Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit

Thoracic and Lumbar Spine Injury: Evidence-Based Diagnosis, Management, and Outcomes

BACKGROUND

Traumatic thoracolumbar spine injuries are associated with significant morbidity and mortality. Targeted for non-spine specialist trauma surgeons, this systematic scoping review aimed to examine literature for up-to-date evidence on presentation, management, and outcomes of thoracolumbar spine injuries in adult trauma patients.

METHODS

This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched four bibliographic databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. Eligible studies included experimental, observational, and evidence-synthesis articles evaluating patients with thoracic, lumbar, or thoracolumbar spine injury, published in English between January 1, 2010 and January 31, 2021. Studies which focused on animals, cadavers, cohorts with N <30, and pediatric cohorts (age <18 years old), as well as case studies, abstracts, and commentaries were excluded.

RESULTS

A total of 2501 studies were screened, of which 326 unique studies were fully text reviewed and twelve aspects of injury management were identified and discussed: injury patterns, determination of injury status and imaging options, considerations in management, and patient quality of life. We found: (1) imaging is a necessary diagnostic tool, (2) no consensus exists for preferred injury characterization scoring systems, (3) operative management should be considered for unstable fractures, decompression, and deformity, and (4) certain patients experience significant burden following injury.

DISCUSSION

In this systematic scoping review, we present the most up-to-date information regarding the management of traumatic thoracolumbar spine injuries. This allows non-specialist trauma surgeons to become more familiar with thoracolumbar spine injuries in trauma patients and provides a framework for their management.

Surgical Versus Non-Surgical Treatment for Thoracolumbar Burst Fractures Without Neurological Deficit: A Systematic Review and Meta-Analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

To update the systematic review comparing the outcomes between surgical and non-surgical treatment for thoracolumbar burst fractures without neurological deficit.

METHODS

We registered a protocol in PROSPERO (ID: CRD42021291769) and searched Medline, Embase, Web of Science, and Google Scholar databases. Surgical and non-surgical treatments were compared in patients with thoracolumbar burst fractures without neurological deficits. Predefined outcomes at ≥6 months included pain (defined as a visual analog scale [VAS] of 0-100), functional outcomes (Oswestry Disability Index [ODI] of 0-50 and Roland-Morris Disability Questionnaire [RMDQ] of 0-24), and kyphotic angulation.

RESULTS

Nineteen studies involving 1056 patients were included in the analyses. For outcomes at ≥6 months, little to no difference was found in pain VAS score (mean difference, .95 [95% confidence interval {CI}, -6.02 to 7.92]; 827 participants; 15 studies; I2 = 92%), ODI (mean difference, -1.40 [95% CI, -5.11 to 2.31]; 446 participants; 7 studies; I2 = 79%), and RMDQ (mean difference, -.73 [95% CI, -5.13 to 3.66]; 216 participants; 5 studies; I2 = 77%). The kyphotic angulation in the surgery group was 6.35° lower than that in the non-surgery group (mean difference, -6.56° [95% CI, -10.26° to -2.87°]; 527 participants; ten studies; I2 = 86%). The trial sequential analysis indicated all outcomes reached adequate statistical power. The certainty of the evidence for all 4 outcomes was very low. For the analysis of minimally invasive procedures compared to traditional open surgeries, a statistically significant subgroup difference was found for VAS and ODI (P < .01 and P < .04, respectively).

CONCLUSION

Surgical and non-surgical treatments showed little or no difference in outcomes at ≥6 months. This review provides a conclusion with adequate statistical power by including non-randomized studies. However, non-randomized studies also lowered the certainty of the evidence to a very low level.

What Factors Influence Surgeons in Decision-Making in Thoracolumbar Burst Fractures? A Survey-Based Investigation of a Panel of Spine Surgery Experts

STUDY DESIGN

Cross-sectional survey study.

OBJECTIVE

To investigate factors affecting decision-making in thoracolumbar burst-fractures without neurologic deficit.

METHODS

A 40-question survey addressing expert-related, economic, and radiological factors was distributed to 30 international trauma experts. Descriptive statistics were used to assess the impact of these factors on operative or non-operative management preferences.

RESULTS

Out of 30 experts, 27 completed the survey. The majority of respondents worked at level 1 trauma centers (81.5%) within university settings (77.8%). They were primarily orthopedic surgeons (66.7%) and had over 10 years of experience (70.4%). About 81% found distinguishing between A3 and A4 fractures relevant for decision-making. Most experts (59%) treated A3 fractures non-surgically, while only 30% treated A4 fractures conservatively. Compensation systems did not influence treatment recommendations, and hospital measures promoting surgeries did not significantly affect distribution. Radiological factors, such as local kyphosis (25/27), fracture comminution (23/27), overall sagittal balance (21/27), and spinal canal narrowing (20/27), influenced decisions.

CONCLUSION

Incomplete burst fractures (A3) are predominantly treated non-surgically, while complete burst fractures (A4) are primarily treated surgically. Compensation, third-party incentives, and outpatient care did not significantly impact decision-making. Radiological factors beyond the AO Spine thoracolumbar classification system seem to be essential and warrant further evaluation.

Understanding Decision Making as It Influences Treatment in Thoracolumbar Burst Fractures Without Neurological Deficit: Conceptual Framework and Methodology

STUDY DESIGN

This paper presents a description of a conceptual framework and methodology that is applicable to the manuscripts that comprise this focus issue.

OBJECTIVES

Our goal is to present a conceptual framework which is relied upon to better understand the processes through which surgeons make therapeutic decisions around how to treat thoracolumbar burst fractures (TL) fractures.

METHODS

We will describe the methodology used in the AO Spine TL A3/4 Study prospective observational study and how the radiographs collected for this study were utilized to study the relationships between various variables that factor into surgeon decision making.

RESULTS

With 22 expert spine trauma surgeons analyzing the acute CT scans of 183 patients with TL fractures we were able to perform pairwise analyses, look at reliability and correlations between responses and develop frequency tables, and regression models to assess the relationships and interactions between variables. We also used machine learning to develop decision trees.

CONCLUSIONS

This paper outlines the overall methodological elements that are common to the subsequent papers in this focus issue.

Using Equipoise to Determine the Radiographic Characteristics Leading to Agreement on Best Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficits

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVES

Our goal was to assess radiographic characteristics associated with agreement and disagreement in treatment recommendation in thoracolumbar (TL) burst fractures.

METHODS

A panel of 22 AO Spine Knowledge Forum Trauma experts reviewed 183 cases and were asked to: (1) classify the fracture; (2) assess degree of certainty of PLC disruption; (3) assess degree of comminution; and (4) make a treatment recommendation. Equipoise threshold used was 77% (77:23 distribution of uncertainty or 17 vs 5 experts). Two groups were created: consensus vs equipoise.

RESULTS

Of the 183 cases reviewed, the experts reached full consensus in only 8 cases (4.4%). Eighty-one cases (44.3%) were included in the agreement group and 102 cases (55.7%) in the equipoise group. A3/A4 fractures were more common in the equipoise group (92.0% vs 83.7%, P < .001). The agreement group had higher degree of certainty of PLC disruption [35.8% (SD 34.2) vs 27.6 (SD 27.3), P < .001] and more common use of the M1 modifier (44.3% vs 38.3%, P < .001). Overall, the degree of comminution was slightly higher in the equipoise group [47.8 (SD 20.5) vs 45.7 (SD 23.4), P < .001].

