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Three Part Question

In [adults diagnosed with burst fracture of the lumbar spine] does [bed rest and TLSO bracing/immobilisation] produce [satisfactory functional outcome]

Clinical Scenario

A 45 year old male presents to the emergency department complaining of lower back pain following a 6 ft fall from a ladder. CT confirms your suspicion of a burst fracture at L1. Neurological examination is normal. You wonder if bed rest and TLSO bracing in these patients will produce a satisfactory functional outcome

Search Strategy

Cochrane Database of Systematic Reviews 2nd Quarter 2007
Medline 1950 to June week 2 2007 using the Ovid interface
EMBASE 1996 to 2007 week 25.
({exp spinal fracture OR spinal fracture mp. OR burst fracture mp. OR thoracolumbar fracture mp. OR spinal trauma mp.} AND {thoracolumbar spinal orthosis mp. OR non-operative mp. OR recumbency mp. OR bed rest mp.} AND {exp treatment outcome OR functional outcome mp.}) LIMIT to english language. LIMIT to humans.

Search Outcome

43 papers were found of which 5 were relavant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Post RB, et al 2006 The Netherlands	33 patients with type A thoracolumbar fracture without neurological deficit treated non-operatively "unbraced group" n = 15 (mobilisation without brace) "braced group" n = 18 (2-6 weeks of bedrest followed by a three-point reclination brace)	Case series	Restrictions in body function and structure using dynamic lifting tests and ergometry exercise test	37 % were unable to perform the dynamic lifitng test within normal range (no difference was found between the braced and unbraced groups, P = 0.792). 40.9 % of the study group performed below the lowest normal value on the ergometry test (there was no significant difference netween the braced and unbraced groups, P = 0.300)	Study groups were small The RMDQ is not validated for spinal fracture, it is validated for low back pain
			Restrictions in activities (RMDQ, VAS)	For the total study group the RMDQ score was 5.2, the mean VAS (Visual Analogue Scale) score was 79, no significant differences were found between the braced and unbraced groups, P = 0.442 and P = 0.190 respectively
			Restrictions in participation/quality of life (SF-36)	Braced and unbraced groups showed no significant differences with respect to SF-36 scores, 10 % patients had stopped working, 24 % had arranged changes in the intensity and duration of work and 3 patients had changed their job due to back complaints
Mumford J, et al 1993 USA	41 patients with single level, non-pathological burst fractures of the thoracolumbar spine (T11-L5) without neurological deficit	Case series	Clinical outcome and efficacy of closed management of thoracolumbar fractures	49 % indicated excellent outcomes relative to pain and function, 17 % good, 22 % fair, and 12 % poor (6-point Likert scale, VAS, RMDQ)	The RMDQ (Roland Morris Disabiltiy Questionaire) is validated for low back paint not for fracture
			Work status	81 % of those who worked prior to injury returned to work, 53 % to the same job and 28 % at lower activity levels
Cantor JB, et al 1993 USA	33 neurologically intact patients with burst fractures at the thoracolumbar junction treated with early ambulation in total orthosis 15 pateints were lost to follow-up	Case series	Pain scale (Denis)	At follow-up of average of 19 months 9/18 patients reported no pain, 6 reported occasional/minimal pain, 2 moderate pain/occasional limitations, 1 moderate to severe pain, 0 reported constant severe pain	Small study group Only 18/33 patients were available for follow-up
			Work scale (Denis)	8/14 patients returned to previous employment heavy labour, 3 patients were able to return to sedentary work and 1 patient was unable to return to work due to disability
Chow GH, et al 1996 USA	24 patients with unstable burst frcatures of the thoracolumbar region (T11-L2)	Retrospective case series	Recreational activity	1 patient reported severe restrictions, 3 reported significant restrictions, 4 reported moderate restrictions, 5 reported minimal restriction and 11 reported no restrictions	Small sample size
			Return to work	6/24 patients were not working at the time of follow-up. The remaining 18 returned to work - 13/18 returned to a job of same physical demands as before injury, 3 worked in less physically demanding jobs. 2 patients were students
			Work restrictions	1 patient reported severe restrictions, 2 patients reported significant restrictions, 3 reported moderate restrictions , 6 minimal restrictions and 12 reported no restrictions
Au H, Kayali C, Arslanta M 2005 Turkey	29 neurologically intact patients with two or three column thoracolumbar burst fractures Group 1 - 16 patients with two-column injury (G1) Group 2 - 13 patients with three-column injury (G2) There were no significant differences with regard to fracture level (P = 0.679), gender (P = 0.702), age (P = 0.503) and follow-up periods (P = 0.170) between the two groups	Case series	Work scale (Denis') and Pain scale (Denis')	Statistically significant differences between G1 and G2 were found when dispersion of percentages of both groups with respect to pain and work status (P = 0.003). Differences between G1 and G2 work and pain status was not significant if functional results were classified as satisfactory or unsatisfactory (P = 0.197)	Small sample size
Tezer M, et al 2005 Turkey	48 pateints with thoracolumbar fracture (32 compression, 16 burst) 29 treated using TLSO 7 treated using body cast 6 treated using body cast and TLSO 6 treated using bed rest for 3 months		Pain and function score (Denis')	Patients with burst fractures had a mean pain and functional score of 1.25 and 0.93 respectively

Comment(s)

Many studies highlight the distinct contreversy which exist regarding the treatment of spinal fractures. Outcome is dependant on fracture type.

Clinical Bottom Line

Satisfactory outcome is achieved through bed rest and TLSO bracing/immobilisation. Satisfactory outcomes are achieved in terms of pain levels, work status and intensity and recreational activity.

References

1. Post RB, et al Functional outcome 5 years after non-operative treatment of a type A spinal fracture Eur Spine J 2006;15:472-478
2. Mumford J, et al Thoracolumbar burst fractures: The clinical efficacy and outcome of non-operative management Spine 1993;18(8):955-970
3. Cantor JB, et al Nonoperative management of stable thoracolumbar burst frcatures with ealry ambulation and bracing Spine 1993;18(8):971-976
4. Chow GH, et al Functional outcome of thoracolumbar fractures managed with hyperextension casting or bracing and early mobilization Spine 1996;21(18):2170-2175
5. Au H, Kayali C, Arslanta M Non-operative treatment of burst-type thoracolumbar vertabra fractures: Clinical and radiological results of 29 patients Eur spine J 2005;14(6):536-540
6. Tezer M, et al Conservative treatment of fractures of the thoracolumbar spine International orthopaedics 2005;29(2):78-82