Delay in Surgical Fixation of Operatively Treated Thoracolumbar Fractures in the Elderly Associated With Minimal Increase in Short-Term Complications

Abstract

Study Design

Retrospective cohort study.

Objectives

Optimal timing of surgical fixation for neurologically intact unstable thoracolumbar fractures (NIUTLFx) in elderly patients remains poorly defined. This study evaluated the association between delay to surgical fixation and short-term postoperative outcomes in elderly patients with NIUTLFx.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients aged 60 years or older who underwent operative fixation for unstable NIUTLFx between 2012 and 2023. Multivariable logistic regression and change-point analyses were used to evaluate the association between surgical delay and 30-day mortality, major complications, perioperative transfusion, and discharge disposition, adjusting for demographic and clinical covariates.

Results

A total of 976 patients met inclusion criteria. The mean time to surgery was 2.8 ± 2.0 days. Surgical delay was not associated with increased 30-day mortality or major postoperative complications. Delays exceeding four days were independently associated with a higher likelihood of discharge to a non-home destination (odds ratio 1.60, 95% CI 1.07-2.38). Delay was not an independent predictor of perioperative blood transfusion after adjustment. Over the study period, mean time to surgery decreased significantly, reflecting a national trend toward earlier operative intervention.

Conclusions

In elderly patients with NIUTLFx, surgical delays of up to four days do not increase short-term mortality or major complications. However, delays beyond four days are associated with a significantly increased risk of non-home discharge. Our data suggest that over short timescales, surgical fixation delays are not associated with significant morbidity but are associated with worse discharge disposition.

Keywords

thoracolumbar fractures elderly surgical timing discharge disposition unstable fractures

Introduction

Thoracolumbar fractures represent a serious and potentially debilitating injury even in the absence of neurologic compromise. Among elderly patients, they often result from low-energy mechanisms such as falls due to age-related bone fragility.^1-4 This demographic faces heightened risks of complications owing to diminished physiological reserves, comorbidities, and impaired mobility.^1-3 Neurologically intact unstable thoracolumbar fractures (NIUTLFx) pose a unique challenge in older adults, as treatment delays can precipitate physical deconditioning, extended hospital stays, prolonged mechanical ventilation, and greater dependence at discharge.⁵ Despite the rising incidence of such injuries amid an aging population, optimal timing for surgical intervention remains contentious, with limited consensus specifically for geriatric patients.^5-7

Existing literature on surgical fixation timing is sparse and predominantly derived from heterogeneous cohorts that inadequately capture elderly characteristics.⁸ Much of the evidence focuses on younger trauma patients with severe neurological deficits, for whom emergent decompression with or without fixation is clearly indicated.⁸ Conflicting findings exist on the implications of delayed biomechanical fixation absent neurologic deficit, with variable impacts on mortality, complications, and functional recovery.^9-11 Data tailored to older adults, with distinct frailty profiles, are particularly scarce.¹² For surgeons, this complicates risk-benefit calculations when weighing preoperative optimization against urgent intervention for bedbound elderly patients.

This is in contrast to the hip fracture literature. In this context evidence from meta-analyses, randomized controlled trials, and clinical guidelines support early surgical intervention (typically within 24-48 hours of admission) which reduces mortality,^13-15 venous thromboembolism,^16,17 pulmonary complications, pressure sores, delirium, infections,¹⁸ and hospital length of stay while improving functional outcomes and independent living probabilities at 1 year.^19-21 For example, a meta-analysis of over 190,000 patients found surgery within 48 hours associated with significantly better outcomes including lower mortality and pressure sores,¹³ while another reported a 20% reduced 12-month mortality risk (RR 0.80, 95% CI 0.66-0.97) and fewer complications (8% vs 17%).¹⁵ Though some debate exists on preoperative optimization, these findings have established early surgery as the global standard.^22,23

No equivalent protocols exist for NIUTLFx in the elderly.²⁴ An enhanced understanding is necessary given the escalating burden of geriatric trauma,⁴ This study attempts to close the data gap between hip and thoracolumbar fracture by examining the effects of delayed surgical fixation on short-term mortality, postoperative complications, and discharge disposition in elderly patients with unstable thoracolumbar fractures, using a large national database.