CONCLUSIONS

The agreement group had a higher degree of certainty of PLC injury and more common use of M1 modifier (more type B fractures). The equipoise group had more A3/A4 type fractures. Future studies are required to identify the role of comminution in decision making as degree of comminution was slightly higher in the equipoise group.

Expert Opinion, Real-World Classification, and Decision-Making in Thoracolumbar Burst Fractures Without Neurologic Deficits?

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVES

To compare decision-making between an expert panel and real-world spine surgeons in thoracolumbar burst fractures (TLBFs) without neurological deficits and analyze which factors influence surgical decision-making.

METHODS

This study is a sub-analysis of a prospective observational study in TL fractures. Twenty two experts were asked to review 183 CT scans and recommend treatment for each fracture. The expert recommendation was based on radiographic review.

RESULTS

Overall agreement between the expert panel and real-world surgeons regarding surgery was 63.2%. In 36.8% of cases, the expert panel recommended surgery that was not performed in real-world scenarios. Conversely, in cases where the expert panel recommended non-surgical treatment, only 38.6% received non-surgical treatment, while 61.4% underwent surgery. A separate analysis of A3 and A4 fractures revealed that expert panel recommended surgery for 30% of A3 injuries and 68% of A4 injuries. However, 61% of patients with both A3 and A4 fractures received surgery in the real world. Multivariate analysis demonstrated that a 1% increase in certainty of PLC injury led to a 4% increase in surgery recommendation among the expert panel, while a .2% increase in the likelihood of receiving surgery in the real world.

CONCLUSION

Surgical decision-making varied between the expert panel and real-world treating surgeons. Differences appear to be less evident in A3/A4 burst fractures making this specific group of fractures a real challenge independent of the level of expertise.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses

OBJECTIVES

This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured.

DESIGN

Systematic review of systematic reviews (umbrella review).

DATA SOURCES

Cochrane Database of Systematic Reviews.

ELIGIBILITY CRITERIA

Systematic reviews attempt to compare surgical to drug interventions.

DATA EXTRACTION

We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review.

SYNTHESIS

The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed.

RESULTS

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance.

CONCLUSIONS

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.

Impact of different surgical and non-surgical interventions on health-related quality of life after thoracolumbar burst fractures without neurological deficit: protocol for a comprehensive systematic review with network meta-analysis

INTRODUCTION

There is no international consensus on how to treat thoracolumbar burst fractures (TLBFs) without neurological deficits. The planned systematic review with network meta-analyses (NMA) aims to compare the effects on treatment outcomes, focusing on midterm health-related quality of life (HRQoL).

METHODS AND ANALYSIS

We will conduct a comprehensive and systematic literature search, identifying studies comparing two or more treatment modalities. We will search MEDLINE, EMBASE, Google Scholar, Scopus and Web of Science from January 2000 until July 2023 for publications. We will include (randomised and non-randomised) controlled clinical trials assessing surgical and non-surgical treatment methods for adults with TLBF. Screening of references, data extraction and risk of bias (RoB) assessment will be done independently by two reviewers. We will extract relevant studies, participants and intervention characteristics. The RoB will be assessed using the revised Cochrane RoB V.2.0 tool for randomised trials and the Newcastle-Ottawa Scale for controlled trials. The OR for dichotomous data and standardised mean differences for continuous data will be presented with their respective 95% CIs. We will conduct a random-effects NMA to assess the treatments and determine the superiority of the therapeutic approaches. Our primary outcomes will be midterm (6 months to 2 years after injury) overall HRQoL and pain. Secondary outcomes will include radiological or clinical findings. We will present network graphs, forest plots and relative rankings on plotted rankograms corresponding to the treatment rank probabilities. The ranking results will be represented by the area under the cumulative ranking curve. Analyses will be performed in Stata V.16.1 and R. The quality of the evidence will be evaluated according to the Grading of Recommendations, Assessment, Development and Evaluations framework.

ETHICS AND DISSEMINATION

Ethical approval is not required. The research will be published in a peer-reviewed journal.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews

Objectives

To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored.

Design

Systematic review of systematic reviews (umbrella review).

Data sources

Cochrane Database of Systematic Reviews (CDSR).

Eligibility criteria and synthesis of results

Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses.

Results

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs.

Conclusions

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed.

Protocol registration

https://osf.io/p9x3j.

Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis on the Anterior and Posterior Approaches

Background

A thoracolumbar burst fracture (BF) is a severe type of compression fracture, which is the most common type of traumatic spine fractures. Generally, surgery is the preferred treatment, but whether the optimal approach is either an anterior or a posterior approach remains unclear. This study aims to determine whether either method provides an advantage.

Methods

Following PRISMA guidelines, a systematic review was conducted, identifying studies comparing anterior versus posterior surgical approaches in patients with thoracolumbar BFs. Data were analyzed using Review Manager 5.3. Seven studies were included.

Results

An operative time of 87.97 min (53.91, 122.03; p<0.0001) and blood loss of 497.04 mL (281.8, 712.28; p<0.0001) were lower in the posterior approach. Length of hospital stay, complications, reintervention rate, neurological outcomes, postoperative kyphotic angle, and costs were similar between both groups.

Conclusions

Surgical intervention is usually selected to rehabilitate patients with BFs. The data obtained from this study suggest that a posterior approach represents a viable alternative to an anterior approach, with various advantages such as a shorter operative time and decreased bleeding.

Electroactive Scaffolds to Improve Neural Stem Cell Therapy for Spinal Cord Injury

Spinal cord injury (SCI) is a serious condition caused by damage to the spinal cord through trauma or disease, often with permanent debilitating effects. Globally, the prevalence of SCI is estimated between 40 to 80 cases per million people per year. Patients with SCI can experience devastating health and socioeconomic consequences from paralysis, which is a loss of motor, sensory and autonomic nerve function below the level of the injury that often accompanies SCI. SCI carries a high mortality and increased risk of premature death due to secondary complications. The health, social and economic consequences of SCI are significant, and therefore elucidation of the complex molecular processes that occur in SCI and development of novel effective treatments is critical. Despite advances in medicine for the SCI patient such as surgery and anaesthesiology, imaging, rehabilitation and drug discovery, there have been no definitive findings toward complete functional neurologic recovery. However, the advent of neural stem cell therapy and the engineering of functionalized biomaterials to facilitate cell transplantation and promote regeneration of damaged spinal cord tissue presents a potential avenue to advance SCI research. This review will explore this emerging field and identify new lines of research.

Surgery versus conservative management of stable thoracolumbar fracture: the PRESTO feasibility RCT

BACKGROUND

There is informal consensus that simple compression fractures of the body of the thoracolumbar vertebrae between the 10th thoracic vertebra and the second lumbar vertebra without neurological complications can be managed conservatively and that obvious unstable fractures require surgical fixation. However, there is a zone of uncertainty about whether surgical or conservative management is best for stable fractures.

OBJECTIVES

To assess the feasibility of a definitive randomised controlled trial comparing surgical fixation with initial conservative management of stable thoracolumbar fractures without spinal cord injury.

DESIGN

External randomised feasibility study, qualitative study and national survey.

SETTING

Three NHS hospitals.

METHODS

A feasibility randomised controlled trial using block randomisation, stratified by centre and type of injury (high- or low-energy trauma) to allocate participants 1 : 1 to surgery or conservative treatment; a costing analysis; a national survey of spine surgeons; and a qualitative study with clinicians, recruiting staff and patients.

