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Does Surgical Intervention or Timing of Surgery Have an Effect on Neurological Recovery in the Setting of a Thoracolumbar Burst Fracture?

Kato, So MD*; Murray, Jean-Christophe MD*; Kwon, Brian K. MD, PhD; Schroeder, Gregory D. MD; Vaccaro, Alexander R. MD, PhD, MBA; Fehlings, Michael G. MD, PhD, FACS, FRCSC§,‖,¶,**,††,‡‡

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Journal of Orthopaedic Trauma: September 2017 - Volume 31 - Issue - p S38-S43
doi: 10.1097/BOT.0000000000000946
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Abstract

INTRODUCTION

Traumatic thoracolumbar burst fractures are one of the most common forms of spinal trauma encountered in the clinical setting, with the majority occurring at the junctional area where mechanical load is maximal.1,2 Burst fractures are often caused by axial loading to the spine, and the resulting compressive force to the vertebral body. They can occur as a result of high-energy trauma in young and healthy individuals, but more typically result from falls from standing height in elderly osteoporotic patients. In the AOSpine Thoracolumbar Spine Injury Classification System, this type of injury is classified as A3 or A4, depending on whether one endplate or both endplates are disrupted.3

Burst fractures, by their definition, entail the involvement of not only the anterior column but also the middle column in Denis 3-column theory.4 That is to say, they are typically associated with bony encroachment of the spinal canal, which may or may not cause compression of the spinal cord, conus medullaris, cauda equina, or a combination of these. Fortunately, more than half of the patients with thoracolumbar burst fractures are neurologically intact due to the wide canal diameter.1

Despite its frequent presentation, consensus has not been met regarding the optimal treatment strategy for this specific type of injury. There has been much debate regarding operative versus nonoperative management, timing of operative management, and surgical approach. Denis et al5 reported that nonoperative management may be associated with neurological decline even in neurologically intact patients. More recently, however, high-quality evidence has revealed that functional outcomes in the long term may be equivalent between operative and nonoperative management, or may even be more favorable with nonoperative management, with lower complication rates in the case of neurologically intact thoracolumbar burst fractures.6–8

Nonetheless, the role of nonoperative management in the presence of neurological deficits is not yet fully understood. A challenge here is that surgical strategies, including the timing of intervention, were not standardized in most of the studies to date, which compromises our ability to draw conclusions from the literature. The primary purpose of this review article is to focus on these controversial issues and summarize the currently available evidence that addresses these clinical questions.

ROLE OF NONOPERATIVE MANAGEMENT IN THORACOLUMBAR BURST FRACTURE WITH NEUROLOGICAL DEFICITS

Nonoperative management of thoracolumbar burst fracture ranges from recumbence to bracing or body casting, with or without closed reduction. The purpose of these forms of management is to stabilize the fracture site and maximize the patient’s comfort. The duration of treatment can be up to 6 months, as reported in the previous studies. Some authors have previously suggested that severe kyphosis (>30–35 degrees) should be addressed surgically because this amount of deformity is believed to be a sign of instability. However, despite the effort to define fracture instability, no generally accepted definition is yet available. Nonsurgical management of a thoracolumbar burst fracture with disruption of the posterior ligamentous complex, significant endplate involvement, or extensive body comminution also carries the risk of posttraumatic progressive deformity, which may lead to significant pain in the long term.9 However, stable fractures may be managed nonoperatively in the context of the fracture healing process. Currently, neurological deficits are relatively widely accepted as an indication for surgery. Most surgeons choose to operate on burst fractures with neurological deficits on initial presentation, and nonoperative management is only chosen for stable, neurologically intact, or minimally impaired fractures in many centers. As a result of this preference, studies discussing the role of nonoperative management in neurological recovery are quite limited in the literature.10

However, neurological deficit is not an absolute contraindication for nonoperative management. Indeed, Mohanty and Venkatram11 reported neurological recovery in consecutive cases of nonoperatively managed thoracolumbar burst fractures. In this case series of 45 patients, 73% initially had neurological deficits after the injury (Frankel grade A to D), of which two-thirds showed neurological recovery after 3 months of recumbence in a body cast with closed reduction. Their findings also indicated that the occupancy of bony fragment in the spinal canal did not correlate with neurological recovery and discouraged surgical intervention to remove this retropulsion of the posterior wall. However, nonoperative management was indicated only in patients with minimal neurological deficits (Frankel D) in all other recent studies.12–15 Weninger et al15 reported that those with unilateral radicular pain on presentation fully recovered with closed reduction and casting, whereas the majority of patients with cauda equina syndrome suffered from persistent bladder dysfunction and did not show any neurological recovery. Similarly, Tropiano et al13 reported that among their neurologically impaired patients, only those with radicular pain fully recovered after closed reduction and those with cauda equina syndrome did not. The contemporary evidence regarding nonoperative management for thoracolumbar burst fractures with neurological deficits is summarized in Table 1.

