Cervical spine fractures in older adults: epidemiology, associations and impacts

Background: Cervical spine fracture incidence in older adults is increasing. The epidemiology of these injuries is under-researched, with limited information regarding long-term impacts and management strategies. Fractures of the second cervical vertebra have shown the greatest increase in incidence; previous research completed as part of my Pre-doctoral NIHR fellowship shows a potential association between low bone density and these injuries. Thoracic and lumbar vertebral fractures are strongly associated with high fracture risk; this association has not been investigated for cervical spine fractures therefore this diagnosis does not prompt bone health investigations. Prompt identification of at-risk patients and commencement of bone protective medications can dramatically reduce future fracture risk, improving patient quality of life and reducing the huge expenditure of public money on fracture care. Older adults sustaining cervical spine fractures are missing out on these investigations, leaving a growing population of older adults at risk of devastating future fractures. My PPIE group have identified this as an important research area and have helped develop this proposal. Aims and Objectives: This research aims to undertake the first ever population-based study to identify the importance of cervical spine fractures in older adults by describing the epidemiology and investigating the drivers and impacts of these fractures. Objectives include 1) describing cervical spine fracture epidemiology; 2) describing cervical spine fracture impact including mortality risk; 3) investigating associations between poor bone health and cervical spine fractures; 4) identifying if associations are affected by the anatomical level of cervical spine fracture. Methods: I will use linked data from Hospital Episode Statistics (HES), Clinical Practice Research Datalink and Office for National Statistics. Data will be analysed in a cross-sectional manner to address objective 1 and using a case-control study design for objectives 2-4. Cervical spine fractures (cases) will be identified from HES; three controls will be matched with each case. Hip fractures recorded in HES will be used as a proxy for poor bone health. Impact measures will include poor bone health and mortality. Incident rates for cervical spine fractures will be calculated for objective 1. Logistic regression will be used for objectives 2-4, with multivariable techniques employed to adjust for potential confounding and identify independent associations between cervical spine fractures and poor bone health. Based on this analysis, and an estimated incidence of hip fracture as 1.56%, we have between 80 and 100% power to identify a true association. Missing data will be managed using multiple imputation. Additional analyses will explore whether the impact of cervical spine fractures (objective 2) differed before and during the pandemic. Anticipated impact and dissemination: I anticipate the outcomes of this research will generate hypotheses, and whether the direction of travel should be to recommend bone health assessment in older people with cervical spine fracture. Results will be disseminated to the wider clinical and research communities with publication and presentation at international conferences. Diverse practices will be used to facilitate EDI-conscious dissemination to the public using platforms such as social media, graphical abstracts, community disseminators and osteoporosis charity publications and events.