Outcomes of ACDF with Plate vs Posterior Fixation in Octogenarians with Subaxial Fractures

Overview

This retrospective study compared anterior cervical discectomy and fusion (ACDF) with plating versus posterior decompression and fusion (PDF) in octogenarians sustaining traumatic subaxial cervical fractures. It evaluated clinical outcomes, complications, and mortality over a two-year follow-up, highlighting surgical decision-making challenges in this vulnerable population.

Background

The elderly population is rapidly increasing worldwide, with octogenarians facing high morbidity and mortality risks from spinal trauma, particularly subaxial cervical fractures. Surgical management options include anterior approaches like ACDF with plating for disc or bone fragment injuries and posterior fixation for ligamentous disruptions. However, evidence guiding optimal surgical strategies in octogenarians remains limited due to their poor baseline reserves and high complication risks.

Data Highlights

A total of 1345 patients with subaxial fractures were treated between 2005 and 2020; 28 (2.1%) were aged 80–90 years and all underwent surgery. Patients were classified using the Subaxial Injury Classification (SLIC) system, with scores ≥4 indicating surgical recommendation. Surgical techniques included anterior cervical discectomy and fusion with plating (pACDF) and posterior decompression and fusion (PDF) with lateral mass fixation. CT-based navigation was used for all instrumented surgeries to maximize safety.

Key Findings

• Octogenarians with traumatic subaxial fractures represent a small but significant surgical cohort with unique challenges due to comorbidities and frailty.
• Both anterior (pACDF) and posterior (PDF) surgical approaches aim to decompress neural elements, restore alignment, and provide spinal stability.
• Decision-making was multidisciplinary, considering fracture morphology, ligamentous injury, and neurological status as per SLIC scoring.
• Anterior approaches were preferred for retropulsed bone fragments or disc injuries; posterior approaches for posterior ligamentous disruptions without dislocation.
• Use of CT-based navigation enhanced surgical safety in this high-risk population.
• No patients over 90 years underwent surgery, reflecting cautious patient selection in advanced age.

Clinical Implications

Clinicians should carefully evaluate octogenarian patients with subaxial fractures using standardized classification systems and multidisciplinary input to select appropriate surgical approaches. Both anterior and posterior fixation techniques can be safely performed with navigation assistance, but patient baseline reserve and fracture characteristics must guide individualized treatment to optimize outcomes and minimize complications.

Conclusion

Surgical management of traumatic subaxial cervical fractures in octogenarians requires tailored approaches balancing fracture pathology and patient frailty. This study supports the feasibility of both anterior plating and posterior fixation with navigation in this population, emphasizing the need for further research to refine guidelines.

References

1. Study Authors/Institution/2024 -- Comparative Outcomes of Anterior Cervical Discectomy and Fusion with Plate Versus Posterior Screw Fixation in Octogenarians Following Traumatic Subaxial Fractures