Scientific Article   |    
Operative Compared with Nonoperative Treatment of a Thoracolumbar Burst Fracture without Neurological Deficit A Prospective, Randomized Study
K. Wood, MD; G. Butterman, MD; A. Mehbod, MD; T. Garvey, MD; R. Jhanjee, MD; V. Sechriest, MD
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Investigation performed at the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, and Midwest Spine and Orthopaedics, Stillwater, Minnesota

K. Wood, MD
A. Mehbod, MD
T. Garvey, MD
R. Jhanjee, MD
V. Sechriest, MD
Department of Orthopaedic Surgery, University of Minnesota, 420 Delaware Street S.E., MMC 492, Minneapolis, MN 55455. E-mail address for K. Wood: woodx003@tc.umn.edu

G. Butterman, MDMidwest Spine and Orthopaedics, 1950 Curve Crest Boulevard West, Suite 100, Stillwater, MN 55082

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

J Bone Joint Surg Am, 2003 May 01;85(5):773-781
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Background: To our knowledge, a prospective, randomized study comparing operative and nonoperative treatment of a thoracolumbar burst fracture in patients without a neurological deficit has never been performed. Our hypothesis was that operative treatment would lead to superior long-term clinical outcomes.

Methods: From 1994 to 1998, forty-seven consecutive patients (thirty-two men and fifteen women) with a stable thoracolumbar burst fracture and no neurological deficit were randomized to one of two treatment groups: operative (posterior or anterior arthrodesis and instrumentation) or nonoperative treatment (application of a body cast or orthosis). Radiographs and computed tomography scans were analyzed for sagittal alignment and canal compromise. All patients completed a questionnaire to assess any disability they may have had before the injury, and they indicated the degree of pain at the time of presentation with use of a visual analog scale. The average duration of follow-up was forty-four months (minimum, twenty-four months). After treatment, patients indicated the degree of pain with use of the visual analog scale and they completed the Roland and Morris disability questionnaire, the Oswestry back-pain questionnaire, and the Short Form-36 (SF-36) health survey.

Results: In the operative group (twenty-four patients), the average fracture kyphosis was 10.1° at the time of admission and 13° at the final follow-up evaluation. The average canal compromise was 39% on admission, and it improved to 22% at the final follow-up examination. In the nonoperative group (twenty-three patients), the average kyphosis was 11.3° at the time of admission and 13.8° at the final follow-up examination after treatment. The average canal compromise was 34% at the time of admission and improved to 19% at the final follow-up examination. On the basis of the numbers available, no significant difference was found between the two groups with respect to return to work. The average pain scores at the time of the latest follow-up were similar for both groups. The preinjury scores were similar for both groups; however, at the time of the final follow-up, those who were treated nonoperatively reported less disability. Final scores on the SF-36 and Oswestry questionnaires were similar for the two groups, although certain trends favored those treated without surgery. Complications were more frequent in the operative group.

Conclusion: We found that operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with nonoperative treatment.

Level of Evidence: Therapeutic study, Level II-2 (poor-quality randomized controlled trial [e.g., <80% follow-up]). See Instructions to Authors for a complete description of levels of evidence.

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    D.K. Sengupta, M.D.
    Posted on April 23, 2004
    Operative vs. Non Operative Treatment of Thoracolumbar Burst Fractures
    William Beaumont Hospital, 3535 W. Thirteen Mile Rd., Royal Oak, MI 48073

    To The Editor:

    We read with great interest the article entitled "Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study" (2003;85:773-81) by Wood et al, and the subsequent discussions by Verlaan et al (2004;86:649- 51) and by Wettstein et al (2004;86:651-2).

    The title of the article does not truly represent the content of the article. This is a very important article which claims credit for being the only "prospective, randomized study comparing operative and nonoperative treatment of a thoracolumbar burst fracture in patients without a neurological deficit". However, the study includes only `stable' burst fractures without neurological deficit, and concludes that operative treatment provides no substantial benefit in `stable' burst fracture. The article therefore should have been titled as a comparison of operative vs. nonoperative treatment in `stable burst fracture'.

    In the absence of neurological deficit, few surgeons recommend surgical stabilization for stable burst fractures. The real question has been which fractures are stable and which are not. The present study fails to answer that question. In the group randomized to surgery there were patients with little or no kyphosis (range -10 to 32°). Ethically, it is difficult to justify randomizing these patients to surgery.

