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Three Part Question

In [adults with neurologically stable fracture of the TL spine] is [operative treatment better than non-operative treatment] at [providing improved radiographic and functional outcome]

Clinical Scenario

A 45 year old adult presents to the emergency department following a fall from a height. Neurological examination is normal, however, CT shows a burst fracture at L1. You wonder what the current method of management in these patients is.

Search Strategy

Cochrane Database of Systematic Reviews 2nd Quarter 2007. Medline 1950 to June week 2 2007 using Ovid interface. EMBASE 1996 to 2007 week 25
({exp spinal fractures} AND {exp thoracic vertebrae OR lumbar vertebrae} AND {exp treatment outcome OR non-operative mp. OR surgical treatment mp. OR exp braces OR exp orthotic devices OR surgery mp.} AND {exp follow up studies OR functional outcome mp.} LIMIT to humans AND english language. LIMIT to "all adult (19 plus years)". Browse references

Search Outcome

154 papers were found of which 5 were relevant to the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Yi L, Jingping B, Gele J, Baoleri X, Taixiang W 2006 China	1 small RCT was included in this review 53 adults with stable thoracolumbar burst fracture surgical (26) Vs. conservative (27)	Systematic Review	Average pain score (VAS)	3.3 in operative group compared with 1.9 in non-operative group at follow-up (visual analogue scale)	RMDQ and Oswestry scale are not validated for spinal fracture. Sample size was small. 11 % were lost to follow-up. Assessor blinding was unclear.
			Improvement in function measured using quality of life scales (Oswestry scale and/or Roland disability scale)	Conservative group had a significantly lower pain scores than operative group (P = 0.02)
			Return to work	17/23 conservatively treated patients were ableto return to work within 6 months and 2 returned between 6 and 24 months, 15 returned to a similar job and 4 returned to a lighter job. 10/24 operatively treated patients returned to work within 6 months, 4 returned within 6 and 24 months, 8 returned to similar job and 7 returned to less physically demanding job
			Sagittal plane kyphosis	Average kyphosis was 13 degrees at follow up in the operative group and 13.8 degrees at final follow-up in the non-operative group
			Degree of canal compromise	In the operative group the average midsagittal diameter of the spinal canl at the level of the fracture at final follow-up was 22% less than normal. In the non-operative group the diameter was 195 at final follow-up
			Correlation between the final amount of kyphosis/canal compromise and the reported pain or disability	No correlation was found
Butler JS, Walsh A, O'Byrne J 2005 Ireland	31 neurologically intact patients with burst L1 fractures. surgically treated (11) Vs. non-surgically treated (15)	Retrospective case series	Radiographic outcome	Mean kyphotic deformity in non-surgical group was 9.5 degrees at time of injury, 8.4 degrees post-mobilisation and 14.4 degrees at 3-month follow-up. Mean kyphotic deformity in surgical group was 15.6 degrees at time of injury, 2.1 degrees post-mobilisation and 9.6 degrees at 3-month follow-up	A small group of patients Patients treated surgically had more severe spinal fracture therefore making outcome comparison unfair
			Pain score	Surgical group: 3 rated pain as severe, 1 as significant, 3 as moderate, 4 as mild. Non-surgical group: 1 rated pain as severe, 5 rated pain as significant, 3 as moderate, 4 as mild and 2 reported no pain
			Return to work	3/15 patients had become unemployed due to their injury, the remaining patients returned to work. 4/11 surgically treated patients became unemplyed due to their injury
			Recreational abilities	In the surgical group: 5 reported severe restriction, 2 moderate restriction, 3 mild restrictions, 1 no restrictions. In the non-surgical group: 3 reported severe restriction, 4 significant restrictions, 1 moderate restrictions, 5 mild restrictions and 1 no restrictions
			Satisfaction levels	In surgical group: 9 reported being very satisfied, 1 slightly dissatisfied and 1 very dissatisfied. In the non-surgical group: 9 reported being very satisfied, 4 slightly satisfied, 2 very dissatisfied
Siebanga J, et al 2006 The Netherlands	34 patients with traumatic fracture of T10-L4, AO type A (compression fracture), no neurological deficit, aged 18 to 60 years old. Non-surgical (16) Vs. operative (18)	Multicenter prospective randomized trial	Radiographic results	Both local and regional kyphotic deformity was significantly less in the operatively treated group at final follow-up examination, P = < 0.0001	RMDQ is validated in pateints with low back pain not spinal fracture
			VAS Pain score	Significant difference in final follow-up pain score was found in favour of the operative treated patients, P = 0.033
			VAS spine score	A significant differance in final follow-up pain score was found in favour of operative treated patients, P = 0.020
			RMDQ-24 (Roland Morris Disability Questionaire)	Non-surgically treated patients were found to have significantly higher RMDQ-24 score in comparison with the operative group, P = 0.030
			Return to work	Percentage of patients resuming their professional careers was found to be significantly higher in ther operative group, P = 0.018. A significant difference concerning time before returning to work could not be found
Shen WJ, Liu TJ, Shen YS 2001 Taiwan	80 patients with neurologically intact, single level closed burst fracture involving T11-L2 with no fracture dislocations or pedicle fractures aged 18 to 65 Non-operative (47) Vs. Operative (33)	Prospective clinical trial	Radiographic outcome	Kyphosis angle in the non-surgical group by an average of 4 degrees. in the surgical group there was correction of kyphosis from an average of 23 degrees to an average of 6 degrees.	Random assignment of pateints to each group was not performed, some patients chose not to be surgically treated due to local social beliefs. These patients were kept in the study. The Greenough low back outcome score is validated for patients with low back pain not fracture
			VAS Pain score	Surgical patients had significantly less pain at the one-month (P = 0.02) and 3-month (P = 0.03) point, however there was no statistical difference in pain scores from the 3-month point onwards
			Work status (Denis 5-point scale)	Only 56 % of non-operatively treated patients returned to heavy work, 63 % of surgically treated patients returned to heavy work.
			Greenhough low back outcome score	Significant difference was seen between the two groups at the 1-month (P = 0.02), 3-month (P = 0.03) and 6-month (P = 0.04) points, but no difference was found thereafter
			Level of satisfaction	In non-surgical patients 18 (38 %) were very satisfied, none were very dissatisfied. In the surgical group 10 were very satisfied (30 %) and 2 were very dissatisfied.
Knight RQ, et al 1993 USA	22 patients with traumatic two and three column lumbar burst fractures operative (12) vs. non-operative (10)	Retrospective case series	Radiographic outcome	Statistically significant difference was found between operative and non-operative patients in terms of anterior column compression at admission (P = < 0.001). Statistical trends were found in terms of average kyphotic angulation (P = 0.085).	Small patient groups were used. QoL and pain scores were not validated
			Quality of Life	No statistical difference was found between the groups (P = 0.80)
			Activity level	No significant difference between the groups (P = 0.973)
			Pain scores	No significant difference was found
			Return to work	Non-operative patients returned to work at a mean time of 4.1 months, whereas operative patients returned to work at a mean time of 10.75 months (P < 0.001)

