Outcomes in Thoracolumbar Burst Fractures With a Thoracolumbar Injury Classification Score (TLICS) of 4 Treated With Surgery Versus Initial Conservative Management

A4 Thoracolumbar Fracture Class Is Associated With a Greater Degree of Vertebral Height Loss in Conservatively Managed Patients

INTRODUCTION

Thoracolumbar (TL) junction fractures are common, often resulting from high-energy trauma or osteoporosis, and may lead to neurological deficits, deformities, or chronic pain. Treatment decisions for neurologically intact patients remain controversial, with nonsurgical management often favored. The AO classification system has been used to characterize thoracolumbar fractures using fracture morphology and clinical factors affecting clinical decision-making for fracture management. This study aims to assess the radiographic outcomes of utilizing a thoracolumbosacral orthosis (TLSO) brace in neurologically intact patients with TL fractures based on the AO classification system.

METHODS

A retrospective analysis of 43 patients was conducted using data from the VCU Spine Database on patients with TL fractures managed conservatively with a TLSO brace from 2010 to 2019. Demographic variables and radiographic measurements of anterior height loss were analyzed and stratified by AO fracture class.

RESULTS

Significant differences were observed in anterior height loss between AO fracture classes, with A4 fractures showing significantly greater anterior height loss at initial presentation (27.6 + 4.8%) compared to A1/A2 (16.1 + 2.2%; p=0.049). At follow up, A4 fractures had a significantly greater anterior height loss (40.2 + 6.6%) than both the A1/A2 (22.4 + 2.9%; p=0.029) and A3 fracture classes (20.5 + 3.6; p=0.020).

CONCLUSIONS

The study highlights significant differences in anterior height loss among AO fracture classes, suggesting varying degrees of severity and potential implications for clinical management. While conservative treatment with TLSO braces may provide pain relief, surgical intervention may offer better structural recovery, especially in more severe fractures. Conservative management of TL fractures with TLSO braces may result in greater anterior height loss, particularly in A4 fractures, emphasizing the need for individualized treatment decisions. Further research, including prospective studies, is warranted to validate these findings and guide clinical practice effectively.

Efficacy and Safety of Conservative Treatment Compared With Surgical Treatment for Thoracolumbar Fracture With Score 4 Thoracolumbar Injury Classification and Severity (TLICS): A Systematic Review and Meta-analysis

STUDY DESIGN

This was a systematic review and meta-analysis.

OBJECTIVE

The clinical outcomes, radiologic outcome, and complications were compared between surgical treatment and conservative treatment of thoracolumbar fractures with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4.

SUMMARY OF BACKGROUND DATA

The thoracolumbar fracture is the main reason leading to the spinal cord injury. Some studies suggested that the treatment of TLICS=4 is a "gray zone." Hence, the efficacy and safety of surgical treatment and conservative treatment of thoracolumbar fractures with scores 4 TLICS was still debated.

MATERIALS AND METHODS

A comprehensive search of PubMed, Embase, and the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was performed up to October 2021. Relevant studies were identified using specific eligibility criteria and data was extracted and analyzed based on primary and secondary outcomes.

RESULTS

A total of 10 studies involving 555 patients were included (3 randomized controlled trials and 7 retrospective studies). There was no significant difference of hospital time (standardized mean difference=0.24, 95% CI: -1.50 to 1.97, P =0.79) and Oswestry Disability Index (mean difference=2.97, 95% CI: -1.07 to 7.01, P =0.15) between surgery and nonsurgery. The length of returning to work was shorter in surgical treatment (standardized mean difference=1.27, 95% CI: 0.07-2.46, P =0.04). Visual Analog Scale in surgical treatment was lower at 1, 3, and 6 months (respectively, P <0.00001, P =0.003, and P =0.02). However, there existed no significant difference between surgical treatment and nonsurgical treatment at 12 and >24 months (respectively, P =0.18 and 0.17). Cobb angle was lower in surgical treatment at postoperative at 6, 12, and >24 months (respectively, P =0.005, P <0.00001, P =0.002, and P =0.0002). Finally, the surgical treatment had a lower incidence of complications (odds ratio=3.89, 95% CI: 1.90-7.94, P =0.0002).