Methods

Data Source and Study Population

We utilized the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify elderly patients undergoing non-emergent surgical fixation for thoracolumbar fractures between January 1, 2012 and December 31, 2023. The NSQIP includes data from over 700 hospitals and is assembled by hospital-appointed, specially trained staff members. The NSQIP database includes data regarding baseline patient demographics, surgical details, and 30-day post-operative outcomes. Diagnostic codes were used to identify patients with of fracture of thoracic (ICD9 805.2, ICD10 S22.0) or lumbar (ICD9 805.4, ICD10 S32.0) vertebra. CPT codes were then used to select patients with codes related to fracture reduction including corpectomy (22325, 22327, 22328, 63087, 63090), posterior instrumentation (22840, 22842, 22843) and fusion (22633, 22556, 22558, 22630, 22586, 22610, 22612, 22614, 22800, 22802). Exclusion criteria included age less than 60, emergency surgery, elective surgery, delay to surgery of greater than 10 days after admission and associated procedures codes for vertebroplasty or kyphoplasty (22520-25). Given limitations of the database, no detail was available to fracture level and morphology. Surgical detail was also limited, with only general categories of intervention analyzed.

Variables and Outcomes

Patient characteristics collected from the registry included patient age, sex, height, weight, smoking history (within 1 year), American Society of Anesthesiologists (ASA) class, operative time (in minutes), and medical comorbidities including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), bleeding disorders, and dialysis-dependent kidney disease. Body mass index (BMI) was calculated from each patient’s height and weight. Functional status was defined as the patient’s ability to perform the activities of daily living (ADLs) in three categories. These categories included ADLs performed independently, in a partially dependent manner, or a completely dependent manner within the 30 days prior to admission.

Data on postoperative medical complications within 30 days were collected. Primary outcomes of the study were major complications, mortality, prolonged ventilation or reintubation, readmission, return to the operating room (OR), venous thromboembolism (VTE, including pulmonary embolism (PE) or deep vein thrombosis (DVT)), surgical site complications (including deep infection, wound infection, superficial infection or dehiscence), post-operative blood transfusion and non-home discharge destination. Major complications were defined as the occurrence of any of the following: death, on ventilator more than 48 hours, unplanned intubation, stroke/cerebrovascular accident, DVT, PE, cardiac arrest, myocardial infarction (MI), acute renal failure (ARF) requiring dialysis, sepsis, septic shock, return to OR, wound dehiscence, superficial infection, wound infection, deep surgical organ/space infection.

Statistical Analysis

Baseline characteristics of patients were summarized using descriptive statistics. Multi-variate Poisson regression was used to identify factors associated with delay to surgery, generalized linear regression and generalized additive regression models were used to explore the functional relationship between delays to surgery and the outcomes of interest while controlling for other variables. Change-point testing was performed to estimate delay thresholds associated with outcomes of interest. Multivariate logistic regression with backward selection was used to estimate the relationship between pre-surgical delay and outcomes of interest, adjusted for age, gender, BMI, ASA class, OR time, and medical comorbidities. Patients with missing covariates were excluded from multivariate analysis. Statistical significance was defined as P < 0.05. Statistical analyses were performed using R 4.2.0 (R Foundation for Statistical Computing, Vienna, Austria).

Results

A total of 976 elderly patients aged 60 years or older with NIUTLFx met inclusion criteria between 2012 and 2023. The mean time from admission to surgical fixation was 2.8 ± 2.0 days, with a median of 2 days and an interquartile range of 2 to 4 days (Figure 1). Over the study period, the mean delay to surgery decreased significantly from 3.3 days in 2013 to 2.3 days in 2023 (P < 0.001), reflecting a national trend toward earlier operative intervention (Figure 2). The majority of patients (72.4%) underwent fixation within 3 days of admission.

