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Evaluation of Patients' Posture and Gait Profile After Lumbar Fusion Surgery by Video Rasterstereography and Treadmill Gait Analysis

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Instrumented vs Non-Instrumented Fusion for Elderly Patients with Lumbar Spondylotic Conditions: A Causal Inference

Brendan M Striano¹, Kaitlyn E Holly, Tino Mukorombindo

¹Department of Orthopaedic Surgery, Mass General Brigham, Harvard Medical School, 75 Francis Street, Boston, MA 02115.

|May 25, 2026

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Instrumented spinal fusion in elderly patients is linked to lower reoperation rates compared to non-instrumented fusion, even when accounting for patient frailty and comorbidities. This suggests instrumentation is generally preferred for spinal fusion in older adults.

Area of Science:

Neurosurgery
Orthopedic Surgery
Spinal Surgery

Background:

Renewed interest in non-instrumented spinal fusion due to payment reform and concerns for elderly/frail patients.
Prior studies on instrumented vs. non-instrumented fusion lack relevance for elderly and frail populations.
Confounding by indication is a significant challenge in comparing these surgical approaches.

Purpose of the Study:

To apply causal inference techniques and a single-surgeon design to address confounding by indication in elderly patients undergoing spinal fusion.
To compare reoperation rates at two years between instrumented and non-instrumented fusion in patients aged 65 and older.
To test the hypothesis that non-instrumented fusion is associated with higher reoperation rates.

Main Methods:

Keywords:

frailty instrumented fusion non-instrumented fusion outcomes reoperation

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Retrospective study of 248 patients (≥65 years) undergoing decompression and fusion for degenerative lumbar conditions.

Propensity-score weighting was used to control for confounding by indication, including age, sex, BMI, comorbidities, and number of fused levels.

Primary outcome: reoperation within two years; primary predictor: instrumented vs. non-instrumented fusion.

Main Results:

Non-instrumented fusion was significantly associated with increased odds of reoperation (OR 1.83; P=0.04) after propensity-score weighting.
When reoperations were limited to mechanical failure, adjacent segment degeneration, or symptom recurrence, no significant difference was found (OR 0.86; P=0.69).

Conclusions:

Instrumented spinal fusion demonstrates a significantly lower reoperation rate in elderly and frail patients when accounting for selection and indication bias.
The findings support the use of instrumentation as the preferred approach for spinal fusion, except in specific circumstances.
Causal inference techniques effectively addressed confounding by indication in this patient cohort.