CONCLUSIONS

Current evidence recommended that surgical treatment is superior to conservative treatment of TLICS score of 4 at the early follow-up. Surgical treatment had lower Cobb angle, Visual Analog Scale scores, and complications compared with a nonsurgical TLICS score of 4. However, these findings needed to be verified further by multicenter, double-blind, and large-sample randomized controlled trials.

Sensitivity and specificity of machine learning and deep learning algorithms in the diagnosis of thoracolumbar injuries resulting in vertebral fractures: A systematic review and meta-analysis

Introduction

Clinicians encounter challenges in promptly diagnosing thoracolumbar injuries (TLIs) and fractures (VFs), motivating the exploration of Artificial Intelligence (AI) and Machine Learning (ML) and Deep Learning (DL) technologies to enhance diagnostic capabilities. Despite varying evidence, the noteworthy transformative potential of AI in healthcare, leveraging insights from daily healthcare data, persists.

Research question

This review investigates the utilization of ML and DL in TLIs causing VFs.

Materials and methods

Employing Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) methodology, a systematic review was conducted in PubMed and Scopus databases, identifying 793 studies. Seventeen were included in the systematic review, and 11 in the meta-analysis. Variables considered encompassed publication years, geographical location, study design, total participants (14,524), gender distribution, ML or DL methods, specific pathology, diagnostic modality, test analysis variables, validation details, and key study conclusions. Meta-analysis assessed specificity, sensitivity, and conducted hierarchical summary receiver operating characteristic curve (HSROC) analysis.

Results

Predominantly conducted in China (29.41%), the studies involved 14,524 participants. In the analysis, 11.76% (N = 2) focused on ML, while 88.24% (N = 15) were dedicated to deep DL. Meta-analysis revealed a sensitivity of 0.91 (95% CI = 0.86-0.95), consistent specificity of 0.90 (95% CI = 0.86-0.93), with a false positive rate of 0.097 (95% CI = 0.068-0.137).

Conclusion

The study underscores consistent specificity and sensitivity estimates, affirming the diagnostic test's robustness. However, the broader context of ML applications in TLIs emphasizes the critical need for standardization in methodologies to enhance clinical utility.

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.

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.

Evaluation of Disc and Endplate Degeneration in AO Type A Fractures Using Magnetic Resonance Imaging Analysis

OBJECTIVE

Disc degeneration after trauma has been the focus of several investigations, although vertebral endplate changes have received comparatively less attention. The main aim of the present study is to radiologically evaluate the prevalence of the degree of degeneration of the adjacent discs and endplates after AO type A thoracolumbar fractures.

METHODS

We retrospectively reviewed 25 patients with an AO type A injury (50 discs and 150 endplates). The type of disc lesion adjacent to the fractured vertebra was classified using the Pfirrmann and Oner classifications immediately after trauma and at the 1-year follow-up. The endplate defects were assessed using the endplate scoring system (total endplate score 1-6) in T1-weighted images. The kyphosis angle and vertebral body height were also measured.

RESULTS

The study population consisted of 18 men (72%) and 7 women (28%), with a mean age of 38.9 ± 11.3 years. Overall, 28% of the fractures were type A1, 4% were type A2, 24% were type A3, and 44% were type A4. On statistical analysis, a significant change was found in the degree of degeneration in the cranial adjacent disc using both the Oner (P = 0.004) and Pfirrmann (P = 0.001) classifications at the end of 1 year. The morphological changes at the cranial adjacent discs at 1 year of follow-up showed a strong positive correlation with superior endplate degeneration.

CONCLUSIONS

The results from the present study indicate that endplate fractures of vertebrae in patients with thoracolumbar burst fractures can cause disc degeneration, especially at the cranial endplate.

Adult Trauma Patients With Thoracolumbar Injury Classification and Severity Score of 4: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

Evaluate characteristics of patients with thoracolumbar injury classification and severity (TLICS) score of 4 (To4) severity traumatic thoracolumbar injury.

SUMMARY OF BACKGROUND DATA

The TLICS score is used to predict the need for operative versus nonoperative management in adult patients with traumatic thoracolumbar injury. Ambiguity exists in its application and score categorization.

METHODS

A systematic review of the literature was performed. The databases of MEDLINE, Embase, Web of Science, and Cochrane Review were queried. Studies included adults with traumatic thoracolumbar injury with assigned TLICS score and description of management strategy.

