<h3>BACKGROUND CONTEXT</h3> The decision to operate in the setting of unstable spine fractures is one not taken lightly, and many factors are taken into account including age, comorbidities and severity of fracture. Whether the benefits of surgery outweigh the risks in the elderly population is a question few studies have investigated. Understanding the clinical outcomes in elderly patients who receive surgical versus conservative treatment can help inform future clinical practice. <h3>PURPOSE</h3> The objective of this study is to utilize a national administrative claims database to identify and compare patient demographics and clinical outcomes in patients over 65 with unstable fractures who received surgery versus those who did not. <h3>STUDY DESIGN/SETTING</h3> Retrospective study using a large national administrative claims database. <h3>PATIENT SAMPLE</h3> Patients with unstable fractures over age 65 in the Optum Claims Database from 2016 to 2021. <h3>OUTCOME MEASURES</h3> Demographic information, CCI, osteopenia/osteoporosis status, length of stay, rates of readmission, rates of postoperative complications and rates of mortality were collected. <h3>METHODS</h3> The Optum Claims Database was used to extract all patients 65 and older between 2016 and 2021 that were diagnosed with unstable fractures using ICD-10 codes. Demographic and clinical outcomes variables were identified, and univariate analysis was performed using Student's t-test and chi square test. <h3>RESULTS</h3> A total of 3,701 elderly patients with unstable spine fractures were identified and of these patients, 1,340 (36.2%) underwent spine surgery and 2,361 (63.8%) were treated conservatively. The average age of patients was greater in the nonoperative group compared to the operative group (81.8 versus 76.3) and the CCI was also higher in the nonoperative group (7.6 versus 6.8). Patients who received surgery had a longer length of stay in the hospital (9.6 versus 6.5 days) and were more likely to be readmitted within 30 days (20.8% versus 17.1%). However, patients in the operative group had lower mortality rates after 30 (4.6% versus 17.5%), 60 (7.6% versus 21.2%) and 90 (9.2% versus 23.8%) days of admission compared to the nonoperative group. This was true across all age stratifications and held true after propensity scoring. <h3>CONCLUSIONS</h3> While elderly patients with an unstable spine fracture who undergo surgery have longer length of hospital stay and a higher chance of being readmitted to the hospital compared to those patients who underwent conservative treatment, they also experience lower mortality rates after 30, 60 and 90 days. This suggests that the benefits of operating on the elderly with unstable spine fractures may outweigh the risks and should be considered as a treatment option. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.