T1
TABLE 1.:
Summary of Contemporary Evidences Regarding Nonoperative Management for Thoracolumbar Burst Fractures With Neurological Deficits

In summary, scientific evidence supporting the need for operative intervention for thoracolumbar burst fractures with neurological deficits is scarce. However, given the poor outcomes reported in the literature for nonoperative management in those with significant deficits and the reported requirement for prolonged (and in many systems unrealistically prolonged) immobilization, operative management should be considered as a first-line strategy.10,16 For those with solitary radiculopathy symptoms, nonoperative management may be justified, especially when the surgical risk outweighs the benefits. Cost and complications associated with operative management should also be taken into consideration.

DOES TIMING OF SURGERY HAVE AN IMPACT ON THE NEUROLOGICAL RECOVERY?

The timing of surgical decompression and stabilization in the setting of a thoracolumbar burst fracture is one of the most controversial topics in the management of these injuries. In the past few years, a number of studies have attempted to address the crucial but still unanswered question: does timing of surgery (early vs. late) have an effect on the clinical outcome of patients sustaining a thoracolumbar fracture, in terms of complications and neurological recovery? Early surgical intervention may have a number of benefits, including (1) earlier mobilization and faster recovery, thus reducing complications related to bed rest; (2) reduced pain and narcotics use related to spinal instability; and (3) reduced respiratory morbidity and length of stay in the intensive care unit (ICU) and in the hospital, and even reduced overall mortality. Similar questions regarding the role of early decompression in neurological recovery in the setting of a spinal cord injury (SCI) are a topic of controversy in basic science and clinical research. The traditional argument against early surgery has been the impact of the “second hit” phenomenon on various potentially associated injuries, such as the brain, lungs, and kidneys. Other disadvantages include (1) increased blood loss from underresuscitation and coagulopathy, (2) associated hypotension that might be detrimental in the setting of a SCI, and (3) operating in a nonoptimal environment with limited resources.

Most of the knowledge related to the impact of the timing of surgery on neurological recovery is derived from the literature on SCI secondary to a cervical spine injury. A retrospective study of 361 patients undergoing surgery for a spine fracture, including 160 cervical spine fractures, found a significantly higher mortality rate in patients treated less than 24 hours after injury than in those treated later than 24 hours after injury (7.6% vs. 2.5%, respectively). Most of the deaths were seen in patients with a cervical spine fracture.17 In contrast, based on multiple prospective and retrospective series, a systematic review of the literature showed that early decompression can be performed safely and may improve neurological outcomes, especially in patients with a cervical SCI.18 Similarly, the STASCIS trial—the largest prospective cohort study on this topic—demonstrated the safety and the benefit on neurological recovery of decompression before 24 hours in 313 patients presenting with a cervical SCI.19 On the basis of this evidence, the general recommendation is that surgery for a cervical SCI should be performed as soon as the patient is medically stable and ideally under 24 hours to maximize neurological recovery.

Evidence regarding the timing of decompression in the specific setting of a thoracolumbar burst fracture is much more sparse and inconsistent than evidence in the setting of cervical SCI. A number of recent retrospective and prospective cohort studies have shown that an early fixation (<24 hours to <72 hours, depending on the study) for thoracolumbar fractures with or without SCI tends to reduce the overall complication rate, hospital and ICU length of stay, number of days on a ventilator, respiratory morbidity, and infections, among other advantages.20–23 Of note, these benefits tend to be specifically increased in the setting of a thoracic injury and in cases with a high injury severity score. In a systematic review to determine whether early spinal stabilization in thoracolumbar trauma decreases morbidity and mortality, Bellabarba et al24 found that early stabilization of thoracic fractures reduced the number of days on a ventilator, the length of stay in the ICU and in hospital, and reduced respiratory morbidity. However, with the exception of the overall length of stay in the hospital, these advantages were not observed for lumbar fractures. For both thoracic and lumbar fractures, no benefit was seen on mortality. The authors concluded that an early fixation strategy (<72 hours) was beneficial for thoracic spine injuries but that evidence was weaker for lumbar injuries. Similarly, 2 other large systematic reviews25,26 found that early surgery for thoracolumbar fractures was consistently associated with fewer complications and shorter hospital and ICU stay. Unfortunately, none of these studies addressed the question of neurological recovery in relation to the timing of surgery. The contemporary evidence regarding the effects of an early fixation strategy of thoracolumbar burst fractures on nonneurological outcomes is summarized in Table 2.

