{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T22:12:53Z","timestamp":1769724773552,"version":"3.49.0"},"reference-count":50,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"15","license":[{"start":{"date-parts":[[2025,10,13]],"date-time":"2025-10-13T00:00:00Z","timestamp":1760313600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2025,10,13]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Three-column unstable fractures represent unstable spinal injuries. Chance fractures, while traditionally occurring in younger populations due to high-energy trauma, are increasingly being observed in older patients following injury caused by low-energy mechanisms. Management of this type of fracture in nonagenarians presents unique challenges due to multiple comorbidities, frailty, and limited evidence-based guidelines for this vulnerable population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>The authors present the case of a 92-year-old male with baseline dementia who sustained a C5\u20136 three-column unstable fracture following a ground-level fall. Despite the fracture\u2019s instability, conservative management with cervical collar immobilization was chosen over surgical intervention after extensive family discussion, considering the patient\u2019s advanced age, cognitive status, medical comorbidities, and history of noncompliance. A systematic literature review revealed no articles addressing three-column unstable injuries in nonagenarians and only 1 previous case report addressing Chance fractures in patients &gt; 90 years of age, highlighting the scarcity of evidence for this population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>Management of three-column unstable fractures in nonagenarians requires individualized decision-making that balances surgical indications with patient-specific factors including cognitive status, compliance potential, family dynamics, and overall functional goals. The lack of standardized protocols necessitates a multidisciplinary approach integrating medical, surgical, psychosocial, and family considerations to optimize outcomes in this vulnerable population.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/abs\/10.3171\/CASE25406\">https:\/\/thejns.org\/doi\/abs\/10.3171\/CASE25406<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case25406","type":"journal-article","created":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T00:03:33Z","timestamp":1762214613000},"source":"Crossref","is-referenced-by-count":0,"title":["Management of a three-column unstable injury in nonagenarian patients: illustrative case"],"prefix":"10.3171","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-8979-1906","authenticated-orcid":true,"given":"Francisco","family":"Rivera","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Centro de Educacion Medica e Investigaciones Clinicas University Institute, Ciudad Aut\u00f3noma de Buenos Aires, Argentina"},{"name":"Department of Neurosurgery, California Neurosurgical Specialists, Thousand Oaks, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arnau","family":"Benet","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, California Neurosurgical Specialists, Thousand Oaks, California"},{"name":"Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"8","key":"bib1","series-title":"Spine (Phila Pa 1976)","first-page":"817","article-title":"The three column spine and its significance in the classification of acute thoracolumbar spinal injuries","volume":"8","author":"Denis","year":"1983","unstructured":"Denis F.The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983;8(8):817-831."},{"key":"bib2","article-title":"DD, Hogg JP. Chance fractures","author":"Koay","year":"2023","unstructured":"Koay J, DavisDD, Hogg JP. Chance fractures. In: StatPearls. StatPearls; 2023. Accessed August 11, 2025. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK536926\/"},{"issue":"249","key":"bib3","series-title":"Br J Radiol","first-page":"452","article-title":"Note on a type of flexion fracture of the spine","volume":"21","author":"Chance","year":"1948","unstructured":"Chance GQ.Note on a type of flexion fracture of the spine. Br J Radiol. 1948;21(249):452."},{"issue":"4","key":"bib4","series-title":"AJR Am J Roentgenol","first-page":"859","article-title":"Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients","volume":"187","author":"Bernstein","year":"2006","unstructured":"Bernstein MPMirvis SEShanmuganathan K.Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients. AJR Am J Roentgenol. 2006;187(4):859-868."},{"issue":"2","key":"bib5","series-title":"J Bone Joint Surg Am","first-page":"239","article-title":"Patterns and mechanisms of lumbar injuries associated with lap seat belts","volume":"51","author":"Smith","year":"1969","unstructured":"Smith WSKaufer H.Patterns and mechanisms of lumbar injuries associated with lap seat belts. J Bone Joint Surg Am. 1969;51(2):239-254."