RESULTS

A total of 16 studies met inclusion criteria representing 1911 adult patients with traumatic thoracolumbar injury. There were 503 (26.32%) patients with To4, of which 298 (59.24%) were operative. Studies focusing on the thoracolumbar junction and AO Type A fracture morphology had To4 patient incidences of 11.15% and 52.94%, respectively. Multiple studies describe better quality of life, pain scores, and radiographic outcomes in To4 who underwent operative treatment patients.

CONCLUSION

To4 injuries are more commonly AO Type A and located in the thoracolumbar junction in adult patients with traumatic thoracolumbar injury. Despite ambiguous recommendations regarding treatment provided by TLICS, outcomes favor operative intervention in this subset of traumatic thoracolumbar injury patients.

Thoracolumbar Injury: The Thoracolumbar Injury Classification and Severity Scoring System or Modified Thoracolumbar Injury Classification and Severity?

OBJECTIVE

To compare the Thoracolumbar Injury Classification and Severity (TLICS) scoring system with its modified (mTLICS) version based on their agreement with the surgeon's opinion regarding treatment for patients with thoracolumbar injuries. Moreover, the Posterior Ligamentous Complex health was compared between intraoperative examinations and magnetic resonance imaging (MRI) reports.

METHODS

MRI was obtained from 114 patients suffering thoracolumbar spinal trauma; the TLICS and mTLICS scores were measured. Approaches 1 and 2 were designed in both scoring systems based on assuming a total score of 4 as surgery and conservative management indication, respectively. Kappa was used to estimate the agreements between each approach and the surgeon's opinion on treatment. The receiver operating curve calculated the appropriate cut-off scores for the above systems over which surgical management was preferred. A P < 0.05 was considered significant.

RESULTS

All the approaches showed moderate agreements with the surgeon's opinion on therapeutic management (TLICS: κ_approach1 = 0.557, κ_approach2 =0.508; mTLICS: κ_approach1 = 0.557, κ_approach2 = 0.551; P < 0.001 for each κ). A score >3.5 best illustrated the indication for surgery in both systems. The radiology report agreed stronger with intraoperatively observed ligamentous health when suspicious cases on MRI were reported as injured (κ_TLICS = 0.830, κ_mTLICS = 0.704) rather than healthy (κ_TLICS = 0.620, κ_mTLICS = 0.620).

CONCLUSIONS

The surgeon's treatment plan agreed moderately with suggestions of the TLICS and mTLICS systems; surgery was the preferred management for the patients with a score of 4. Moreover, radiologic suspicion of Posterior Ligamentous Complex injury seemed to indicate a damaged ligament rather than a healthy one.

Assessment of Instability in Thoracolumbar Burst Fractures Using a New Bone Scan Scoring System

Background and Objectives: Unstable thoracolumbar burst fractures require surgical management as they can result in neurological deficits if left untreated. This study aimed to evaluate whether a new bone scan scoring system could accurately assess instability in thoracolumbar burst fractures. Materials and Methods: Fifty-two patients with thoracolumbar burst fractures who underwent bone scans and magnetic resonance imaging prior to surgery between January 2015 and August 2017 at Ulsan University Hospital were selected for inclusion. Instability was determined by clinical assessment and imaging, and the Thoracolumbar Injury Classification and Severity score was determined. Bone scans were visually evaluated using a new bone scan scoring system. Bone scan findings of vertebral body (B_B) and posterior column (B_P) were scored separately and were summed to produce B_TS {B_TS (total score) = B_B (body score, 5 points) + B_P (posterior score, 2 points)}. The diagnostic performance of the scoring system for identifying unstable then thoracolumbar burst fractures were assessed. Results: Of the 52 thoracolumbar burst fractures, 34 (65.4%) were unstable and 31 (59.6%) had a Thoracolumbar Injury Classification and Severity score ≥ 5. The diagnostic performance of using B_TS ≥ 4 to identify unstable thoracolumbar burst fractures and those with a Thoracolumbar Injury Classification and Severity score ≥ 5 was as follows: sensitivity, 61.8% and 58.1%; specificity, 94.4% and 81.0%; positive predictive value, 95.5% and 81.8%; and negative predictive value, 56.7% and 56.7%, respectively. Conclusions: The proposed bone scan scoring system has a high specificity and positive predictive value for identifying thoracolumbar burst fractures that are unstable or have a Thoracolumbar Injury Classification and Severity score ≥ 5. This scoring system may help to inform decisions regarding surgical management.