PARTICIPANTS

Adults aged ≥ 16 years with a high- or low-energy fracture of the body of a thoracolumbar vertebra between the 10th thoracic vertebra and the second lumbar vertebra, confirmed by radiography, computerised tomography or magnetic resonance imaging, with at least one of the following: kyphotic angle > 20° on weight-bearing radiographs or > 15° on a supine radiograph or on computerised tomography; reduction in vertebral body height of 25%; a fracture line propagating through the posterior wall of the vertebra; involvement of two contiguous vertebrae; or injury to the posterior longitudinal ligament or annulus in addition to the body fracture.

INTERVENTIONS

Surgical fixation: open spinal surgery (with or without spinal fusion) or minimally invasive stabilisation surgery. Conservative management: mobilisation with or without a brace.

MAIN OUTCOME MEASURE

Recruitment rate (proportion of eligible participants randomised).

RESULTS

Twelve patients were randomised (surgery, n = 8; conservative, n = 4). The proportion of eligible patients recruited was 0.43 (95% confidence interval 0.24 to 0.63) over a combined total of 30.7 recruitment months. Of 211 patients screened, 28 (13.3%) fulfilled the eligibility criteria. Patients in the qualitative study (n = 5) expressed strong preferences for surgical treatment, and identified provision of information about treatment and recovery and when and how they are approached for consent as important. Nineteen surgeons and site staff participated in the qualitative study. Key themes were the lack of clinical consensus regarding the implementation of the eligibility criteria in practice and what constitutes a stable fracture, alongside lack of equipoise regarding treatment. Based on the feasibility study eligibility criteria, 77% (50/65) and 70% (46/66) of surgeons participating in the survey were willing to randomise for high- and low-energy fractures, respectively.

LIMITATIONS

Owing to the small number of participants, there is substantial uncertainty around the recruitment rate.

CONCLUSIONS

A definitive trial is unlikely to be feasible currently, mainly because of the small number of patients meeting the eligibility criteria. The recruitment and follow-up rates were slightly lower than anticipated; however, there is room to increase these based on information gathered and the support within the surgical community for a future trial.

FUTURE WORK

Development of consensus regarding the population of interest for a trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12094890.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 62. See the NIHR Journals Library website for further project information.

Kyphoplasty Solves Stabilization and Pain Control Inadequately Treated via Prior Hartshill Rectangle for Thoracolumbar Burst Fracture

Surgical management of spinal burst fractures has progressed to include minimally invasive techniques as preferred modalities of treatment. Burst fractures with indications for surgical treatment either through instability or intractable pain classically have required pedicle screw fixation, which requires extensive dissection resulting in postoperative pain and significant recovery time, and also requires longer operative times with more potential blood loss. Balloon kyphoplasty is an established percutaneous technique that can provide quick pain relief for patients with intractable pain following compression and burst fractures, and vertebral body height can also be restored. In the present case, a female patient was seen in the emergency room with intractable pain and a dehiscent thoracolumbar incision after recently undergoing surgery with placement of a Hartshill rectangle and sublaminar wires at another institution for a T12 burst fracture (AO classification [AO] A4 and thoracolumbar injury classification and severity score [TLICS] 4) caused by a motor vehicle accident. Imaging identified an acute unhealed fracture at T12 and other vertebrae with questionable lesions. She underwent surgery to remove the Hartshill construct, stabilize the fracture, biopsy lesions (T7, T10, L2, and L4), and debride and close the wound. Following hardware removal, kyphoplasty was then performed through the open exposure at T12, which could have otherwise been done percutaneously. The patient experienced immediate and complete resolution of her pain associated with the fracture and had no neurological deficits. Modern minimally invasive techniques including kyphoplasty should be favored when indicated as alternative treatment options over more invasive treatment modalities, as they lead to quicker resolution of pain and recovery when compared to techniques requiring a large exposure.

How Should Patients with a Thoracolumbar Injury Classification and Severity Score of 4 Be Treated?

The thoracolumbar injury classification and severity score (TLICS) system help surgeons decide whether patients should undergo initial operative treatment or nonoperative treatment. However, the best treatment for patients with TLICS 4 fracture remains unknown. The aim of this study was to identify the risk factors for nonoperative treatment failure in patients with TLICS 4 fracture and establish treatment standards for TLICS 4 fractures. This study included 44 patients with TLICS 4 fracture who initially received nonoperative treatment. We divided these patients into two groups: the successful nonoperative treatment group included 18 patients, and the operative treatment group after nonoperative treatment failure included 26 patients. In multiple logistic regression analysis, spinal canal compromise (odd ratio = 1.316) and kyphotic angle (odd ratio = 1.416) were associated with nonoperative treatment failure in patients with TLICS 4 fracture. Other factors, including age, sex, BMI, initial VAS score, and loss of vertebral body height, were not significantly associated with nonoperative treatment failure in these patients. Spinal canal compromise and kyphotic angle were associated with nonoperative treatment failure in patients with TLICS 4 fracture. Therefore, we recommend the surgeon observe spinal canal compromise and kyphotic angle more carefully when deciding on the treatment of patients with TLICS 4 fracture.

A comparison of three different surgery approaches and methods for neurologically intact thoracolumbar fractures: a retrospective study

OBJECTIVES

The purpose of this study was to evaluate and compare the feasibility, safety, and efficacy of conventional open pedicle screw fixation (COPSF), percutaneous pedicle screw fixation (PPSF), and paraspinal posterior open approach pedicle screw fixation (POPSF) for treating neurologically intact thoracolumbar fractures.

METHODS

We retrospectively reviewed 108 patients who were posteriorly stabilized without graft fusion. Among them, 36 patients underwent COPSF, 38 patients underwent PPSF, and 34 patients underwent POPSF. The clinical outcomes, relative operation indexes, and radiological findings were assessed and compared among the 3 groups.

RESULTS

All of the patients were followed up for a mean time of 20 months. The PPSF group and POPSF group had shorter operation times, lower amounts of intraoperative blood loss, and shorter postoperative hospital stays than the COPSF group (P < 0.05). The radiation times and hospitalization costs were highest in the PPSF group (P < 0.05). Every group exhibited significant improvements in the Cobb angle (CA) and the vertebral body angle (VBA) correction (all P < 0.05). The COPSF group and the POPSF group had better improvements than the PPSF group at 3 days postoperation and the POPSF group had the best improvements in the last follow-up (P < 0.05).

CONCLUSION

Both PPSF and POPSF achieved similar effects as COPSF while also resulting in lower incidences of injury. PPSF is more advantageous in the early rehabilitation time period, compared with COPSF, but POPSF is a better option when considering the long-term effects, the costs of treatment, and the radiation times.

Reliability and Clinical Usefulness of Current Classifications in Traumatic Thoracolumbar Fractures: A Systematic Review of the Literature

BACKGROUND

A validated classification remains the key to an appropriate treatment algorithm of traumatic thoracolumbar fractures. Considering the development of many classifications, it is remarkable that consensus about treatment is still lacking. We conducted a systematic review to investigate which classification can be used best for treatment decision making in thoracolumbar fractures.

METHODS

A comprehensive search was conducted using PubMed, Embase, CINAHL, and Cochrane using the following search terms: classification (mesh), spinal fractures (mesh), and corresponding synonyms. All hits were viewed by 2 independent researchers. Papers were included if analyzing the reliability (kappa values) and clinical usefulness (specificity or sensitivity of an algorithm) of currently most used classifications (Magerl/AO, thoracolumbar injury classification and severity score [TLICS] or thoracolumbar injury severity score, and the new AO spine).

