Thoracolumbar Trauma in the Aging Spine : Limitations of Conventional Classification Systems and an Integrated Frailty-Based Treatment Framework

¹Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
²University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
³Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
⁴Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
⁵Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
⁶Department of Neurosurgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
⁷Department of Neurosurgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
⁸Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea

Correspondence

Woo-Keun Kwon ,Tel: +82-2-2626-3100, Fax: +82-2-863-1684, Email: kwontym@gmail.com

Received: June 29, 2026; Revised: July 21, 2026 Accepted: July 29, 2026. Published online: August 7, 2026.

ABSTRACT

Thoracolumbar trauma in elderly patients has become increasingly important as population aging has reshaped the epidemiology of spinal injury. In the aging spine, low-energy trauma can produce clinically significant or unstable fractures because osteoporosis, degenerative stiffness, and rigid spine disorders alter mechanical behavior. Conventional classification systems and guideline-based algorithms remain useful for describing fracture morphology, neurological status, and structural instability. However, their applicability in elderly patients is limited because treatment decisions must account for frailty-related vulnerability and the functional consequences of immobilization. This review summarizes the distinctive features of thoracolumbar trauma in the aging spine and proposes an integrated framework that combines structural injury severity with frailty-based assessment of treatment tolerance. Frailty reduces physiologic reserve and limits the ability to tolerate treatment and recover after injury, while poor bone quality and spinal rigidity increase the risk of structural failure even with guideline-concordant care. Treatment should aim to restore stability, preserve neurological function, control pain, and enable early mobilization while minimizing physiologic burden. Depending on structural demand, treatment may range from non-operative care or vertebral augmentation in appropriate patients to definitive fixation, with selection guided by bone quality, frailty, and expected functional benefit. Thoracolumbar trauma in the aging spine should be managed as a distinct clinical entity for which an integrated frailty-based framework may better support practical, patient-centered decision-making.

Key Words: Spinal fractures · Thoracolumbar fractures · Frailty · Elderly · Neurotrauma