Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The overall evidence for nonoperative management of patients with traumatic thoracolumbar burst fractures is unknown. There is no agreement on the optimal method of conservative treatment. Recent randomized controlled trials that have compared nonoperative to operative treatment of thoracolumbar burst fractures without neurological deficits yielded conflicting results. By assessing the level of evidence on conservative management through validated methodologies, clinicians can assess the availability of critically appraised literature. The purpose of this study was to examine the level of evidence for the use of conservative management in traumatic thoracolumbar burst fractures.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A comprehensive search of the English literature over the past 20 years was conducted using PubMed (MEDLINE). The inclusion criteria consisted of burst fractures resulting from a traumatic mechanism, and fractures of the thoracic or lumbar spine. The exclusion criteria consisted of osteoporotic burst fractures, pathological burst fractures, and fractures located in the cervical spine. Of the studies meeting the inclusion/exclusion criteria, any study in which nonoperative treatment was used was included in this review.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>One thousand ninety-eight abstracts were reviewed and 447 papers met inclusion/exclusion criteria, of which 45 were included in this review. In total, there were 2 Level-I, 7 Level-II, 9 Level-III, 25 Level-IV, and 2 Level-V studies. Of the 45 studies, 16 investigated conservative management techniques, 20 studies compared operative to nonoperative treatments, and 9 papers investigated the prognosis of conservative management.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>There are 9 high-level studies (Levels I–II) that have investigated the conservative management of traumatic thoracolumbar burst fractures. In neurologically intact patients, there is no superior conservative management technique over another as supported by a high level of evidence. The conservative technique can be based on patient and surgeon preference, comfort, and access to resources. A high level of evidence demonstrated similar functional outcomes with conservative management when compared with open surgical operative management in patients who were neurologically intact. The presence of a neurological deficit is not an absolute contraindication for conservative treatment as supported by a high level of evidence. However, the majority of the literature excluded patients with neurological deficits. More evidence is needed to further classify the appropriate burst fractures for conservative management to decrease variables that may impact the prognosis.</jats:p></jats:sec>

Nonoperative Management in Neurologically Intact Thoracolumbar Burst Fractures

“…For patients who are neurologically intact, nonoperative treatment may prove sufficient. [6][7][8]10,11,14,[27][28][29] Surgery is undertaken when neurological deficits and/or persistent pain are present, or the fracture is deemed unstable with disruption of the posterior ligaments. In the absence of neurological deficit or biomechanical instability, the decision favoring one approach (surgical or nonsurgical) becomes more contentious and ambiguous.…”

“…The consensus from the aforementioned studies and other meta-analyses is the inconsistency of outcomes, rendering a decision in favor of operative versus nonoperative treatment inconclusive. 8,[29][30][31][32] In our management of neurologically intact burst fractures, with intact PLC or a TLICS score of 2, patients were initially all treated nonoperatively with bracing and gradual mobilization. Thoracolumbar braces were used in all patients, although recent reports have shown that braces did not add sufficiently to clinical outcomes to justify their cost or use.…”

Perioperative morbidity and mortality after lumbar trauma in the elderly

“…As with all spinal fractures, those within the lumbar spine can take on a variety of patterns 15 and can range from stable to unstable; most fractures therefore have both operative and nonoperative management options. 1,7,41 The decision to operate is traditionally based on such factors as fracture morphology, integrity of the posterior ligamentous complex, and neurological presentation. 16,39 For the elderly, however, there must also be a careful consideration of perioperative risk (including preexisting comorbidities, premorbid quality of life, and goals of care) versus potential benefit.…”

Telehealth‐based model of care redesign to facilitate local fitting and management of patients with a spinal fracture requiring a thoracic lumbar sacral orthosis in rural hospitals in New South Wales

“…Thoracic lumbar sacral orthoses (TLSO) are used to facilitate management of spinal fractures and are the most common orthosis used in the conservative management of spinal fractures in the thoracolumbar spine . A TLSO is prescribed when surgical intervention is not required and aids in stabilisation, analgesia and early mobilisation .…”