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Nonoperative Management in Neurologically Intact Thoracolumbar Burst Fractures

Clinical and Radiographic Outcomes

Hitchon, Patrick W. MD; Abode-Iyamah, Kingsley MD; Dahdaleh, Nader S. MD; Shaffrey, Christopher MD; Noeller, Jennifer ARNP; He, Wenzhuan MD; Moritani, Toshio MD

doi: 10.1097/BRS.0000000000001253

Study Design. Retrospective cohort study.

Objective. The identification of factors that lead to the failure of nonoperative management in neurologically intact thoracolumbar burst fractures.

Summary of Background Data. The treatment of thoracolumbar burst fractures (TLBF) can be controversial, particularly in the neurologically intact. Surgery for intact burst fractures has been advocated for early mobilization and a shorter hospital stay. These goals, however, have not always been achieved, rejuvenating an interest in nonoperative treatment.

Methods. Sixty-eight neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2), and a thoracolumbar injury classification and severity score (TLICS) of 2, were treated at our institution. Based on CT scans, patients were scored based on the load-sharing classification (LSC) scale. Initial treatment consisted of bracing in clamshell thoracolumbar orthosis and gradual mobilization.

Results. Owing to pain limiting mobilization, 18 patients failed nonoperative management and required instrumentation. Those who failed nonsurgical management were significantly more kyphotic (8°±10) and stenotic (52% ± 14%) than those successfully treated nonoperatively (3°±7 and 63 ± 12%, respectively). The LSC score of those undergoing surgery (6.9 ± 1.1) was also greater than those successfully treated nonoperatively (5.8 ± 1.3, P = 0.006). Length of hospitalization was longer, and hospital charges higher in those requiring surgery compared to the nonoperative group. At follow-up there was no difference between groups in the visual analog score for pain (VAS) or the Oswestry disability index.

Conclusion. Owing to pain limiting mobilization, a quarter of neurologically intact patients with thoracolumbar burst fractures and a TLICS score of 2 failed nonsurgical management. The greater the kyphosis, stenosis, and fragmentation of the fracture, the more likely patients required surgery. In addition to the TLICS classification, other radiographic and clinical parameters should be included in selecting appropriate treatment strategy. The cost savings with nonoperative treatment of intact burst fractures, when appropriate, are significant.

Level of Evidence: 3

*Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA

Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL

Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA

§Department of Neurology & Neurosciences, Rutgers-New Jersey Medical School, Newark, NJ

Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA.

Address correspondence and reprint requests to Patrick W. Hitchon, MD, Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, 1826 JPP, Iowa City, IA; E-mail:

Received 22 April, 2015

Revised 28 July, 2015

Accepted 11 September, 2015

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, employment, expert testimony, grants, patents, royalties, stocks.

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