Osteoporotic thoracolumbar fractures: age-modified Osteoporotic Fracture–based treatment decisions and length of hospital stay in elderly patients – a prospective single-centre cohort study

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Abstract Purpose Treatment decisions for osteoporotic thoracolumbar vertebral fractures (OVF) in elderly patients are challenging. The AO Spine–DGOU Osteoporotic Fracture (OF) classification and OF-score support treatment allocation but do not explicitly account for chronological age, despite its known prognostic relevance. In addition, determinants of length of hospital stay (LOS) in older and very old patients with OVF remain incompletely defined. Methods In this prospective single-centre cohort study, patients aged ≥ 65 years with low-energy OVF were systematically classified using the OF system and treated conservatively or surgically. Multivariable logistic regression was used to identify determinants of surgical treatment, including age-dependent effects. Determinants of LOS were analysed using linear regression of log-transformed LOS, including interaction analyses between age group and treatment. Results A total of 171 patients were included. Higher OF grades and neurological deficits strongly favoured surgical treatment (OF 3: OR 11.53, 95% CI 2.60–51.23; OF 4–5: OR 31.54, 95% CI 7.21–137.97), whereas increasing age was independently associated with a lower likelihood of surgery (OR 0.85 per year, 95% CI 0.79–0.91). While OF 5 fractures were allocated to surgery irrespective of age, a pronounced age-dependent difference in treatment allocation was observed in OF 4 fractures, with surgical treatment rates of 82.8% in patients aged 65–79 years compared with 43.2% in patients aged ≥ 80 years. Surgical treatment was associated with longer LOS (median 17.5 vs. 7.0 days). Higher OF grade, poor pre-fracture mobility, greater comorbidity burden and neurological deficit independently prolonged LOS. Interaction analysis showed that surgery prolonged LOS to a similar extent in both age groups, with no significant interaction between treatment and age group ( p = 0.41). Conclusions Age was independently associated with treatment allocation in osteoporotic thoracolumbar fractures, particularly for OF 4 fractures. Surgical treatment was associated with longer hospital stay irrespective of age. No significant interaction between treatment and age group was observed, although smaller interaction effects cannot be excluded because of limited statistical power. Incorporating age- and frailty-related parameters into OF-based decision algorithms may improve treatment guidance in very elderly patients.