T2
TABLE 2.:
Summary of Contemporary Evidence Regarding the Effect of an Early Fixation Strategy of Thoracolumbar Burst Fractures on Nonneurological Outcomes

To our knowledge, only 2, prospective, nonrandomized, cohort studies have addressed the specific outcome of neurological recovery following thoracolumbar burst fractures. One study by Bourassa-Moreau et al27 evaluated the impact of early surgical decompression (<24 hours) on neurological recovery in complete [American Spinal Injury Association (ASIA) impairment scale A] SCI. Fifty-three patients were included in the study, and 33 of them had thoracolumbar fractures. The primary end point was the improvement in ASIA score between the preoperative state and discharge from the rehabilitation center. In patients having a cervical spine injury, results showed a significantly higher rate of improvement on the ASIA score in the early decompression group as compared with the late decompression group (64% vs. 0%, respectively). However, no significant difference in the rate of neurological recovery was seen in patients with a thoracolumbar injury. The other study by Cengiz et al28 looked at the neurological outcome of patients with a thoracolumbar injury (T8–L2) with or without a SCI, following an early (<8 hours) or late (3–15 days) surgery. Patients were assessed for neurological deficits and improvement as defined by the ASIA score at discharge from the hospital or when transferring to a rehabilitation unit. Among those presenting with a SCI, the authors report a significantly higher proportion of patients demonstrating a neurological improvement in the early surgery group, although this study suffers from important methodological shortcomings and potential bias coming from the randomization process. A summary of these 2 studies is provided in Table 3.

T3
TABLE 3.:
Evidence Regarding the Effect of an Early Fixation Strategy of Thoracolumbar Burst Fractures on Neurological Recovery

Overall, the literature consistently demonstrates a benefit of early decompression and stabilization for thoracolumbar burst fractures with or without SCI in terms of the length of stay in the ICU and in hospital, respiratory morbidity, and avoidance of complications. The benefits of this strategy seem to be more clearly defined for thoracic spine injuries because these patients usually suffer from associated chest wall, lung, or other visceral or musculoskeletal injuries. Consequently, those patients might benefit to a greater extent from early stabilization and avoidance of bed rest. However, for lumbar spine injuries, the literature is less consistent regarding the benefits of an early intervention strategy on nonneurological outcomes. In terms of neurological recovery, no high-level evidence was found for thoracolumbar burst fractures, although there is evidence that decompression before 24 hours after a cervical SCI is safe and associated with improved neurological outcome.19 Therefore, the general recommendation is that surgery should be performed as soon as the patient is medically stable.

CASE PRESENTATION

A 48-year-old woman with a history of osteoporosis was transferred from a community hospital after falling on a set of stairs 48 hours ago. She initially presented in the emergency department right after the fall with worsening mid back pain, but no lower extremity symptoms. Initial lumbar spine plain x-rays (Figs. 1A, B), computed tomographic scan (Figs. 1C, D), and magnetic resonance imaging (Figs. 1E, F) showed a T12 compression fracture with a retropulsed fragment causing 40% canal compromise. There was a subtle high signal change within the spinal cord at this level, consistent with edema. On arrival at our tertiary referral center, she had dysesthetic sensation in both thighs and numbness in L1 bilaterally. The motor examination of the lower extremities revealed full power in all muscle groups, and the deep tendon reflexes were unremarkable.

F1
FIGURE 1.:
T12 burst fracture in a 48-year-old woman. Preoperative anteroposterior (A) and lateral (B) x-ray of the lumbar spine. Preoperative computed tomography (C, D) and magnetic resonance imaging (E, F). Immediate postoperative (G, H) axial and sagittal computed tomographic reconstruction. One-year and a half postoperative anteroposterior and lateral x-ray of the lumbar spine (I, J). Reproduced with permission copyright Wolters Kluwer Health.

In view of the bilateral sensory deficit associated with a severe canal compromise, the patient underwent an anterior T12 corpectomy from a left thoracoabdominal approach, followed by a reconstruction using a humeral allograft packed with local graft, and segmental instrumentation from T11 to L1. The surgery was done as an emergency case 12 hours after arrival at our hospital. Fig. 1G and H shows the postoperative axial cut through T12 and sagittal cut computed tomography of the thoracolumbar junction. She was then followed over the next year and a half, and she exhibited a complete recovery of the sensory deficit at 2 months postoperatively. Final lumbar plain x-rays (Fig. 1I, J) demonstrated a good alignment with no hardware complication and a solid fusion.

CONCLUSIONS

In conclusion, although operative management is generally recommended for thoracolumbar fracture with significant neurological deficits, evidence is weak. Nonoperative management can also be an option for those with solitary radicular symptoms. With regards to timing of operative management, high-quality studies comparing early and delayed intervention are lacking. Extrapolating from the evidence in cervical spine injury leads to an assumption that early intervention would also be beneficial for neurological recovery in these patients. Further investigation is warranted to elucidate these specific clinical questions.

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Keywords:

spine; thoracolumbar burst fractures; surgery; timing of surgery; nonoperative; treatment

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