Classifications and level of evidence trends from the most influential literature on thoracolumbar burst fractures: A bibliometric analysis

Background

There are known classifications that describe thoracolumbar (TL) burst type injury but it is unclear which have the most influence on management. Our objective is to investigate the association of classification publications with the quantity and type of the most influential articles on TL burst fractures.

Methods

Web of Science was searched, and exclusion and inclusion criteria were used to extract the top 100 cited articles on TL burst fractures. The effects on type, number, and other variables were separated into four eras as defined by four major classification publications.

Results

30 out of the top 100 articles represent level 1 or 2 evidence. The most influential journal was Spine, accounting for 35 articles and 4,537 citations. The highest number of articles (53) was published between the years 1995-2005, culminating with the Thoracolumbar Injury Severity Classification Score (TLICS) paper. After 2005, there was an increase in average citations per year. Following 2013, the number of highly influential articles decreased, and systematic reviews (SRs) became a larger proportion of the literature. There was a statistically significant increase in the level of 1 and 2 evidence articles with time until the publication of TLICS. The predictive value of time for higher levels of evidence was only seen in the pre-2005 years (AUC: 0.717, 95% CI 0.579-0.855, p = 0.002).

Conclusions

In 1994, two articles marked the beginning of an era of highly influential TL burst fracture literature. The 2005 TLICS score was associated with a preceding increase in LOE and productivity. Following 2005, the literature saw a decrease in productivity and an increase in systematic review/meta-analysis (SR-MAs). These trends represent an increase in scholarly discussion that led to a systematic synthesis of the existing literature after publication of the 2005 TLICS article.

Classification and Radiological Diagnosis of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

The aim of this review to determine recommendations for classification and radiological diagnosis of thoracolumbar spine fractures. Recommendation was made through a literature review of the last 10 years. The statements created by the authors were discussed and voted on during 2 consensus meetings organized by the WFNS (World Federation Neurosurgical Societies) Spine Committee. The literature review was yielded 256 abstracts, of which 32 were chosen for full-text analysis. Thirteen papers evaluated the reliability of a classification system by our expert members and were also chosen in this guideline analysis. This literature review-based recommendation provides the classification and radiologic diagnosis in thoracolumbar spine fractures that can elucidate the management decision-making in clinical practice.

Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

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.

Clinical efficacy and therapeutic value of delayed surgery in patients with symptomatic old thoracolumbar fractures

Background

To investigate the clinical efficacy and therapeutic value of posterior decompression reduction, bone grafting fusion, and internal fixation for treatment of symptomatic old thoracolumbar fractures.

Method

Retrospective analysis was conducted for 14 patients (9 men, 5 women; average age 40.1 years) with old thoracolumbar fractures who underwent posterior operation. American Spinal Injury Association (ASIA) scores were used to evaluate neurologic function. Vertebral body height, Cobb angle in the sagittal plane, spinal canal volume ratio (%) and bone graft fusion were analyzed by radiography and computed tomography on different follow-up times.

Results

Mean follow-up was 27.1 months (23–36 months). Of three patients with ASIA grade A, 2 had improved postoperative urination and defecation, although no classification change. Preoperative ASIA score for eight patients with incomplete injury was grade B; four patients recovered to grade C at final follow-up. Preoperative ASIA score was C in three patients, increased to D in two patients and returned to normal E in one patient. Preoperative results showed average injured vertebra height loss rate decreased from 50.4 to 8.9%; average Cobb angle on the sagittal plane recovered from 39.6 to 6.9°; and the average spinal canal volume ratio recovered from 33.8 to 5.9%. Bony fusion was achieved; local lumbago and leg pain were relieved to some extent. No patients exhibited loosening of the fracture treated by internal fixation, pseudoarthrosis, or other related serious complications.

Conclusion

Treatment of old thoracolumbar fractures by posterior decompression reduction, bone grafting fusion, and internal fixation can relieve spinal cord compression, improve neurologic function of some patients (ASIA grades B–C), effectively relieve pain, correct deformity, restore biomechanical stability, and significantly improve quality of life.