Figure 1.

Distribution of surgical delay across the study cohort. Histogram demonstrating the distribution of time from admission to operative fixation. The majority of patients (72.4%) underwent surgery within 3 days of admission (median = 2 days, IQR 2-4)

Figure 2.

Temporal trend in time to surgery for unstable thoracolumbar fractures among elderly patients (2012211; 2023). Mean days from admission to operative fixation are plotted by year of surgery. The mean delay decreased significantly over the study period, from 3.3 days in 2013 to 2.3 days in 2023 (P < 0.001), reflecting a national trend toward earlier surgical intervention in elderly patients

Baseline demographic and clinical characteristics are presented in Table 1. The cohort consisted of 56.2% females with a mean age of 74.1 ± 8.1 years and a mean body mass index (BMI) of 30.6 ± 7.7 kg/m². Most patients were classified as ASA class III or IV (85.3%), and 11.6% reported smoking within the past year. Hypertension was the most prevalent comorbidity, affecting 72.4% of the cohort, followed by diabetes (34.5%), chronic obstructive pulmonary disease (9.8%), and congestive heart failure (5.6%). The majority of patients (86.0%) were independent in activities of daily living prior to admission. The mean operative duration was 198 ± 105 minutes. Patients who experienced surgical delays greater than 2 days had higher ASA classifications (P = 0.039) and were more likely to have congestive heart failure (P = 0.0055) or diabetes (P = 0.007). There were no significant differences between early and delayed surgery groups in terms of age, sex, BMI, diabetes, or smoking status.

Table 1.

Baseline Cohort Characteristics

		Delay 0-2 Days	Delay 2+ days	P-val^a
		n = 539	n = 437	P-val^a
Sex, female		46.8% (252)	52.4 (229)	0.09
Age	Mean (SD)	74.3 (8.1)	74.0 (8.1)	0.60
	60-69	36.9% (199)	37.1% (162)	0.99
	70-79	33.8% (182)	33.4% (146)
	80+	29.3% (158)	29.5% (129)
Race	White	73.7% (397)	76.1% (332)	0.012
	Black	3.2% (17)	4.1% (18)
	Hispanic	4.8% (26)	7.8% (34)
	Other	8% (43)	3.7% (16)
	Missing	10.4% (56)	8.3% (36)
BMI	Mean (SD)	30.7 (8.1)	30.3 (7.1)	0.39
ASA score	1-2	16.9% (91)	11.5% (50)	0.037
	3	64.9% (349)	66.7% (291)
	4+	18.2% (98)	21.8% (95)
OR time (min)	Mean (SD)	189 (95)	210 (115)	0.002
Surgical intervention	Instrumentation	72.0% (380)	76.9% (327)	0.095
	Fusion	81.3 % (429)	84.4% (359)	0.0008
	Corpectomy	3.2% (17)	4.0% (17)	0.63
Function	Independent	87.5% (462)	84.2% (358)	0.18
Medical comorbidities	Diabetes	30.4% (164)	38.9% (170)	0.007
	HTN	71.1% (383)	73.5% (321)	0.45
	COPD	10.2% (55)	9.6% (42)	0.84
	CHF	3.5% (19)	7.8% (34)	0.0055
	Cancer	2.8% (15)	5.7% (25)	0.032
	Bleeding disorder	10.8% (58)	10.1% (44)	0.81

ASA, American society of anesthesiologists; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disorder; HTN, hypertension; OR, operating room; SD, standard deviation.

^aThreshold for statistical significance after Bonferroni correction P < 0.0038.