RESULTS

Twenty articles are included. The presented kappa values indicate moderate to substantial agreement for all 3 classifications. Regarding the clinical usefulness, > 90% agreement between actual treatment and classification recommendation is reported for most fractures. However, it appears that over 50% of the patients with a stable burst fracture (TLICS 2, AO-A3/A4) in daily practice are operated, so in these cases treatment decision is not primarily based on classification.

CONCLUSION

AO, TLICS, and new AO spine classifications have acceptable accuracy (kappa > 0.4), but are limited in clinical usefulness since the treatment recommendation is not always implemented in clinical practice. Differences in treatment decision making arise from several causes, such as surgeon and patient preferences and prognostic factors that are not included in classifications yet. The recently validated thoracolumbar AO spine injury score seems promising for use in clinical practice, because of inclusion of patient-specific modifiers. Future research should prove its definite value in treatment decision making.

LEVEL OF EVIDENCE

2.

CLINICAL RELEVANCE

Without the appropriate treatment, the impact of traumatic thoracolumbar fractures can be devastating. Therefore it is important to achieve consensus in the treatment of thoracolumbar fractures.

An Epidemiological Overview of Spinal Trauma in the Kingdom of Saudi Arabia

Introduction

The World Report on Road Traffic Injury Prevention indicates that by 2020, road traffic injuries will be a major killer, accounting for half a million deaths and 15 million disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) has one of the highest rates of spinal cord injuries in the world, with 62 people injured per 1 million, and the injuries are mostly due to traffic accidents.

Methods

All polytrauma patients associated with spinal injuries admitted to Prince Mohammed bin Abdul Aziz Hospital (PMAH), Riyadh, from January 2017 to June 2018, were included in this study. Patients with old spinal injuries, any previous spinal surgery, spine infection, or concomitant diagnosed malignancies or osteoporotic collapse with or without falls were excluded. All patients underwent whole-spine computed tomography scan and, in selective cases, magnetic resonance imaging of the spine.

Results

Of the 230 patients, 90.0% were male, and 60% were in the second and third decades. Motor vehicle accidents were responsible for 83% of the cases, of which 50% of the victims were the drivers, and 80% were passengers with no seatbelt on. Nearly 50% of the spinal injuries were associated with injuries in the other body parts. Cervical spine injury accounted for 44% of the cases, followed by the lumbar spine injury. Twenty five percent of the patients presented with fixed neurologic deficit in the form of quadriplegia or paraplegia (ASIA-A). The mortality rate was 1.3%.

Conclusions

This study revealed that motor vehicle accidents are a major cause of spinal injuries in the KSA. One-fourth of the spinal Injuries are associated with complete spinal cord injuries. Therefore, in order to prevent lifelong disability in the young population, a nationwide program should be initiated to prevent road traffic accidents.

Assessment of load-sharing thoracolumbar injury: A modified scoring system

BACKGROUND

Many classification systems of thoracolumbar spinal fractures have been proposed to enhance treatment protocols, but none have achieved universal adoption.

AIM

To develop a new patient scoring system for cases with thoracolumbar injury classification and severity score (TLICS) = 4, namely the load-sharing thoracolumbar injury score (LSTLIS).

METHODS

Based on thoracolumbar injury classification and severity score, this study proposes the use of the established load-sharing classification (LSC) to develop an improved classification system (LSTLIS). To prove the reliability and reproducibility of LSTLIS, a retrospective analysis for patients with thoracolumbar vertebral fractures has been conducted.

RESULTS

A total of 102 cases were enrolled in the study. The scoring trend of LSTLIS is roughly similar as the LSC scoring, however, the average deviation based on the former method is relatively smaller than that of the latter. Thus, the robustness of the LSTLIS scoring method is better than that of LSC. LSTLIS can further classify patients with TLICS = 4, so as to assess more accurately this particular circumstance, and the majority of LSTLIS recommendations are consistent with actual clinical decisions.

CONCLUSION

LSTLIS is a scoring system that combines LSC and TLICS to compensate for the lack of appropriate inclusion of anterior and middle column compression fractures with TLICS. Following preliminary clinical verification, LSTLIS has greater feasibility and reliability value, is more practical in comprehensively assessing certain clinical circumstances, and has better accuracy with clinically significant guidelines.

The 'armed concrete' approach: stent-screw-assisted internal fixation (SAIF) reconstructs and internally fixates the most severe osteoporotic vertebral fractures

BACKGROUND

The treatment of severe osteoporotic vertebral compression fractures (VCFs) with middle-column (MC) involvement, high fragmentation, large cleft and/or pedicular fracture is challenging. Minimally invasive 'stent-screw-assisted internal fixation' (SAIF) can reduce the fracture, reconstruct the vertebral body (VB) and fix it to the posterior elements.

OBJECTIVE

To assess feasibility, safety, technical and clinical outcome of the SAIF technique in patients with severe osteoporotic VCFs.

METHODS

80 treated vertebrae were analyzed retrospectively. Severe VCFs were characterized by advanced collapse (Genant grade 3), a high degree of osseous fragmentation (McCormack grade 2 and 3), burst morphology with MC injury, pediculo-somatic junction fracture, and/or large osteonecrotic cleft. VB reconstruction was evaluated on postprocedure radiographs and CT scans by two independent raters. Clinical and radiological follow-ups were performed at 1 and 6 months.

RESULTS

SAIF was performed at 28 thoracic and 52 lumbar levels in 73 patients. One transient neurological complication occurred. VB reconstruction was satisfactory in 98.8% of levels (inter-rater reliability 96%, κ=1). Follow-up at 1 month was available for 78/80 levels and at 6 months or later (range 6-24, mean 7.9 months) for 73/80 levels. Significant improvement in the Visual Analog Scale score was noted at 1 and 6 months after treatment (p<0.05). Patients reported global clinical benefit during follow-up (Patient's Global Impression of Change Scale 5.6±0.9 at 1 month and 6.1±0.9 at 6 months). Fourteen new painful VCFs occurred at different levels in 11 patients during follow-up, treated with vertebral augmentation or SAIF. Target-level stability was maintained in all cases.

CONCLUSIONS

SAIF is a minimally invasive, safe, and effective treatment for patients with severe osteoporotic VCFs with MC involvement.

[Minimally invasive posterior and anterior stabilization of the thoracolumbar spine after traumatic injuries]

Injuries of the thoracolumbar junction are the most common fractures of the spine due to their anatomical position and load. Common classification systems differentiate between stable and unstable injuries and thus also between operative and conservative therapy. The majority of injuries can be treated conservatively; however, unstable injuries require surgical treatment for a variety of reasons. In the grey area between stable and unstable injuries, a clinical decision based on clinical experience is necessary in order to select the best treatment. A wide variety of parameters must be included and a change in strategy from conservative to operative may also be necessary. Posterior instrumentation is the most common procedure; purely anterior stabilization is rarely used. The length of the instrumentation/spondylodesis depends on bone quality, age of the patient, and fracture. The decision as to whether anterior operative treatment should be performed depends on fracture morphology, success of reduction, and the resulting stability. The open surgical procedure is increasingly being replaced by minimally invasive procedures in posterior and anterior techniques but can be an advantage in complex injuries (B and C injuries according to AO). Hybrid procedures are also possible. This also applies to the treatment of osteoporotic fractures, since a clear assignment between traumatic and osteoporotic cause is not always easy and possible. This article describes the principles, the possible indications, and limitations of minimally invasive posterior and anterior stabilization.