Clinical relevance and validity of TLICS system for thoracolumbar spine injury

In order to enhance the reliability of the application to clinical practice of the TLICS classification, we retrospectively reviewed the patients with thoracolumbar spine injuries who underwent magnetic resonance imaging (MRI) and analyzed the validity of the TLICS classification and the necessity of MRI. We enrolled 328 patients with thoracolumbar spine injury who underwent MRI. All patients were classified into conservative and operative treatment groups. The TLICS score of each group was analyzed and the degree of consistent with the recommended treatment through the TLICS classification was examined. Of the total 328 patients, 138 patients were treated conservatively and 190 patients were treated by surgery. Of the 138 patients who underwent conservative treatment, 131 patients (94.9%) had a TLICS score of 4 points or less, and matched with the recommendation score for conservative treatment according to the TLICS classification (match rate 94.9%, 131/138). Of the 190 patients who underwent operative treatment, 160 patients (84.2%) had a TLICS score of 4 points or more (match rate 84.2%, 160/190). All of 30 mismatched patients with a TLICS score of 3 points or less (15.8%) had stable burst fracture without neurological deficit. We retrospectively reviewed the validity of the TLICS classification for the injuries of the thoracolumbar spine, based on MRI in a large group of patients. Treatment with TLICS classification showed high validity, especially in conservative group, and MRI should be an essential diagnostic tool for accurate evaluation of posterior ligamentous complex injury.

Evaluation of disc degeneration adjacent to AOspine A fractures: pre- and post-operative MRI analysis

INTRODUCTION

The management of type A thoracolumbar fractures varies from conservative treatment to multiple level fusion. Indeed, although Magerl defined the type A fracture as a strictly bone injury, several authors suggested associated disc lesions or degeneration after trauma. However, the preservation of mobility of the adjacent discs should be a major issue. This study was conducted to analyze the presence of immediate post-traumatic disc injuries and to know if discs degenerate after receiving treatment.

METHODS

We retrospectively reviewed the files of 27 patients with an AOspine A fracture, corresponding to 34 fractures (64 discs) with pre and post-operative MRI (mean follow-up: 32.4 months). Based on Pfirrmann's and Oner's classifications of disc injuries, two observers analyzed independently the type of lesion in the discs adjacent to the fractured vertebra in immediate post-trauma and at the last follow-up.

RESULTS

The immediate post-traumatic analysis according to Pfirrmann's classification found 97% of the cranial adjacent discs and 100% of the caudal discs classified Pfirrmann 3 or less. The analysis on the secondary MRI revealed that 78% of cranial adjacent discs and 88% of caudal adjacent discs still were classified Pfirrmann 3 or less.

CONCLUSIONS

Since, the great majority of type A fractures does not cause immediate disc injuries, these fractures are, as described by Magerl, strictly bony injuries. The quality of the body reduction seems to prevent secondary degeneration. These results may encourage surgeons not to perform arthrodesis on type A fractures even for A3 and A4.

Functional Outcome of Surgical versus Conservative Therapy in Patients with Traumatic Thoracolumbar Fractures and Thoracolumbar Injury Classification and Severity Score of 4; A Non-randomized Clinical Trial

OBJECTIVE

To compare the effectiveness of surgical intervention to conservative treatment in patients with thoracolumbar fracture and thoracolumbar injury classification and severity score (TLICS) of 4.

METHODS

Twenty-five patients with TLICS 4 were enrolled in this non-randomized clinical trial. Based on clinical symptoms and radiologic findings, patients were considered under surgical or conservative treatments. The JOA Back Pain Evaluation Questionnaire (JOABPEQ) was assessed at baseline and at 3, 6, 12 months after treatment. A 20-point improvement from the baseline JOABPEQ scores was considered as clinical success in both the conservative and surgery groups. Additionally, residual canal, angulations and height loss were determined in all patients.

RESULTS

Eight patients received conservative and 17 surgical treatment. Both study groups were comparable regarding the baseline characteristics. Both study demonstrated treatment success, regarding functional recovery when compared to baseline (p<0.001). However, those undergoing surgical intervention had significantly better JOABPEQ score (p<0.001) and higher residual canal (p=0.042) when compared to those receiving conservative therapy. The success rate of treatment was comparable between the two study groups in 6- (p=0.998) and 12-month (p=0.852) intervals; however, surgical therapy had significantly higher success arte in 3-month interval (p=0.031).

CONCLUSION

Our findings revealed that surgical treatment was preferred more in comparison to conservative treatment in patients with TLICS 4. Additionally, residual canal might be a modifying factor to decide the ideal therapeutic approach.