Operative Versus Nonoperative Management of Unstable Spine Fractures in the Elderly

Outcomes and Mortality

Karen Malacon, BA; Taiyeb Rangwalla, BS; Harsh Wadhwa, BS; Corinna Zygourakis, MD


Spine. 2023;48(1):39-48. 

In This Article

Abstract and Introduction


Study Design: Retrospective cohort study.

Objective: To assess outcomes and mortality in elderly patients following unstable spine fractures depending on treatment modality.

Summary of Background Data: Operative management of unstable spine fractures in the elderly remains controversial due to increased risk of perioperative complications. Mortality rates after operative versus nonoperative treatment of these injuries have not been well-characterized.

Materials and Methods: Patients aged above 65 with unstable spine fractures without neurologic injury from 2015 to 2021 were identified from the Clinformatics® Data Mart (CDM) Database. Demographics, complications, and mortality were collected. Multivariable logistic regression was used to adjust for the effect of baseline characteristics on mortality following unstable fracture diagnosis.

Results: Of the 3688 patients included, 1330 (36.1%) underwent operative management and 2358 (63.9%) nonoperative. At baseline, nonoperative patients were older, female, had higher Elixhauser comorbidity scores, and were more likely to have a cervical fracture. Operative patients had a longer length of stay in the hospital compared with nonoperative patients (9.7 vs. 7.7 days; P<0.001). Although patients in the operative group had higher rates of readmission at 30, 60, 90, and 120 days after diagnosis (P<0.01), they had lower mortality rates up to five years after injury. After adjusting for covariates, nonoperative patients had a 60% greater risk of mortality compared with operative patients (hazard ratio: 1.60, 95% confidence interval: 1.40–1.78, P<0.001). After propensity score matching, operative patients age 65 to 85 had greater survivorship compared with their nonoperative counterparts.

Conclusions: Elderly patients with an unstable spine fracture who undergo surgery experience lower mortality rates up to five years postdiagnosis compared with patients who received nonoperative management, despite higher hospital readmission rates and an overall perioperative complication rate of 37.3%. Operating on elderly patients with unstable spine fractures may outweigh the risks and should be considered as a viable treatment option in appropriately selected patients.


The number of patients older than 65 has increased over the past few decades and is one of the fastest-growing demographics in the United States, with projections to reach 98 million by 2060.[1] Patients with increased age have poorer bone density and are more susceptible to falls, which can result in spine fractures from minor trauma.[2] While many of these patients have been managed nonoperatively due to higher perioperative risk, advances in surgical technique and general anesthesia have increased the possibility of operative management of these injuries in elderly patients.

Outcomes associated with spine fractures among older adults are poor, with high morbidity and mortality rates and low home discharge rates.[2,3] In general, patients with stable fractures are treated conservatively, and patients with unstable fracture patterns or progressive neurologic deficits are treated operatively if they are deemed to be suitable operative candidates. However, the management of unstable spine fractures without neurologic injury in our increasingly elderly population remains controversial,[4–7] due to an increased perioperative complication risk, multiple comorbidities, and reduced functional reserves.[8–11]

Survival and outcomes after operative versus nonoperative management of unstable spine fractures has not been well-characterized. The objective of this study was to evaluate the mortality risk, length of stay (LOS), readmission rates, and complications for elderly patients with unstable spine fractures undergoing different treatment modalities.