Pragmatic randomised evaluation of stable thoracolumbar fracture treatment outcomes (PRESTO): study protocol for a randomised controlled feasibility trial combined with a qualitative study and survey

Background

A thoracolumbar fracture is the most common fracture of the spinal column. Where the fracture is not obviously stable or unstable, the optimal management is uncertain. There are variations between surgeons, treating centres and within the evidence base as to whether surgical or non-surgical approaches should be used. In addition, the boundaries of this zone of uncertainty for stability are unclear.

This study has been designed in response to an NIHR HTA commissioning brief to assess the feasibility of undertaking a large-scale trial to evaluate the effectiveness of surgical and non-surgical treatments for thoracolumbar fractures without neurological deficit.

Methods

Assessment of feasibility will be addressed through three elements: a randomised external feasibility study, a national survey of surgeons and a qualitative study.

The external feasibility study is a pragmatic, parallel-group, randomised controlled trial comparing surgical fixation (intervention) versus non-surgical management (control). Recruitment will take place in three secondary care centres in the UK.

The primary outcome is recruitment rate, defined as the proportion of eligible participants who are randomised. Further outcomes related to recruitment, randomisation, drop-out, cross-over, loss to follow-up, completeness of outcome data, study processes and details of the interventions delivered will be collected.

The survey of surgeons and qualitative study of clinicians, recruiting staff and patients will enhance the feasibility study, enabling a broad overview of current practice in the field in addition to perceived facilitators and barriers to running a full-scale trial.

Discussion

PRESTO is a feasibility study which aims to inform methodology for a definitive trial comparing surgical fixation with non-surgical management for patients with stable thoracolumbar fractures.

Trial registration

The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN12094890). Date of registration was 22/02/2018 (http://www.isrctn.com/ISRCTN12094890).

Stent-Screw Assisted Internal Fixation of Osteoporotic Vertebrae: A Comparative Finite Element Analysis on SAIF Technique

Vertebral compression fractures are one of the most relevant clinical consequences caused by osteoporosis: one of the most common treatment for such fractures is vertebral augmentation through minimally invasive approaches (vertebroplasty or balloon-kyphoplasty). Unfortunately, these techniques still present drawbacks, such as re-fractures of the treated vertebral body with subsidence of the non-augmented portions or re-fracture of the non-augmented middle column at the junction with the augmented anterior column. A novel minimally-invasive augmentation technique, called Stent-Screw Assisted Internal Fixation, has been recently proposed for the treatment of severe osteoporotic and neoplastic fractures: this technique uses two vertebral body stents and percutaneous cannulated and fenestrated pedicular screws, through which cement is injected inside the expanded stents to achieve optimal stents' and vertebral body's filling. The role of the pedicle screws is to anchor the stents-cement complex to the posterior column, acting as a bridge across the middle column and preserving its integrity from possible collapse. In order to evaluate the potential of the new technique in restoring the load bearing capacity of the anterior and middle spinal columns and in reducing bone strains, a Finite Element model of an osteoporotic lumbar spine has been developed. Both standard vertebroplasty and Stent-Screw Assisted Internal Fixation have been simulated: simulations have been run taking into account everyday activities (standing and flexion) and comparison between the two techniques, in terms of strain distribution on vertebral endplates and posterior and anterior wall, was performed. Results show that Stent-Screw Assisted Internal Fixation significantly decrease the strain distribution on the superior EP and the cortical wall compared to vertebroplasty, possibly reducing the re-fracture risk of the middle-column at the treated level.

Percutaneous fixation and balloon kyphoplasty for the treatment of A3 thoracolumbar fractures

BACKGROUND

Despite a long history of descriptive and clinical series, there is still no consensus in the treatment of traumatic thoracolumbar fractures. It is now widely accepted that percutaneous surgery in thoracolumbar spine trauma management can achieve the same results as conventional treatment but less morbidity but it is still not clear which are the best indications for these minimal invasive procedures.

METHODS

Thirty-two adult patients with single type A3 thoracolumbar burst fractures without neurologic deficits were included in this retrospective review of clinical and radiological outcomes after surgical management. All patients underwent combined percutaneous kyphoplasty and short fixation with screws in the vertebral pedicles above and below the fracture. Radiographic evaluation of segmental kyphosis and local kyphotic corrections were made preoperatively, 3 days postoperatively, 12 months post-operatively and at the last follow-up (the mean last follow-up was 41 months post-operatively). Clinical outcomes were determined by SF-36^® Health Survey and Oswestry Disability Index scores at 3-month and 12-month follow-ups.

RESULTS

Clinical assessments suggested good outcomes as early as the third postoperative month. The clinical outcomes were sustained at one year follow-up. At the last follow-up the segmental kyphosis correction and local kyphotic correction were maintained.

CONCLUSIONS

Our analysis demonstrates that minimally invasive kyphoplasty and percutaneous short fixation applied to thoracolumbar A3 burst fractures without neurological deficit may achieve results comparable to nonsurgical or open surgical treatment, but with less morbidity and complication, and should be considered as a valid treatment option.

Is cast an option in the treatment of thoracolumbar vertebral fractures?

Background:

Thoracolumbar vertebral fractures are common in high-energy trauma and often are associated to other concomitant injuries. Currently, brace and Closed Reduction and Casting (CRC) are the two conservative treatments proposed by literature. Despite CRC was widely used in the past, today brace is preferred. The aim of our study is to evaluate clinical and radiographic outcomes of thoracolumbar type A fractures, not associated with other injuries, treated with CRC.

Materials and Methods:

We retrospectively evaluated all patients treated from 2008 to 2015, with a mean age of 26.69 years (range 15–45). All patients were affected by AO type A fracture: 26 type A1, 17 type A2, and 21 type A3. All patients were evaluated by X-ray, computed tomography, and magnetic resonance imaging. Radiological evaluations included vertebral kyphosis (VK), segmental kyphosis (SK), regional kyphosis (RK) angle, and vertebral ratio (VR) measures. Patients were clinically assessed through visual analog scale, Oswestry Disability Index, Roland–Morris Disability Questionnaire, and Short Form 36 Health Survey.

Results:

Seventy-four patients (41 males and 33 females) were included in the study. At follow-up (mean 28.48 months ± 5.16), we found significant improvements in VK (P = 0.000013), SK (P = 0.000455), and RK (P = 0.000016). No significant differences were observed in VR (P = 0.26). Good clinical results were reported in patients in all scores and 90.7% of patients returned to work.

Conclusions:

Closed reduction and casting is still a reliable treatment option in selected thoracolumbar fractures without spinal cord involvement. A correct fracture evaluation, patient compliance, and motivation are essentials.

Level of evidence:

IV.

A retrospective study comparing percutaneous and open pedicle screw fixation for thoracolumbar fractures with spinal injuries

BACKGROUND

The purpose of this study was to evaluate the effectiveness between percutaneous and open pedicle screw fixation for treating thoracolumbar fractures with spinal injuries.

METHODS

A total of 105 patients with thoracolumbar fractures and spinal injuries were divided into a percutaneous pedicle screw fixation (PPSF) group with 56 patients, who underwent percutaneous pedicle screw fixation, and an open pedicle screw fixation (OPSF) group with 49 patients, who underwent open pedicle screw fixation in accordance with the treatment project. Relative operation indexes, radiologic, and effectiveness parameters were assessed and compared between the 2 groups.

