comorbidities, degree of neurological impairment, type of injury, and other associated traumas (3). Most neurologic recovery occurs in the first 6 to 9 months with the most rapid rate of recovery happening in the first 3 months after injury (14).  After one-year, older adults who survived high-energy trauma (with or without a cervical fracture), like a motor vehicle accident, returned to walking outdoors without an assistive device 67% of the time and were living independently in 74% of the cases (15). In comparison, older adults after a low-energy trauma, such as a ground level fall, were half as successful, presumably due to worse baseline functional status (15). In assessing how a patient is likely to do, it is helpful to consider the etiologies of the fall and their important implications in recovery. Some causes are potentially modifiable, such as balance or gait impairment at times, or medication use, while others like cancer, heart failure, or neurocognitive disorders are not (16). In one study of patients hospitalized with cervical fractures, 5% died while inpatient, over one-third of patients were discharged home with assistance or home health care, over half went to acute rehabilitation or skilled nursing facility, and about 10% enrolled in hospice (11).

References 

1. Kakara RS, Lee R, Eckstrom EN. Cause-Specific Mortality Among Adults Aged ≥65 Years in the United States, 1999 Through 2020. Public Health Rep Wash DC 1974. 2024;139(1):54-58. doi:10.1177/00333549231155869.
2. Wang H, Coppola M, Robinson RD, et al. Geriatric Trauma Patients with Cervical Spine Fractures Due to Ground Level Fall: Five Years Experience in a Level One Trauma Center. J Clin Med Res. 2013;5(2):75-83. doi:10.4021/jocmr1227w.
3. Chibbaro S, Mallereau CH, Ganau M, et al. Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome. Neurosurg Rev. 2022;45(1):709-718. doi:10.1007/s10143-021-01594-2.
4. Berlowitz DJ, Wadsworth B, Ross J. Respiratory problems and management in people with spinal cord injury. Breathe Sheff Engl. 2016;12(4):328-340. doi:10.1183/20734735.012616.
5. Rupp R, Biering-Sørensen F, Burns SP, et al. International Standards for Neurological Classification of Spinal Cord InjuryRevised 2019. Top Spinal Cord Inj Rehabil. 2021;27(2):1-22. doi:10.46292/sci2702-1.
6. Mputu PM, Beauséjour M, Richard-Denis A, et al. Does Improvement in American Spinal Injury Association Impairment Scale Grade Correlate With Functional Recovery in All Patients With a Traumatic Spinal Cord Injury? Am J Phys Med Rehabil. 2024;103(2):117-123. doi:10.1097/PHM.0000000000002313.
7. Zeitouni D, Catalino M, Kessler B, et al. 1-Year Mortality and Surgery Incidence in Older US Adults with Cervical Spine Fracture. World Neurosurg. 2020;141:e858-e863. doi:10.1016/j.wneu.2020.06.070.
8. Moran CG, Wenn RT, Sikand M, et al. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005;87(3):483-489. doi:10.2106/JBJS.D.01796.
9. Bokhari AR, Sivakumar B, Sefton A, et al. Morbidity and mortality in cervical spine injuries in the elderly. ANZ J Surg. 2019;89(4):412-417. doi:10.1111/ans.14875.
10. Sokolowski MJ, Jackson AP, Haak MH, et al. Acute mortality and complications of cervical spine injuries in the elderly at a single tertiary care center. J Spinal Disord Tech. 2007;20(5):352-356. doi:10.1097/BSD.0b013e31802d0bc5.
11. Mormol J, Krech L, Pounders S, et al. Protect the neck: Devastating outcomes of cervical spin  fractures in the elderly. Am J Surg. Published online December 3, 2023:S0002-9610(23)00639-6. doi:10.1016/j.amjsurg.2023.11.034.
12. Harris MB, Reichmann WM, Bono CM, et al. Mortality in elderly patients after cervical spine fractures. J Bone Joint Surg Am. 2010;92(3):567-574. doi:10.2106/JBJS.I.00003.
13. Pearson AM, Martin BI, Lindsey M, et al. C2 Vertebral Fractures in the Medicare Population: Incidence, Outcomes, and Costs. J Bone Joint Surg Am. 2016;98(6):449-456. doi:10.2106/JBJS.O.00468.
14. Chay W, Kirshblum S. Predicting Outcomes After Spinal Cord Injury. Phys Med Rehabil Clin N Am. 2020;31(3):331-343. doi:10.1016/j.pmr.2020.03.003.
15. Shah J, Titus AJ, OʼToole RV, et al. Are Geriatric Patients Who Sustain High-Energy Traumatic Injury Likely to Return to Functional Independence? J Orthop Trauma. 2019;33(5):234-238. doi:10.1097/BOT.0000000000001436. 
16. Colón-Emeric CS, McDermott CL, Lee DS, et al. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review. JAMA. 2024;331(16):1397-1406. doi:10.1001/jama.2024.1416.

Conflicts of Interest: The authors have disclosed no conflicts of interest.
Authors’ Affiliations: University of Pittsburgh Medical Center, Pittsburgh, PA (CJW, CS); University of Maryland, Baltimore, MD (MMR); Icahn School of Medicine at Mt Sinai, New York, NY (RMA).
Version History: First electronically published in March 2025; originally edited by Drew A Rosielle MD.