},{"issue":"1","key":"bib6","series-title":"Alzheimers Dement","first-page":"S56","article-title":"The oldest old and the 90+ Study","volume":"4","author":"Kawas","year":"2008","unstructured":"Kawas CH.The oldest old and the 90+ Study. Alzheimers Dement. 2008;4(1)(suppl 1):S56-S59."},{"key":"bib7","series-title":"Compendium of Innovative E-Government Practices","volume":"236","author":"United Nations","year":"2010:","unstructured":"United Nations Department of Economic and Social Affairs.Compendium of Innovative E-Government Practices. Vol III. 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Neurospine. 2019;16(4):764-769."},{"issue":"26","key":"bib10","series-title":"N Engl J Med","first-page":"1701","article-title":"Risk factors for falls among elderly persons living in the community","volume":"319","author":"Tinetti","year":"1988","unstructured":"Tinetti MESpeechley MGinter SF.Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-1707."},{"issue":"8","key":"bib11","series-title":"Am J Public Health","first-page":"1292","article-title":"Lumbar spine surgery and mortality among Medicare beneficiaries, 1986","volume":"84","author":"Oldridge","year":"1994","unstructured":"Oldridge NBYuan ZStoll JERimm AR.Lumbar spine surgery and mortality among Medicare beneficiaries, 1986. Am J Public Health. 1994;84(8):1292-1298."},{"issue":"3","key":"bib12","series-title":"J Am Geriatr Soc","first-page":"424","article-title":"Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery","volume":"53","author":"Hamel","year":"2005","unstructured":"Hamel MBHenderson WGKhuri SFDaley J.Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc. 2005;53(3):424-429."},{"issue":"2","key":"bib13","series-title":"Neurosurg Focus","first-page":"E2","article-title":"Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation","volume":"35","author":"Grossbach","year":"2013","unstructured":"Grossbach AJDahdaleh NSAbel TJWoods GDDlouhy BJHitchon PW.Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation. 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Neurosurgery. 2013;72(suppl 2):187-194."},{"key":"bib16","series-title":"Brain Spine","first-page":"102745","article-title":"Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review","volume":"4","author":"Vercoulen","year":"2024","unstructured":"Vercoulen TFGNiemeyer MJSPeuker FVerlaan JJOner FCSadiqi S.Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review. Brain Spine. 2024;4:102745."},{"issue":"1","key":"bib17","series-title":"J Neurosurg Spine","first-page":"71","article-title":"Percutaneous surgical treatment of chance fractures using cannulated pedicle screws. Report of two cases","volume":"7","author":"Schizas","year":"2007","unstructured":"Schizas CKosmopoulos V.Percutaneous surgical treatment of chance fractures using cannulated pedicle screws. Report of two cases. 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Arch Orthop Trauma Surg. 2016;136(4):453-455."},{"key":"bib20","series-title":"Sage Open Med Case Rep","first-page":"2050313X18819617","article-title":"Traumatic hemothorax due to chance fracture requiring emergency surgical management: a report of two cases","volume":"6","author":"Okamoto","year":"2018","unstructured":"Okamoto KIchinose MHanaoka J.Traumatic hemothorax due to chance fracture requiring emergency surgical management: a report of two cases. Sage Open Med Case Rep. 2018;6:2050313X18819617."},{"issue":"8","key":"bib21","series-title":"Glob Spine J","first-page":"887","article-title":"Postoperative complications associated with spine surgery in patients older than 90 years: a multicenter retrospective study","volume":"8","author":"Kobayashi","year":"2018","unstructured":"Kobayashi KImagama SSato KPostoperative complications associated with spine surgery in patients older than 90 years: a multicenter retrospective study. Glob Spine J. 2018;8(8):887-891."},{"issue":"3","key":"bib22","series-title":"J Clin Gerontol Geriatr","first-page":"115","article-title":"Neurological recovery at age 92 after acute trauma and operative spinal decompression","volume":"7","author":"Eltahawy","year":"2016","unstructured":"Eltahawy HRansom ARajah G.Neurological recovery at age 92 after acute trauma and operative spinal decompression. J Clin Gerontol Geriatr. 2016;7(3):115-117."},{"key":"bib23","series-title":"World Neurosurg","first-page":"519","article-title":"How to improve outcomes of spine surgery in geriatric patients","volume":"140","author":"Zileli","year":"2020","unstructured":"Zileli MDursun E.How to improve outcomes of spine surgery in geriatric patients. World Neurosurg. 