RESULTS

Demographic and clinical features including age, body mass index, gender, fracture level, fracture classification, and Frankel grade in both groups were not significantly different (all P >.05). The PPSF group exhibits significantly lower operation time, intraoperative blood loss, postoperative drainage volume, and hospital stay on average compared with the OPSF group (all P < .05). Besides, the average postoperative radiologic parameters, including Cobb angle (CA), vertebral wedge angle (VWA), vertebral front height percentage (VFHP), and sagittal index (SI), in both the groups were not significantly different (all P > .05). Nevertheless, both visual analogue scale (VAS) and Oswestry disability index (ODI) after surgery decreased more substantially in the PPSF group than in the OPSF group (all P < .05) while no significant difference in VAS scores or ODI during the last follow-up period was demonstrated in both the groups (both P > .05). Frankel classifications were stimulated in both the groups during the last follow-up period.

CONCLUSION

PPSF has a smaller incision, less intraoperative blood loss, shorter recovery time, higher safety measures on average compared with OPSF with respect to managing thoracolumbar fractures with spinal injuries.

Post-operative bracing after pedicle screw fixation for thoracolumbar burst fractures: A cost-effectiveness study

PURPOSE

While frequently prescribed to patients following fixation for spine trauma, the utility of spinal orthoses during the post-operative period is poorly described in the literature. In this study, we calculated rates of reoperation and performed a decision analysis to determine the utility of bracing following pedicle screw fixation for thoracic and lumbar burst fractures.

METHODS

Pubmed was searched for articles published between 2005 and 2015 for terms related to pedicle screw fixation of thoracolumbar fractures. Additionally, a database of neurosurgical patients operated on within the authors institution was also used in the analysis. Incidences of significant adverse events (wound revision for either dehiscence or infection or re-operation for non-union or instability due to hardware failure) were determined. Pooled means and variances of reported parameters were obtained using a random-effects, inverse variance meta-analytic model for observational data. Utilities for surgical outcome and complications were assigned using previously published values.

RESULTS

Of the 225 abstracts reviewed, 48 articles were included in the study, yielding a total of 1957 patients. After including patients from the institutional registry, together a total of 2081 patients were included in the final analysis, 1328 of whom were braced. Non-braced patients were older then braced patients, although this only approached significance (p=0.051). Braced patients had significantly lower rates of re-operation for non-union or clinically significant hardware failure (1.3% vs. 1.8%, p<0.001) although the groups had comparable rates of operative wound dehiscence and infection (p=1.000). These two approaches yielded comparable utility scores (p=0.120). Costs between braced and non-braced patients were comparable excluding the cost of the brace (p=0.256); hence, the added cost of the brace suggests that bracing post-operatively is not a cost effective measure.

CONCLUSIONS

Bracing following operative stabilization of thoracolumbar fracture does not significantly improve stability, nor does it increase wound complications. Moreover, our data suggests that post-operative bracing may not be a cost-effective measure.

Does Operative or Nonoperative Treatment Achieve Better Results in A3 and A4 Spinal Fractures Without Neurological Deficit?: Systematic Literature Review With Meta-Analysis

STUDY DESIGN

Systematic literature review with meta-analysis.

OBJECTIVE

Thoracolumbar (TL) fractures can be treated conservatively or surgically. Especially, the treatment strategy for incomplete and complete TL burst fractures (A3 and A4, AOSpine classification) in neurologically intact patients remains controversial. The aim of this work was to collate the clinical evidence on the respective treatment modalities.

METHODS

Searches were performed in PubMed and the Web of Science. Clinical and radiological outcome data were collected. For studies comparing operative with nonoperative treatment, the standardized mean differences (SMD) for disability and pain were calculated and methodological quality and risk of bias were assessed.

RESULTS

From 1929 initial matches, 12 were eligible. Four of these compared surgical with conservative treatment. A comparative analysis of radiological results was not possible due to a lack of uniform reporting. Differences in clinical outcomes at follow-up were small, both between studies and between treatment groups. The SMD was 0.00 (95% CI -0.072, 0.72) for disability and -0.05 (95% CI -0.91, 0.81) for pain. Methodological quality was high in most studies and no evidence of publication bias was revealed.

CONCLUSIONS

We did not find differences in disability or pain outcomes between operative and nonoperative treatment of A3 and A4 TL fractures in neurologically intact patients. Notwithstanding, the available scores have been developed and validated for degenerative diseases; thus, their suitability in trauma may be questionable. Specific and uniform outcome parameters need to be defined and enforced for the evaluation of TL trauma.

Short Posterior Stabilization in Combination With Cement Augmentation for the Treatment of Thoracolumbar Fractures and the Effects of Implant Removal

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Short posterior stabilization with vertebroplasty is one treatment option for thoracolumbar burst fractures (AO A3). Whether it avoids progression in segmental kyphosis, especially after implant removal, is unclear. In a retrospective case-control study, its stability and the effect on intervertebral discs with and without implant removal was studied.

METHODS

Fifty-nine consecutive patients were treated with bisegmental short posterior instrumentation and additional vertebroplasty of the fractured vertebra. Twenty-nine patients (male/female 17/12; age: 41.7 ± 15.4 years) underwent implant removal. Changes of segmental kyphosis and disc heights between both groups (with and without implant removal) were compared on lateral X-rays preoperative, postoperative, after 1 year and after implant removal. Risk factors for loss of reduction were analyzed.

RESULTS

Kyphosis increased up to 12 months after implant removal. The loss of bisegmental correction was 6.0 ± 4.2 (range 0° to 16°) 12 months after implant removal. Risk factors for loss of reduction are younger patient age, fractures of the thoracolumbar junction (Th12), and degree of traumatic kyphosis. Intervertebral discs traversed by the stabilization lose height and don't recover within 1 year after implant removal. Without implant removal, disc height of the lower adjacent level is reduced after 24 months.

CONCLUSIONS

Short posterior stabilization in combination with vertebroplasty is a treatment alternative for thoracic and lumbar AO A3 fractures. After implant removal kyphosis increases, predominantly in the segment above the augmented vertebra. Risk factors for loss of reduction include younger age, fractures of the thoracolumbar junction (T12), and higher fracture kyphosis.

Thoracolumbar fractures without neurological impairment: A review of diagnosis and treatment

An appropriate protocol and unified management of thoracolumbar fractures without neurological impairment has not been well defined.

This review attempts to elucidate some controversies regarding diagnostic tools, the ability to define the most appropriate treatment of classification systems and the evidence for conservative and surgical methods based on the recent literature.

Cite this article: Vilà-Canet G, García de Frutos A, Covaro A, Ubierna MT, Caceres E. Thoracolumbar fractures without neurological impairment: a review of diagnosis and treatment. EFORT Open Rev 2016;1:332-338. DOI: 10.1302/2058-5241.1.000029

[Fractures of the thoracic and lumbar spine]

Fractures of the thoracic and lumbar spine result from high velocity trauma, assuming bone density is normal. The main location of fractures is the thoracolumbar junction. Most injuries can be treated conservatively; however, patients transferred to hospitals and spine centers represent a preselection with more severe trauma and a higher incidence of operative treatment. There is a large variety of operative techniques that can be used, which can be principally differentiated by the approach: posterior or anterior. Dorsal approaches are differentiated by the instrumentation for spondylodesis as open or percutaneous techniques. Minimally invasive options are favored more and more. For osteoporotic bone, cement augmented solutions may be used. Correct reduction of mainly kyphotic malalignment is crucial for the long-term outcome. Biomechanically stable reconstruction of the anterior spinal column is important mainly for the thoracolumbar junction.

