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Operative Compared with Nonoperative Treatment of a Thoracolumbar Burst Fracture without Neurological Deficit

A Prospective Randomized Study with Follow-up at Sixteen to Twenty-Two Years*

Wood, Kirkham B. MD1; Buttermann, Glenn R. MD2; Phukan, Rishabh BA1; Harrod, Christopher C. MD3; Mehbod, Amir MD4; Shannon, Brian MD5; Bono, Christopher M. MD6; Harris, Mitchel B. MD6

doi: 10.2106/JBJS.N.00226
Scientific Articles

Background: Studies comparing operative with nonoperative treatment of a stable burst fracture of the thoracolumbar junction in neurologically intact patients have not shown a meaningful difference at early follow-up. To our knowledge, longer-term outcome data have not before been presented.

Methods: From 1992 to 1998, forty-seven consecutive patients with a stable thoracolumbar burst fracture and no neurological deficit were evaluated and randomized to one of two treatment groups: operative treatment (posterior or anterior arthrodesis) or nonoperative treatment (a body cast or orthosis). We previously reported the results of follow-up at an average of forty-four months. The current study presents the results of long-term follow-up, at an average of eighteen years (range, sixteen to twenty-two years). As in the earlier study, patients at long-term follow-up indicated the degree of pain on a visual analog scale and completed the Roland and Morris disability questionnaire, the Oswestry Disability Index (ODI) questionnaire, and the Short Form-36 (SF-36) health survey. Work and health status were obtained, and patients were evaluated radiographically.

Results: Of the original operatively treated group of twenty-four patients, follow-up data were obtained for nineteen; one patient had died, and four could not be located. Of the original nonoperatively treated group of twenty-three patients, data were obtained for eighteen; two patients had died, and three could not be located. The average kyphosis was not significantly different between the two groups (13° for those who received operative treatment compared with 19° for those treated nonoperatively). Median scores for pain (4 cm for the operative group and 1.5 cm for the nonoperative group; p = 0.003), ODI scores (20 for the operative group and 2 for the nonoperative group; p <0.001) and Roland and Morris scores (7 for the operative group and 1 for the nonoperative group; p = 0.001) were all significantly better in the group treated nonoperatively. Seven of eight SF-36 scores also favored nonoperative treatment.

Conclusions: While early analysis (four years) revealed few significant differences between the two groups, at long-term follow-up (sixteen to twenty-two years), those with a stable burst fracture who were treated nonoperatively reported less pain and better function compared with those who were treated surgically.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey OCC #3800 Boston, MA 02114. E-mail address for K.B. Wood:

2Midwest Spine Institute, 1950 Curve Crest Boulevard West, Suite 100, Stillwater, MN 55082

3Bone and Joint Clinic of Baton Rouge, 7301 Hennessy Boulevard, Suite 300, Baton Rouge,‎ LA‎ 70808

4Twin Cities Spine Center, Piper Building, 913 East 26th Street, Suite 600, Minneapolis, MN 55404

5Sharon Regional Hospital, 740 East State Street, Sharon, PA 16146

6Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115

Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated
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