2020;140:519-526."},{"issue":"24","key":"bib24","series-title":"Spine (Phila Pa 1976)","first-page":"2815","article-title":"The radiographic failure of single segment anterior cervical plate fixation in traumatic cervical flexion distraction injuries","volume":"29","author":"Johnson","year":"2004","unstructured":"Johnson MGFisher CGBoyd MPitzen TOxland TRDvorak MF.The radiographic failure of single segment anterior cervical plate fixation in traumatic cervical flexion distraction injuries. Spine (Phila Pa 1976). 2004;29(24):2815-2820."},{"issue":"11","key":"bib25","series-title":"Am J Geriatr Psychiatry","first-page":"996","article-title":"Perioperative anxiety and depression in older adults: epidemiology and treatment","volume":"31","author":"Srifuengfung","year":"2023","unstructured":"Srifuengfung MAbraham JAvidan MSLenze EJ.Perioperative anxiety and depression in older adults: epidemiology and treatment. Am J Geriatr Psychiatry. 2023;31(11):996-1008."},{"issue":"8","key":"bib1","series-title":"Spine (Phila Pa 1976)","first-page":"817","article-title":"The three column spine and its significance in the classification of acute thoracolumbar spinal injuries","volume":"8","author":"Denis","year":"1983","unstructured":"Denis F.The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983;8(8):817-831."},{"key":"bib2","article-title":"DD, Hogg JP. Chance fractures","author":"Koay","year":"2023","unstructured":"Koay J, DavisDD, Hogg JP. Chance fractures. In: StatPearls. StatPearls; 2023. Accessed August 11, 2025. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK536926\/"},{"issue":"249","key":"bib3","series-title":"Br J Radiol","first-page":"452","article-title":"Note on a type of flexion fracture of the spine","volume":"21","author":"Chance","year":"1948","unstructured":"Chance GQ.Note on a type of flexion fracture of the spine. Br J Radiol. 1948;21(249):452."},{"issue":"4","key":"bib4","series-title":"AJR Am J Roentgenol","first-page":"859","article-title":"Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients","volume":"187","author":"Bernstein","year":"2006","unstructured":"Bernstein MPMirvis SEShanmuganathan K.Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients. AJR Am J Roentgenol. 2006;187(4):859-868."},{"issue":"2","key":"bib5","series-title":"J Bone Joint Surg Am","first-page":"239","article-title":"Patterns and mechanisms of lumbar injuries associated with lap seat belts","volume":"51","author":"Smith","year":"1969","unstructured":"Smith WSKaufer H.Patterns and mechanisms of lumbar injuries associated with lap seat belts. J Bone Joint Surg Am. 1969;51(2):239-254."},{"issue":"1","key":"bib6","series-title":"Alzheimers Dement","first-page":"S56","article-title":"The oldest old and the 90+ Study","volume":"4","author":"Kawas","year":"2008","unstructured":"Kawas CH.The oldest old and the 90+ Study. Alzheimers Dement. 2008;4(1)(suppl 1):S56-S59."},{"key":"bib7","series-title":"Compendium of Innovative E-Government Practices","volume":"236","author":"United Nations","year":"2010:","unstructured":"United Nations Department of Economic and Social Affairs.Compendium of Innovative E-Government Practices. Vol III. United Nations; 2010:236."},{"issue":"5","key":"bib8","series-title":"Spine (Phila Pa 1976)","first-page":"369","article-title":"Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015","volume":"44","author":"Martin","year":"2019","unstructured":"Martin BIMirza SKSpina NSpiker WRLawrence BBrodke DS.Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976). 2019;44(5):369-376."},{"issue":"4","key":"bib9","series-title":"Neurospine","first-page":"764","article-title":"Is spinal surgery safe for elderly patients aged 80 and above? Predictors of mortality and morbidity in an Asian population","volume":"16","author":"Tan","year":"2019","unstructured":"Tan JYWKaliya-Perumal AKOh JYL.Is spinal surgery safe for elderly patients aged 80 and above? Predictors of mortality and morbidity in an Asian population. Neurospine. 2019;16(4):764-769."},{"issue":"26","key":"bib10","series-title":"N Engl J Med","first-page":"1701","article-title":"Risk factors for falls among elderly persons living in the community","volume":"319","author":"Tinetti","year":"1988","unstructured":"Tinetti MESpeechley MGinter SF.Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-1707."},{"issue":"8","key":"bib11","series-title":"Am J Public Health","first-page":"1292","article-title":"Lumbar spine surgery and mortality among Medicare beneficiaries, 1986","volume":"84","author":"Oldridge","year":"1994","unstructured":"Oldridge NBYuan ZStoll JERimm AR.Lumbar spine surgery and mortality among Medicare beneficiaries, 1986. Am J Public Health. 1994;84(8):1292-1298."