Management of burst fractures in the thoracolumbar spine

The most common fractures in the spine take place in the thoracolumbar region. Currently there is no consensus regarding optimum treatment.

OBJECTIVE

Analyze the current medical literature available regarding treatment of compression fractures of the thoracolumbar spine.

METHODS

Research of current literature in medical databases.

RESULTS

Regarding current available literature, we found no consensus in the treatment of compression fractures in the thoracolumbar spine.

CONCLUSIONS

Burst fractures of the thoracolumbar junction is a very common condition, treatment of each patient must be individualized. Conservative treatment is recommended for stable fractures without neurological compromise and less than 35° of kyphosis.

Decision-Making Process in Patients with Thoracolumbar and Lumbar Burst Fractures with Thoracolumbar Injury Severity and Classification Score Less than Four

STUDY DESIGN

Cross-sectional.

PURPOSE

To develop a strategy to determine a sound method for decision-making based on postoperative clinical outcome satisfaction.

OVERVIEW OF LITERATURE

The ideal management of thoracolumbar and lumbar burst fractures (TLBF) without neurological compromise remains controversial.

METHODS

This was a prospective study. Patients with thoracolumbar injury severity and classification score (TLICS) <4 were treated nonoperatively, with bed rest and bracing until the pain decreased sufficiently to allow mobilization. Surgery was undertaken in patients with intractable pain despite an appropriate nonoperative treatment (surgery group). The Oswestry disability index (ODI) measure was observed at baseline and at the last follow-up. Clinically success was defined at least a 30% improvement from the baseline ODI scores in both the conservative and surgery groups. All case records were assessed for gender, age, residual canal and angulations at the site of the fracture in order to determine which patients benefited from surgery or conservative treatment and which did not.

RESULTS

In all 113 patients with T11-L5, TLBFs were treated. The patients' mean age was 49.2 years. Patients successfully completed either nonoperative (n=99) or surgical (n=14) treatment based on ODI. Clinical examinations revealed that all of the patients had intact neurology. The mean follow-up period was 29.5 months. There was a significant difference between the two groups based on age and residual canal. The mean ODI score significantly improved for both groups (p <0.01). According to the findings, a decision matrix was proposed.

CONCLUSIONS

The findings confirm that TLICS <4, age, and residual canal can be used to guide the treatment of TLBF in conservative decision-making.

The long-term efficacy of pedicular screw fixation at patients suffering from thoracolumbar burst fractures without neurological deficit

OBJECTIVES

Treatment of choice at stable burst fracture is still a matter of debate. The aim of this study is assessment of health-related quality of life (HRQOL) regarding short form-36 (SF-36) and its correlation with kyphosis in patients affected by thoracolumbar burst fracture without neurological deficit undergoing posterior short segment pedicular screw fixation.

MATERIALS AND METHODS

Twenty patients with thoracolumbar burst fractures without neurological deficits, meeting our criteria were enrolled in this study. The patients underwent short segment pedicular screw fixation. After 2 years of follow-up, the outcome assessment was performed with evaluating HRQOL; SF-36. The mean ± standard deviation was measured at each eight category of SF-36 and compared with normative values of Iran. The correlation of Cobb angle and body pain was analyzed by linear regression.

RESULTS

The study detected reduced quality of life (QOL), with total mean of 49.7 ± 14 and physical function grade of 61.2 ± 22 which was significantly lower than Iran normative reported as 85.9 ± 19. Fifty percent still suffered from moderate to severe pain and Cobb angle had no statistically significant correlation with body pain.

CONCLUSIONS

It seems that surgical treatment could not improve pain related disability of patients with stable thoracolumbar burst fracture at long term follow up.

Clinical and radiological outcomes of conservative treatment after stable post-traumatic thoracolumbar fractures in elderly: Is it really best option for all elderly patients?

Objective

The purpose of this study was to research the effectiveness of conservative treatment of stable post-traumatic thoracolumbar vertebral fractures in elderly patients.

Methods

The study included 21 elderly patients (13 females, 8 males) with post-traumatic thoracolumbar compression fracture who were treated with a brace. Fractures without any trauma history, pathological fractures, patients younger than 60 years old and patients with no malignancy history were excluded from study. Neurological examination and posterior ligamentous complex (PLC) were intact in all patients. Radiological parameters and pain scores were recorded in regular follow-up.

Results

The mean age and follow-up were 71.3 years (range, 60–84 years) and 20.1 months (range, 12–26 months) respectively. During follow-up, 4 patients had significant height loss resulting in kyphotic deformity and intractable pain. There was a significant increase in the local kyphosis angle (p = 0.001) and height loss percentage (p = 0.017). At the final follow-up, the mean Denis Score of pain was 1.62 ± 0.74.

Conclusion

Although there is wide acceptance of conservative treatment of post-traumatic stable thoracolumbar fracture with intact PCL according to the Thoracolumbar Injury Classification and Severity Score (TLICS), elderly female patients with a post-traumatic compression fracture in the junctional region are at great risk of conservative treatment failure. These patients should be well-informed about the possible complications and poor results of conservative treatment, and surgical treatment should be considered in selective cases with the informed consent of the patients.

•

Brace isn't always best in spine fractures elderly.

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Conservative treatment has failure risk for female patients and junction fractures.

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Elderly patients with risk factors should be informed about the possible complications and poor results of conservative treatment.

Single-stage posterior vertebral column resection and internal fixation for old fracture-dislocations of thoracolumbar spine: a case series and systematic review

PURPOSE

To evaluate the efficacy of single-stage posterior vertebral column resection for old thoracolumbar fracture-dislocations with spinal cord injury.

METHODS

From January 2007 to June 2013, twelve male patients (average age, 32.6 years; range 19-57 years) with old fracture-dislocations of the thoracolumbar spine and spinal cord injury underwent single-stage posterior vertebral column resection and internal fixation. All patients were assessed for relief of the pain and restoration of neurologic function. Postoperative Cobb angle was measured and bone graft fusion was evaluated by X-ray. A systematic review of 25 studies evaluating surgical management of thoracolumbar fractures with spinal cord injuries was also performed.

RESULTS

From our case series, six of the nine patients with Frankel grade A had significant improvement in urination and defecation after surgery. The three patients with Frankel grades B and C had progression of 1-2 grades after surgery. Bony fusion was achieved and local back pain was relieved in all patients after surgery. From our systematic review of 25 studies, the majority of patients had improved back pain, the postoperative kyphotic angle was significantly reduced compared with pre-operative kyphotic angle.

CONCLUSION

Single-stage posterior vertebral column resection and internal fixation for old thoracolumbar fracture-dislocations is an ideal treatment allowing for thorough decompression, relief of pain, correction of deformities, and restoration of spinal stability.

LEVEL OF EVIDENCE

IV.

Treatment of thoracolumbar fracture

The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar fracture are leading to early mobilization and rehabilitation by restoring mechanical stability of fracture and inducing neurologic recovery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic injury should be identified by thorough physical examination for motor and sensory nerve system in order to determine the appropriate treatment. The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structure or posterior ligament complex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which saves mobile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controversial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be decreased and good clinical and radiologic outcomes can be achieved if the recent operative treatments are used carefully considering the fracture pattern and the injury severity.

