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Cervical spine fractures (CSFs) in elderly patients are increasingly common as the population ages. In many centers, halo vest immobilization (HVI) is the treatment of choice. Our anecdotal experience suggested that elderly patients treated with HVI have frequent bad outcomes. The purpose of this study was to compare the outcomes of elderly and younger CSF patients as related to treatment (HVI, surgery, or hard collar).Registry data from our Level I trauma center were reviewed to identify patients admitted with CSFs during an 80-month period. We excluded those with Glasgow Coma Scale (GCS) score of 3 at admission or death within 24 hours of admission. Patients were grouped as OLD (aged ≥ 66 years) or YNG (aged 18–65 years). Data were compared using χ2 and Student’s t test, with p < 0.05 considered statistically significant.One hundred twenty-nine OLD (aged 79.7 ± 0.7 years) and 289 YNG (aged 38.3 ± 0.8 years) patients met study criteria. Injury Severity Score was higher in YNG (18.9 ± 0.8 vs. 14.8 ± 1.0, p < 0.05), and GCS score was the same (OLD, 13.7 ± 0.2; YNG, 13.0 ± 0.2; p = 0.06) in both, but mortality was higher in OLD patients (21% vs. 5%, p < 0.05). OLD HVI patients had higher mortality than YNG HVI (40% vs. 2%). Among OLD patients, age, Injury Severity Score, GCS, and number of comorbidities were the same for each treatment subgroup. Despite this, mortality for the HVI subgroup was higher than either the surgery or collar subgroup. Of the OLD HVI patients that died, 14 died with pneumonia and 10 had a cardiac or respiratory arrest that preceded death.OLD patients with CSFs have higher mortality than YNG. HVI in OLD patients is associated with the worst outcomes, irrespective of injury severity, and should be considered a last resort. Further study is warranted to determine the optimal treatment for CSF in OLD patients.