Elective Lumbar Decompression With Fusion Is Associated With Increased Mortality Compared With Decompression Alone: A National Propensity-Matched Analysis of Aging Cohorts

Study Design Propensity–matched cohort study. Objectives To evaluate short/mid-term safety and mortality of elective lumbar decompression alone (LD) versus lumbar decompression with fusion (LDF) for degenerative lumbar disease in octogenarians and the aging patient. Methods The TriNetX research network was queried for adults with degenerative lumbar disease who underwent LD or LDF (2012–2025). Patients with deformity, instability, spondylolisthesis, or congenital malformation were excluded. Patients were stratified by decade of life (60–69, 70–79, 80–89 years) and matched 1:1 for demographics, steroid use, lipoprotein disorders, and modified Frailty Index-5 comorbidities. Outcomes were compared at 30 days, 90 days, 1 year, and 2 years. The primary outcome was mortality; secondary outcomes included medical and surgical complications. Results Across all age decades, LDF was associated with >5-fold higher 30-day mortality (OR 5.16–6.34, all p<0.0001) and >3.5-fold higher 90-day mortality (OR 3.83–6.35, all p<0.0001) compared to LD. In octogenarians, 30-day mortality was significantly higher with LDF versus LD (4.19% vs. 0.68%, p<0.0001). At 90 days, LDF was associated with higher rates of wound infection, sepsis, respiratory complications, DVT/PE, stroke, revision surgery, ED visits, and readmissions (all p<0.03). By 2 years, LDF was associated with higher mortality, revision surgery, and chronic pain (all p<0.009). Conclusions In this large, frailty-matched national analysis, LDF was consistently associated with higher mortality and morbidity compared to LD for degenerative lumbar disease. Octogenarians demonstrated six-fold higher 30-day mortality with LDF, underscoring the importance of careful patient selection for elective lumbar fusion. Level of Evidence III.