In regression model of days to surgery, female sex was associated with an increased time to surgery (Incidence Rate Ratio, IRR, 1.12, P = 0.006, Table 2). Black (IRR 1.25, P = 0.018) patients also had an increased time to surgery compared to white patients. Increase in ASA (IRR 1.17 per unit ASA increase, P < 0.001), diabetes (IRR 1.22, P < 0.001) and CHF were associated with increased time to surgery (IRR 1.28, P = 0.001). Surgical technique and pre-injury functional status were not associated with delays in time to surgery.

Table 2.

Best-Fitting Multivariate Regression Model Results to Probability of Blood Transfusion, Probability of Non-home Discharge and Days to Surgery

Variable	Transfusion			Discharge to facility			Days to surgery
Variable	OR	95% CI	P	OR	95% CI	P	IRR	95% CI	P
Delay ≥2 days	1.28	0.92-1.80	0.15	—	—	—	—	—	—
Delay ≥4 days	—	—	—	1.62	1.08-2.43	0.022	—	—	—
Age >74 years	—	—	—	2.11	1.54-2.90	<0.001	—	—	—
Female sex	1.61	1.14-2.28	0.007	—	—	—	1.12	1.03-1.22	0.006
Black race	—	—	—	—	—	—	1.25	1.02-1.54	0.018
Hispanic race	—	—	—	—	—	—	1.15	0.99-1.33	0.063
Other race	—	—	—	—	—	—	0.74	0.62-0.88	0.001
ASA class	2.40	1.76-3.27	<0.001	1.65	1.26-2.15	<0.001	1.17	1.10-1.25	<0.001
BMI	—	—	—	—	—	—	0.99	0.99-1.00	0.001
Hypertension	—	—	—	1.81	1.30-2.51	<0.001	—	—	—
Diabetes	—	—	—	—	—	—	1.22	1.11-1.35	<0.001
Congestive heart failure	—	—	—	3.64	1.07-12.2	0.036	1.28	1.11-1.48	0.001
Operative time (per 10 min)	1.09	1.07-1.11	<0.001	1.03	1.01-1.04	<0.001	—	—	—
Corpectomy	2.37	1.04-5.41	0.040	—	—	—	—	—	—
Fusion	—	—	—	1.52	1.03-2.24	0.035	—	—	—

ASA, American society of anesthesiologists; BMI, body mass index; CI, confidence interval; IRR, incidence rate ratio; OR, odds ratio.

Unadjusted 30-day postoperative outcomes are summarized in Table 3. The overall 30-day mortality rate was 2.1%, which did not differ significantly between patients undergoing early vs delayed fixation (2.0% vs 2.3%, P = 0.78). Major complications occurred in 13.7% of patients, with no significant difference between groups (13.2% vs 14.1%, P = 0.67). Rates of readmission (7.9%), return to the operating room (5.4%), venous thromboembolism (2.5%), and surgical site complications (3.1%) were similar regardless of surgical timing (all P > 0.05). However, patients with delayed fixation experienced higher rates of perioperative blood transfusion (28.5% vs 20.8%, P = 0.011) and were more frequently discharged to non-home destinations such as rehabilitation or skilled nursing facilities (63.7% vs 54.8%, P = 0.004).

Table 3.

Summary of Unadjusted Complications Rate by Days to Surgical Fixation

Complication	Delay		P-Val
Complication	<=2 Days	>2 Days	P-Val
Death	4.64% (25)	4.35% (19)	0.95
Unplanned re-admit	9.09% (49)	10.98% (48)	0.38
Ventilator complication	7.05% (38)	8.7% (38)	0.40
Venous thromboembolism	1.86% (10)	3.66% (16)	0.12
Transfusion	19.85% (107)	27.23% (119)	0.008
Surgical site complication	4.64% (25)	6.64% (29)	0.22
Discharge to facility	65.68% (354)	71.62% (313)	0.055
Major complication	18.92% (102)	18.31% (80)	0.87
Any complication	38.03% (205)	45.08% (197)	0.031