    Indications for surgery in thoracolumbar burst fractures include decompression of neural tissue in presence of neurological deficit, or stabilization in presence of mechanical instability. The diagnostic criteria for instability in burst fractures are not clear. The radiological parameters commonly considered for assessment of stability include kyphotic angle, loss of vertical height of the vertebral body, and the degree of canal compromise. An absolute kyphosis exceeding 35°1, relative kyphosis exceeding 20° compared to the adjacent segments, or sagittal index (SI: a measurement of the kyphotic segmental deformity corrected for the normal sagittal contour of the spine at the injured level) exceeding 15°3 have been suggested as indicative of instability. The canal encroachment exceeding 50%2'4'5 and loss of vertical height of the vertebral body exceeding 50%2'4 has been suggested as the other radiological criteria of instability and a predictor of poor prognosis with nonoperative management. However, these criteria are not universally accepted, and many clinicians reported good outcome following nonoperative treatment in all the cases of burst fractures irrespective of these radiological parameters. 6,7 There is ample evidence of spontaneous canal remodelling, and many authors do not accept the degree of canal encroachment as a criterion for mechanical instability. 7-10

    While the original article did not mention thoracolumbar burst fracture classification scheme, the reply to the letter by Verlaan et al. mentioned the AO classification system and that the study included type-A3 fractures (compression injury to anterior and middle column and posterior column intact). In reply to Wettstein et al, the authors proposed that the involvement of two of three columns does not always constitute an unstable injury.

    In their article, the authors excluded posterior osteoligamentous injury, since that indicates flexion-distraction injury (AO type-B), or flexion -rotation /shear injury or fracture dislocation (AO type-C). What were their criteria of `stable burst fractures' as they mentioned in materials and conclusion sections of the original article? From their presented data, it is seen that the upper limit of the kyphosis in both the groups were 32°. If this was the angle of kyphosis without correction for segmental lordosis, then all these fractures may be mechanically stable. The degree of loss of vertebral height has not been presented. Why were these fractures subjected to operative treatment at all?

    As entitled, this important prospective randomized controlled study promises to answer an important question, but in the absence of the above data, it is misleading, and disappointing.

    Yours truly,

    D. K. Sengupta, M.D. E. Truumees, M.D. J. S. Fischgrund, M.D. L. T. Kurz, M.D. D. Montgomery, M.D. H. N. Herkowitz, M.D.

    Corresponding author: D. K. Sengupta, Department of Orthopedics William Beaumont Hospital 3535 West Thirteen Mile Road, Suite 604 Royal Oak, MI, 48073, USA dksg@hotmail.com

    References l.Reid DC, Hu R, Davis LA, Saboe LA. The nonoperative treatment of burst fractures of the thoracolumbar junction. J Trauma. 1988;28:1188-94. 2.Benson DR, Burkus JK, Montesano PX, Sutherland TB, McLain RE Unstable thoracolumbar and lumbar burst fractures treated with the AO fixateur interne. JSpinal Disord. 1992;5:335-43. 3.Farcy JP, Weidenbaum M, Glassman SD. Sagittal index in management of thoracolumbar burst fractures. Spine. 1990;15:958-65. 4.Willen J, Anderson J, Toomoka K, Singer K. The natural history of burst fractures at the thoracolumbar junction. JSpinal Disord. 1990;3:39-46. 5. Trafton PG, Boyd CA, Jr. Computed tomography of thoracic and lumbar spine injuries. J Trauma. 1984;24:506-15. 6.Hartman MB, Chrin AM, Rechtine GR. Non-operative treatment of thoracolumbar fractures. Paraplegia. 1995;33:73-6. 7.Celebi L, Muratli HH, Dogan O, Yagmurlu MF, Aktekin CN, Bicimoglu A. [The efficacy of non-operative treatment of burst fractures of the thoracolumbar vertebrae]. Acta Orthop Traumatol Turc. 2004;38:16-22. 8.de Klerk LW, Fontijne WP, Stijnen T, Braakman R, Tanghe HL, van Linge B. Spontaneous remodeling of the spinal canal after conservative management of thoracolumbar burst fractures. Spine. 1998;23:1057-60. 9.Aligizakis A, Katonis P, Stergiopoulos K, Galanakis I, Karabekios S, Hadjipavlou A. Functional outcome of burst fractures of the thoracolumbar spine managed non-operatively, with early ambulation, evaluated using the load sharing classification. Acta Orthop Belg. 2002;68:279-87. 10.Boerger TO, Limb D, Dickson RA. Does 'canal clearance' affect neurological outcome after thoracolumbar burst fractures? JBone Joint Surg Br. 2000;82:62935.

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