Comment(s)

Of the studies found, results were inconclusive and results were contradicting. Once a universal classification system is accepted, a RCT should be carried out to compare functional and radiographic outcome in patients who are treated operatively and non-operatively. No consistent statistically significant results were found.

Clinical Bottom Line

Treatment of thoracolumbar spinal fracture remains inconclusive. A more robust, universally accepted thoracolumbar fracture classification is needed.

References

1. Yi L, Jingping B, Gele J, Baoleri X, Taixiang W Operative versus non-operative treatment for thoracolumbar burst fracture without neurological deficit (Review) Cochrane database of systematic reviews Oct 2006;issue2:1 - 14
2. Butler JS, Walsh A, O'Byrne J Functional outcome of burts fractures of the first lumbar vertebrae managed surgically and conservatively International orthopaedics 2005;29:51-54
3. Siebenga J, et al Treatment of traumatic thoracolumbar spine fractures: A multicenter prospective randomized study of operative versus nonsurgical treatment Spine 2006;31(25):2881-2890
4. Shen W, Liu T, Shen Y Nonoperative treatment versus posterior fixation for thoracolumbar junction burst frcatures without neuroligical deficit Spine 2001;26(9):1038-1045
5. Knight RQ, et al Comparison of operative versus non-operative treatment of lumbar burst fractures Clinical orthopaedics and related research 1993;293:112-121