},{"issue":"3","key":"bib12","series-title":"J Am Geriatr Soc","first-page":"424","article-title":"Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery","volume":"53","author":"Hamel","year":"2005","unstructured":"Hamel MBHenderson WGKhuri SFDaley J.Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc. 2005;53(3):424-429."},{"issue":"2","key":"bib13","series-title":"Neurosurg Focus","first-page":"E2","article-title":"Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation","volume":"35","author":"Grossbach","year":"2013","unstructured":"Grossbach AJDahdaleh NSAbel TJWoods GDDlouhy BJHitchon PW.Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation. Neurosurg Focus. 2013;35(2):E2."},{"issue":"4","key":"bib14","series-title":"J Neurosurg Spine","first-page":"622","article-title":"Perioperative complications of spine surgery in patients 80 years of age or older: a multicenter prospective cohort study","volume":"32","author":"Watanabe","year":"2020","unstructured":"Watanabe TKanayama MTakahata MPerioperative complications of spine surgery in patients 80 years of age or older: a multicenter prospective cohort study. J Neurosurg Spine. 2020;32(4):622-630."},{"issue":"suppl 2","key":"bib15","series-title":"Neurosurgery","first-page":"187","article-title":"Treatment of subaxial cervical spinal injuries","volume":"72","author":"Gelb","year":"2013","unstructured":"Gelb DEAarabi BDhall SSTreatment of subaxial cervical spinal injuries. Neurosurgery. 2013;72(suppl 2):187-194."},{"key":"bib16","series-title":"Brain Spine","first-page":"102745","article-title":"Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review","volume":"4","author":"Vercoulen","year":"2024","unstructured":"Vercoulen TFGNiemeyer MJSPeuker FVerlaan JJOner FCSadiqi S.Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review. Brain Spine. 2024;4:102745."},{"issue":"1","key":"bib17","series-title":"J Neurosurg Spine","first-page":"71","article-title":"Percutaneous surgical treatment of chance fractures using cannulated pedicle screws. Report of two cases","volume":"7","author":"Schizas","year":"2007","unstructured":"Schizas CKosmopoulos V.Percutaneous surgical treatment of chance fractures using cannulated pedicle screws. Report of two cases. J Neurosurg Spine. 2007;7(1):71-74."},{"issue":"7","key":"bib18","series-title":"JAAPA","first-page":"27","article-title":"Lumbar artery avulsion after a low-energy chance fracture","volume":"20","author":"Larrabee","year":"2007","unstructured":"Larrabee KAStevens MHAllen TL.Lumbar artery avulsion after a low-energy chance fracture. JAAPA. 2007;20(7):27-28."},{"issue":"4","key":"bib19","series-title":"Arch Orthop Trauma Surg","first-page":"453","article-title":"Chance fracture in an older patient with positive sagittal imbalance and previous lumbar arthrodesis: what can be done?","volume":"136","author":"Zwolak","year":"2016","unstructured":"Zwolak PKr\u00f6ber M.Chance fracture in an older patient with positive sagittal imbalance and previous lumbar arthrodesis: what can be done? Arch Orthop Trauma Surg. 2016;136(4):453-455."},{"key":"bib20","series-title":"Sage Open Med Case Rep","first-page":"2050313X18819617","article-title":"Traumatic hemothorax due to chance fracture requiring emergency surgical management: a report of two cases","volume":"6","author":"Okamoto","year":"2018","unstructured":"Okamoto KIchinose MHanaoka J.Traumatic hemothorax due to chance fracture requiring emergency surgical management: a report of two cases. Sage Open Med Case Rep. 2018;6:2050313X18819617."},{"issue":"8","key":"bib21","series-title":"Glob Spine J","first-page":"887","article-title":"Postoperative complications associated with spine surgery in patients older than 90 years: a multicenter retrospective study","volume":"8","author":"Kobayashi","year":"2018","unstructured":"Kobayashi KImagama SSato KPostoperative complications associated with spine surgery in patients older than 90 years: a multicenter retrospective study. Glob Spine J. 2018;8(8):887-891."},{"issue":"3","key":"bib22","series-title":"J Clin Gerontol Geriatr","first-page":"115","article-title":"Neurological recovery at age 92 after acute trauma and operative spinal decompression","volume":"7","author":"Eltahawy","year":"2016","unstructured":"Eltahawy HRansom ARajah G.Neurological recovery at age 92 after acute trauma and operative spinal decompression. J Clin Gerontol Geriatr. 2016;7(3):115-117."},{"key":"bib23","series-title":"World Neurosurg","first-page":"519","article-title":"How to improve outcomes of spine surgery in geriatric patients","volume":"140","author":"Zileli","year":"2020","unstructured":"Zileli MDursun E.How to improve outcomes of spine surgery in geriatric patients. 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