Navigating the Surgical Dilemma in Metastatic Spine Disease: Does Age Influence Treatment Strategy and Outcomes?

Spinal metastases are increasingly common. Yet, the optimal surgical strategy-particularly in elderly patients-remains debated due to perioperative risks. This study examines demographics, clinical presentation, and surgical outcomes, focusing on age-related differences and management of patients with Spinal Instability Neoplastic Score (SINS) 7-12.

We retrospectively included all patients with spinal metastases operated in our department from 2015 to 2024. Data on demographics, neurological status, surgical approach, complications and 90-day mortality were collected.

217 patients (median age: 60 years, range: 5-88) were included. Lung (17%), breast (17%), and prostate (12%) were the most common primaries. Older patients presented with worse neurological deficits (Frankel A/B: 36% vs. 5%, P < 0.01) but had comparable short-term mortality (≥65 years: 15% vs. <65 years: 13%, P = 0.837) and lower intraoperative blood loss (260 ± 373 mL vs. 759 ± 860 mL, P < 0.001). Surgical approaches were similar across age groups, with instrumentation in 32% and minimally invasive techniques in 18%. Regarding SINS, older patients were more frequently categorized as potentially unstable (65% vs. 38%, P < 0.001) yet more frequently treated with decompression. Younger patients undergoing instrumentation predominantly had SINS 7-18.

Age alone does not determine surgical success or survival in metastatic spine disease. Despite worse baseline status, older patients achieved short-term outcomes comparable to younger patients. Variation in managing SINS 7-12 suggests underuse of instrumentation in older patients underscoring the need for age-inclusive evidence-based guidelines integrating SINS with tumor biology, functional status and prognosis.