On univariate regression, each additional day of surgical delay was associated with increased odds of requiring perioperative transfusion (odds ratio [OR] 1.08; 95% confidence interval [CI], 1.01-1.14; P = 0.024) and increased odds of non-home discharge (OR 1.12; 95% CI, 1.05-1.20; P < 0.001) (Figure 3). No significant associations were observed between surgical delay and mortality, major complications, prolonged ventilation, venous thromboembolism, wound complications, or readmission (all P > 0.05). On change-point analysis, a significant threshold was identified at greater than 2 days for increased transfusion risk (OR 1.08; P = 0.0036) and greater than four days for increased risk of non-home discharge (OR 1.13; P < 0.001). A smaller but significant increase in discharge to a facility was also noted for delays exceeding 2 days (OR 1.07; P = 0.019).

Figure 3.

Change-point analysis of surgical delay and postoperative outcomes. Functional plots illustrating threshold effects of preoperative delay on (A) perioperative transfusion risk and (B) non-home discharge. Inflection points were identified at > 2 days for increased transfusion odds and > 4 days for increased non-home discharge odds. Curves represent fitted generalized additive models adjusted for demographic and clinical covariates

In multivariate logistic regression adjusting for demographic and clinical variables, delay to surgery was not independently associated with the need for transfusion (P = 0.15, Table 2). Independent predictors of transfusion included higher ASA classification (P < 0.001), female sex (P = 0.007), longer operative duration (P < 0.001) and corpectomy (P = 0.04). In contrast, a delay to surgery greater than four days remained an independent predictor of non-home discharge (OR 1.62; 95% CI, 1.08-2.43; P = 0.022, Table 2). Older age (P < 0.001), higher ASA score (P < 0.001), hypertension (P < 0.001), congestive heart failure (P = 0.036), longer operative time (P < 0.001) and listed coded for fusion (P = 0.035) were also independently associated with discharge to a facility. After adjustment, surgical delay was not associated with 30-day mortality, major medical complications, venous thromboembolism, wound complications, or readmission (all P > 0.05).

Discussion

In this analysis of elderly patients undergoing operative fixation for NIUTLFx, surgical delay was not associated with increased 30-day mortality or major postoperative complications. The primary finding of this study was that delays greater than four days were independently associated with an increased likelihood of discharge to a non-home destination, suggesting that prolonged preoperative hospitalization is associated with compromised short-term functional recovery and disposition. Importantly, however, our data suggest that risk-benefit calculations with respect to surgical timing are distinct for NIUTLFx as compared to hip fractures.^13–17

Previous literature on the timing of thoracolumbar fracture fixation has been heterogeneous, often including younger trauma patients or those with neurological injury, for whom emergent decompression is clearly indicated.²⁵ A methodological systematic review by Xing et al. emphasized benefits of early surgery (<72 hours), such as shorter hospital stays, reduced ICU/ventilator days, and lower rates of thromboembolism and pneumonia, though early risks like hypotension and hemorrhage in unstable patients must be balanced; however, evidence quality was limited by methodological flaws in included studies.²⁵ Studies examining neurologically intact or elderly populations remain sparse.^12,24,26 For instance, Pfeifle et al. found no impact of time-to-surgery on 1-year mortality in elderly osteoporotic vertebral compression fractures, but noted correlations with prolonged hospitalization.²⁴ Mahon et al. reported shorter hospital stays and fewer complications with fixation within 72 hours in mixed-age cohorts, though elderly subgroups were underpowered.¹¹ Similarly, Bellabarba et al. showed reduced pulmonary complications with early fixation, primarily in younger high-energy cases.⁹ European Society for Trauma and Emergency Surgery recommendations highlight ongoing uncertainties in timing for neurologically intact elderly patients, advocating individualized approaches balancing medical optimization and early mobilization.⁵ World Federation of Neurosurgical Societies Spine Committee consensus supports surgery for early mobilization and reduced complications in suitable patients.⁶ The present study addresses these gaps by focusing on elderly patients with unstable fractures lacking neurologic deficits, a group ideal for semi-elective stabilization.^27,28

