Study design <p>Retrospective cohort study.</p> Objectives <p>To examine whether frailty, assessed using the 5-factor modified frailty index (mFI-5), predicts pneumonia and other complications in older adults with cervical spinal cord injury (CSCI).</p> Setting <p>A university-affiliated tertiary care hospital in Japan.</p> Methods <p>Data from 94 adults aged ≥65 years who were treated for CSCI were retrospectively reviewed. Frailty was defined as mFI-5 score ≥2. Patients were classified into frail (mFI-5 ≥ 2) and non-frail (mFI-5 &lt; 2) groups. Logistic regression analyses were performed to evaluate associations between frailty and the incidence of complications, infections, and pneumonia. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Model performance was assessed using receiver operating characteristic analysis.</p> Results <p>Frailty was identified in 19% of patients. Overall, 45% of patients experienced complications, 37% developed infections, and 23% developed pneumonia. The frail group demonstrated significantly higher rates of complications, infections, and pneumonia compared with the non-frail group. In the multivariate analyses, frailty independently predicted pneumonia (OR: 6.8, 95% CI: 2.0–26) and infections (OR: 8.7, 95% CI: 2.1–45). Frailty, alongside high neurological injury level, was associated with an increased overall risk of complications. Predictive models demonstrated acceptable discriminatory ability for complications and infections.</p> Conclusions <p>Frailty, assessed using the mFI-5, is an independent predictor of pneumonia and infections in older adults with CSCI. Early assessment of frailty may facilitate perioperative risk stratification, targeted preventive strategies, and informed clinical decision-making in this high-risk population.</p> Sponsorship <p>This work was supported by the Jikei University Research Fund.</p>