Early morbidity and mortality following subaxial cervical spine fractures in older patients

Introduction

Subaxial cervical spine fractures in older adults are increasingly common and often occur in the context of frailty, multimorbidity, and low-energy trauma. Despite this, outcome data to guide optimal management are limited. We aimed to describe early morbidity and mortality and identify factors associated with poor outcomes in older patients with these injuries.

Method
We conducted a retrospective cohort study of consecutive patients aged 65 years and over admitted to our Major Trauma Centre with subaxial cervical spine fractures. Data collected included demographics, pre-injury functional status, Clinical Frailty Scale (CFS), comorbidities, fracture morphology, concomitant injuries, and treatment modality. Outcomes included 30-day, 90-day and one-year mortality, length of stay, change in mobility and residence, and readmission within one year. Associations with mortality were analysed using multivariable logistic regression analysis.

Results
104 patients were included. The mean age was 77.9 years; 57% were male. The median CFS was 4, and 84% were managed non-operatively. Mortality was high: 15.4% at 30 days, 18.3% at 90 days and 26.9% at one year. Concomitant intracranial injury was associated with a significant increase in 30-day mortality, while respiratory complications were significantly associated with increased one-year mortality. Among patients managed non-operatively, increasing age and higher frailty scores were independently associated with higher one-year mortality. Survivors frequently experienced functional decline and loss of independence.

Conclusions

Subaxial cervical spine fractures in older adults are associated with mortality of 26.9% at one year. The heterogeneity in fracture morphology and injury patterns adds complexity to clinical decision making. Frailty and age were key predictors of one-year mortality, highlighting the importance of early Geriatrician and Spinal Surgeon input. Improved risk stratification may inform conversations around shared decision-making and the development of multidisciplinary care pathways for older patients with spinal trauma.