The observed increase in non-home discharge aligns with geriatric fracture patterns. In hip fractures, delays beyond 8-72 hours raise complications, immobility, and non-independent living risks.^{8,14,16,17,19,29,30} For vertebral fractures, Pfeifle et al. linked delays to extended stays without mortality effects, emphasizing deconditioning.²⁴ Thoracolumbar trends toward earlier surgery (eg, from 3.3 to 2.3 days over the study period) mirror national shifts.²⁷ While timelines differ between axial/appendicular injuries, both prioritize mobilization; delays >4 days here likely curtailed rehab, boosting facility discharges.^12,26 However, selection bias may play a role as more frail patients with a higher likelihood of non-home discharge may require additional pre-operative optimization, delaying surgical intervention.

No multivariate association was found between surgical delay and the need for perioperative blood transfusion after adjusting for confounders such as frailty (eg, higher ASA classification), female sex, and longer operative duration. Similarly, rates of major medical complications—including venous thromboembolism, respiratory failure, and sepsis—remained unaffected by timing of surgery,²⁸ which provides reassurance regarding the safety of modest delays for medical optimization in frail elderly patients.¹² Ultimately, prolonged delays exerted a greater influence on postoperative disposition than on acute morbidity.⁵ It is possible that certain post-operative complications not included in the database, such a delirium, could be affected by delays to surgery and also contribute to discharge destination.

Delays were more frequently observed in patients with higher ASA classification, congestive heart failure, and bleeding disorders, indicating these reflect necessary periods for preoperative medical optimization rather than systemic inefficiencies in care.³¹ The sickest patients, particularly those with significant comorbidities, stand to benefit most from preoperative stabilization.²⁹ Access-related barriers can further exacerbate delays, as evidenced in multicenter studies from Latin America where surgical timing was hindered by high implant costs, diagnostic delays at primary facilities, prolonged transfers to specialized centers, limited hospital resources, and prioritization of multiple-trauma cases.³¹ Univariate analyses in the present study also identified associations between race (with non-White patients experiencing longer delays) and surgical timing, underscoring potential healthcare access disparities that contribute to prolonged preoperative hospitalization. Thus, while indicated delays for optimization should be accepted, surgery should be expedited to optimize functional recovery, early mobilization, and likelihood of discharge to home.⁶

This study has several limitations. The NSQIP database captures only 30-day outcomes and does not include long-term functional or radiographic data, which limits assessment of rehabilitation potential or ultimate ambulatory status. Neurological injury severity and fracture morphology are not recorded, although inclusion criteria aimed to isolate unstable fractures requiring fixation in the absence of emergent neurological compromise. Additionally, selection bias is possible, as patients with more severe comorbidities may have been preferentially delayed for optimization and also more likely to experience a discharge to facility. While available factors were controlled for on regression analysis, this was by no means a comprehensive list. Furthermore, patients at smaller hospitals with less access to specialty surgeon coverage may have experienced longer delays to surgery, which may be related to resources available for discharge. Nonetheless, the large sample size, standardized data collection, and national representation strengthen the generalizability of these findings across diverse practice settings.

Conclusion

Delays in surgical fixation of NIUTLFx in elderly patients within several days of admission may not result in increased short-term mortality or medical complication rates. Operative delays beyond four days are associated with higher rates of discharge to non-home destinations, likely reflecting the adverse functional consequences of prolonged immobility waiting for surgery. These findings suggest that while limited delays for optimization are appropriate, surgery should be performed expeditiously to facilitate recovery and maintain independence following injury.

Footnotes

ORCID iDs

Alexander Upfill-Brown

William L Sheppard

Ethical Considerations

Not needed for publicly available, de-identified database.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The NSQIP database is maintained and available through the American College of Surgeons.*

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