Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit

Yi, Liao; Jing-ping, Bai; Jin, Gele; Baoleri, X; Wu, Taixiang

doi:10.1002/14651858.cd005079

Cited by 14 publications

(24 citation statements)

References 20 publications

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“…33 Recent studies comparing operative to nonoperative treatment in burst fractures without a neurological deficit have found no differences in the functional outcome between these treatment modalities, and moreover, operative management has been correlated with increased costs and complications. 1,24,58,65 While operative management was reported to be more effective in preventing the progression of sagittal deformity in stable burst fractures, it has been shown to have no correlation with the functional outcomes reported by patients. 55 Nonoperative management is used to stabilize the spine by limiting motion and can consist of recumbent bed rest, closed reduction, orthosis, and body cast with or without ambulation.…”

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confidence: 99%

“…Current systematic reviews compared operative and nonoperative treatment in neurologically intact patients. 1,24,58,65 These studies were limited by mainly including randomized controlled trials (RCTs) or using nonstandardized criteria to assess the level of evidence. By assessing the level of evidence in conservative management through validated methodologies, clinicians can assess the availability of critically appraised literature.…”

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confidence: 99%

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

Bakhsheshian¹,

Dahdaleh²,

Fakurnejad³

et al. 2014

FOC

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Object 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. Methods 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. Results 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. Conclusions 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.

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confidence: 99%

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confidence: 99%

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

Bakhsheshian¹,

Dahdaleh²,

Fakurnejad³

et al. 2014

FOC

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“…he treatment of thoracolumbar burst fractures re mains controversial. 42,44,49,50 A variety of treatment options are available and effective, but none has been definitively shown to be superior. 44 There are sev eral reasons for clinical equipoise in management.…”

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Comparison of thoracolumbosacral orthosis and no orthosis for the treatment of thoracolumbar burst fractures: interim analysis of a multicenter randomized clinical equivalence trial

Bailey

Dvorak

Thomas

et al. 2009

SPI

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Object The authors compared the outcome of patients with thoracolumbar burst fractures treated with and without a thoracolumbosacral orthosis (TLSO). Methods As of June 2002, all consecutive patients satisfying the following inclusion criteria were considered eligible for this study: 1) the presence of an AO Classification Type A3 burst fractures between T-11 and L-3, 2) skeletal maturity and age < 60 years, 3) admission within 72 hours of injury, 4) initial kyphotic deformity < 35°, and 5) no neurological deficit. The study was designed as a multicenter prospective randomized clinical equivalence trial. The primary outcome measure was the score based on the Roland-Morris Disability Questionnaire assessed at 3 months postinjury. Secondary outcomes are assessed until 2 years of follow-up have been reached, and these domains included pain, functional outcome and generic health-related quality of life, sagittal alignment, length of hospital stay, and complications. Patients in whom no orthotic was used were encouraged to ambulate immediately following randomization, maintaining “neutral spinal alignment” for 8 weeks. The patients in the TLSO group began being weaned from the brace at 8 weeks over a 2-week period. Results Sixty-nine patients were followed to the primary outcome time point, and 47 were followed for up to 1 year. No significant difference was found between treatment groups for any outcome measure at any stage in the follow-up period. There were 4 failures requiring surgical intervention, 3 in the TLSO group and 1 in the non-TLSO group. Conclusions This interim analysis found equivalence between treatment with a TLSO and no orthosis for thoracolumbar AO Type A3 burst fractures. The influence of a brace on early pain control and function and on long-term 1- and 2-year outcomes remains to be determined. However, the authors contend that a thoracolumbar burst fracture, in exclusion of an associated posterior ligamentous complex injury, is inherently a very stable injury and may not require a brace.

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“…[37][38][39][40] Surgical versus nonsurgical treatment of thoracolumbar burst fractures, however, remains a controversial issue because several welldesigned studies exhibit conflicting results. [41][42][43][44] In a prospective, randomized trial of 53 patients with a thoracolumbar fracture without neurological deficit, Wood et al 43 found no difference in functional outcome between patients managed operatively or nonoperatively with a body cast or orthosis. In a second prospective, randomized trial on When surgery is required, continually evolving operative techniques and the availability of specialized instrumentation, such as pedicle rod and screw fixation systems, have enabled surgeons to more aggressively pursue the goal of stability to the injured spine.…”

Section: Surgery or Conservative Treatmentmentioning

confidence: 99%

4 The Impact of Evidence-Based Medicine in Thoracolumbar Trauma

Vaccaro¹,

Fehlings²,

Dvorak³

2011

Spine and Spinal Cord Trauma

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Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit

Cited by 14 publications

References 20 publications

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

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

Comparison of thoracolumbosacral orthosis and no orthosis for the treatment of thoracolumbar burst fractures: interim analysis of a multicenter randomized clinical equivalence trial

4 The Impact of Evidence-Based Medicine in Thoracolumbar Trauma

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