Management of a three-column unstable injury in nonagenarian patients: illustrative case.

BACKGROUND: 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. OBSERVATIONS: The authors present the case of a 92-year-old male with baseline dementia who sustained a C5-6 three-column unstable fracture following a ground-level fall. Despite the fracture's instability, conservative management with cervical collar immobilization was chosen over surgical intervention after extensive family discussion, considering the patient's 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 > 90 years of age, highlighting the scarcity of evidence for this population. LESSONS: 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. https://thejns.org/doi/abs/10.3171/CASE25406.