Evidence-Based Medicine of Traumatic Thoracolumbar Burst Fractures: A Systematic Review of Operative Management across 20 Years

Study Design Systematic literature review. Objective The management of traumatic thoracolumbar burst fractures (TLBF) remains challenging, and analyzing the levels of evidence (LOEs) for treatment practices can reform the decision-making process. However, no review has yet evaluated the operative management of traumatic thoracolumbar burst fractures with particular attention placed on LOE from an established methodology. The objective of the present study was to characterize the literature evidence for TLBF, specifically for operative management. Methods A comprehensive search of the English literature over the past 20 years was conducted using PubMed (MEDLINE). The inclusion criteria consisted of (1) traumatic burst fractures (2) in the thoracic or lumbar spine. Exclusion criteria included (1) osteoporotic burst fractures, (2) pathologic burst fractures, (3) cervical fractures, (4) biomechanical studies or those involving cadavers, and (5) computer-based studies. Studies were assigned an LOE and those meeting level 1 or 2 were included. Results From 1,138 abstracts, 272 studies met the criteria. Twenty-three studies (8.5%) met level 1 (n = 4, 1.5%) or 2 (n = 19, 7.0%) criteria. All 23 studies were reported. Conclusions The literature contains a high LOE to support the operative management of traumatic thoracolumbar burst fractures. For patients who are neurologically intact, a high LOE demonstrated similar functional outcomes, lower complication rates, and less costs with conservative management when compared with surgical management. There is a high LOE for short- or long-segment pedicle instrumentation without fusion and less invasive (percutaneous and paraspinal) approaches. Furthermore, the posterior approaches are associated with lower complications as opposed to the anterior or combined approaches.

Percutaneous vertebral augmentation with polyethylene mesh and allograft bone for traumatic thoracolumbar fractures

Purpose. In cases of traumatic thoracolumbar fractures, percutaneous vertebral augmentation can be used in addition to posterior stabilisation. The use of an augmentation technique with a bone-filled polyethylene mesh as a stand-alone treatment for traumatic vertebral fractures has not yet been investigated. Methods. In this retrospective study, 17 patients with acute type A3.1 fractures of the thoracic or lumbar spine underwent stand-alone augmentation with mesh and allograft bone and were followed up for one year using pain scales and sagittal endplate angles. Results. From before surgery to 12 months after surgery, pain and physical function improved significantly, as indicated by an improvement in the median VAS score and in the median pain and work scale scores. From before to immediately after surgery, all patients showed a significant improvement in mean mono- and bisegmental kyphoses. During the one-year period, there was a significant loss of correction. Conclusions. Based on this data a stand-alone approach with vertebral augmentation with polyethylene mesh and allograft bone is not a suitable therapy option for incomplete burst fractures for a young patient collective.

Thoracolumbar spine fractures in the geriatric fracture center: early ambulation leads to good results on short term and is a successful and safe alternative compared to immobilization in elderly patients with two-column vertebral fractures

INTRODUCTION

Thoracolumbar spine fractures are common osteoporotic fractures among elderly patients. Several studies suggest that these fractures can be treated successfully with a nonoperative management. The aim of this study is to evaluate the conservative treatment of elderly patients with a vertebral fracture.

METHODS

This study is a retrospective cohort study, which included all patients with an age of 65 years and older, who were diagnosed with a vertebral fracture and where therefore admitted to the Geriatric Fracture Center over a period of 2 years. Primary outcome was the level of functioning 6 weeks and 3 months after admission.

RESULTS

We included 106 patients with 143 vertebral fractures, of which 61 patients were evaluated after 3 months. In our population, 53% of the patients had a fracture involving both middle and anterior columns. The majority of the patients functioned sufficiently 6 weeks and 3 months after admission. Analysis showed that age <80 years is an independent predictor of a sufficient level of functioning after 6 weeks.

DISCUSSION

The nonoperative treatment of elderly patients with a vertebral fracture leads to a sufficient level of functioning 6 weeks and 3 months after admission. In our population, only age <80 years is an independent predictor for a sufficient level of functioning 6 weeks after admission. The level of functioning at 6 weeks predicts the level of functioning 3 months after admission. On comparison, the level of functioning after early ambulation is equal to the level of functioning after immobilization. Where immobilization may lead to complications, early ambulation was not associated with new complications or neurological damage. Based on these advantages, the treatment of elderly patients with a fracture involving both middle and anterior columns may be altered from immobilization to mobilization in the future.

Balloon kyphoplasty for osteoporotic spinal fractures with middle column compromise

BACKGROUND

Balloon kyphoplasty (BKP) is an effective method for osteoporotic vertebral compression fractures. However osteoporotic spinal fractures with middle column compromise are mentioned as a relative contraindication to BKP. Thus we investigated the safety and efficacy of BKP in the treatment of osteoporotic spinal fractures with middle column compromise but without neurological deficit.

METHODS

In this retrospective study, 45 patients who suffered osteoporotic fractures with middle column compromise but without neurological deficits were treated by BKP from May 2007 to December 2010. The final follow-ups were finished during the time of July 2011-September 2011. The mean follow-up period was 20.2 months. The height of the compromised vertebral body, the kyphotic angle and spinal canal compromise were measured before surgery, one day after surgery, and at the final follow-up. A visual analogue scale (VAS) and the Oswestry disability index (ODI) were chosen to evaluate pain and functional activity.

RESULTS

The mean VAS and ODI scores improved significantly from pre- to post-operation (p<0.05), and this improvement was sustained at the final follow-up. The mean anterior vertebral body height ratio improved from 57.6%± 11.8% preoperatively to 86.2%± 12.2% postoperatively (p<0.05), so did the mean middle vertebral body height ratio. The kyphotic angle improved from 16.3° ± 3.7° preoperatively to 9.3° ± 2.6° postoperatively (p<0.05). At final follow-up, BKP stabilised vertebral height and prevented further kyphotic deformity. While there were no differences in spinal canal compromise between pre-operation and one day after surgery (p>0.05), there was a significant difference from the measurement at the final follow-up (p<0.05).

CONCLUSION

BKP is a safe and effective method for osteoporotic spinal fractures with middle column compromise but without neurological deficit. Spontaneous remodelling of the spinal canal also occurs after BKP.

Orthosis for thoracolumbar burst fractures without neurologic deficit: A systematic review of prospective randomized controlled trials

BACKGROUND

Traditionally, conservative treatment of thoracolumbar (TL) burst fractures without neurologic deficit has encompassed the application of an extension brace. However, their effectiveness on maintaining the alignment, preventing posttraumatic deformities, and improving back pain, disability and quality of life is doubtful.

OBJECTIVE

The objective was to identify and summarize the evidence from randomized controlled trials (RCTs) to determine whether bracing patients who suffer TL fractures adds benefices to the conservative manage without bracing.

MATERIALS AND METHODS

Seven databases were searched for relevant RCTs that compared the clinical and radiological outcomes of orthosis versus no-orthosis for TL burst fractures managed conservatively. Primary outcomes were: (1) Loss of kyphotic angle; (2) failure of conservative management requiring subsequent surgery; and (3) disability and pain outcomes. Secondary outcomes were defined by health-related quality of life and in-hospital stay.

RESULTS

Based on predefined inclusion criteria, only two eligible high-quality RCTs with a total of 119 patients were included. No significant difference was identified between the two groups regarding loss of kyphotic angle, pain outcome, or in-hospital stay. The pooled data showed higher scores in physical and mental domains of the Short-Form Health Survey 36 in the group treated without orthosis.

CONCLUSION AND RECOMMENDATION

The current evidence suggests that orthosis could not be necessary when TL burst fractures without neurologic deficit are treated conservatively. However, due to limitations related with number and size of the included studies, more RCTs with high quality are desirable for making recommendations with more certainty.