Commentary and Perspective
Burst fractures of the thoracolumbar spine are common, but no consensus has been reached as to the best treatment. Although all burst fractures are characterized by the common finding of retropulsion of the posterior vertebral body wall into the spinal canal, burst fractures vary in severity with respect to amount of comminution, canal narrowing, associated neurologic deficit, and involvement of posterior structures. The latter structures are of primary importance in defining stability.
To determine the best treatment, the authors conducted a randomized clinical trial from 1992 to 1998 in which they compared the outcomes of forty-seven patients who received either surgical or nonoperative treatment of a stable thoracolumbar burst fracture. This type of fracture has an intact posterior osteoligamentous complex. Nonoperative care consisted of bracing or casting. The surgical group was treated by anterior corpectomy and fusion with a plate or short-segment (two to four-level) posterior pedicle-screw instrumentation and arthrodesis. The four-year results showed no difference in clinical or radiographic outcomes but higher complications among the operatively treated patients1. This was an important result and led to a decrease in operative treatment in these patients.
The authors followed the patients from sixteen to twenty-two years and currently report the results for thirty-seven of the original randomized forty-seven patients. Of those who were lost to follow-up, three had died and seven could not be contacted. Contrary to the findings at earlier follow-up, long-term outcomes for pain and function were significantly better for the nonoperatively treated patients. A greater number of patients in the nonoperative group were working: 72% compared with 47% in the operative group. Radiographic results showed no significant differences between the two groups in final kyphotic angulation, overall sagittal balance, and degeneration of segments adjacent to the fracture level. However, greater degenerative disease in the lower lumbar spine was noted in the operatively treated patients. The radiographic results other than degeneration did not change over time.
These findings show that, in properly selected neurologically intact patients, stable thoracolumbar burst fractures are best treated nonoperatively. These results became more important with long-term follow-up. The authors should be congratulated for their diligence in identifying and performing long-term follow-up for this population of patients. The results can be applied to clinical care and should help guide surgeons and patients when making treatment decisions. However, the inclusion criteria must be considered when applying the results of this study; the patients had a very specific type of stable fracture, were neurologically intact, and did not have multiple injuries or other spinal fractures, which might change indications for surgery.
In addition, the landscape of the treatment of thoracolumbar fractures is changing, which is not reflected in this study. Minimally invasive techniques and nonfusion instrumentation are now commonly used, and results from high-quality randomized trials show excellent short-term outcomes of these newer approaches2,3. These techniques were not available and thus were not compared in the current study. To provide a balanced perspective, one should consider a contradictory randomized trial by Siebenga et al. comparing operative with nonoperative treatment of similar fracture type in neurologically intact patients4. In this study, the opposite findings were observed: patients treated operatively had significantly less pain, better function, and higher rates of return to work than nonoperatively treated patients. The lack of homogeneity between these two similar randomized trials limits any definitive conclusions as to the best treatment of these injuries. Further research is needed to evaluate newer treatments through the use of rigorous methods similar to those in the current study. Finally, the role of bracing can even be questioned, as a recent randomized trial failed to show any benefit of the use of a brace compared with no brace in the management of stable burst fractures5.
1. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85(5):773-81.
2. Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. A five to seven-year prospective randomized study. J Bone Joint Surg Am. 2009 May;91(5):1033-41.
3. Wang ST, Ma HL, Liu CL, Yu WK, Chang MC, Chen TH. Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine?: a prospective, randomized study. Spine (Phila Pa 1976). 2006 Nov 1;31(23):2646-52; discussion 2653.
4. Siebenga J, Leferink VJ, Segers MJ, Elzinga MJ, Bakker FC, Haarman HJ, Rommens PM, ten Duis HJ, Patka P. Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment. Spine (Phila Pa 1976). 2006 Dec 1;31(25):2881-90.
5. Bailey CS, Urquhart JC, Dvorak MF, Nadeau M, Boyd MC, Thomas KC, Kwon BK, Gurr KR, Bailey SI, Fisher CG. Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial. Spine J. 2013 Oct 31. Epub 2013 Oct 31.