<b>BACKGROUND: </b>To our knowledge, a prospective, randomized study comparing operative and nonoperative treatment of a thoracolumbar burst fracture in patients without a neurological deficit has never been performed. Our hypothesis was that operative treatment would lead to superior long-term clinical outcomes.<b>METHODS: </b>From 1994 to 1998, forty-seven consecutive patients (thirty-two men and fifteen women) with a stable thoracolumbar burst fracture and no neurological deficit were randomized to one of two treatment groups: operative (posterior or anterior arthrodesis and instrumentation) or nonoperative treatment (application of a body cast or orthosis). Radiographs and computed tomography scans were analyzed for sagittal alignment and canal compromise. All patients completed a questionnaire to assess any disability they may have had before the injury, and they indicated the degree of pain at the time of presentation with use of a visual analog scale. The average duration of follow-up was forty-four months (minimum, twenty-four months). After treatment, patients indicated the degree of pain with use of the visual analog scale and they completed the Roland and Morris disability questionnaire, the Oswestry back-pain questionnaire, and the Short Form-36 (SF-36) health survey.<b>RESULTS: </b>In the operative group (twenty-four patients), the average fracture kyphosis was 10.1 degrees at the time of admission and 13 degrees at the final follow-up evaluation. The average canal compromise was 39% on admission, and it improved to 22% at the final follow-up examination. In the nonoperative group (twenty-three patients), the average kyphosis was 11.3 degrees at the time of admission and 13.8 degrees at the final follow-up examination after treatment. The average canal compromise was 34% at the time of admission and improved to 19% at the final follow-up examination. On the basis of the numbers available, no significant difference was found between the two groups with respect to return to work. The average pain scores at the time of the latest follow-up were similar for both groups. The preinjury scores were similar for both groups; however, at the time of the final follow-up, those who were treated nonoperatively reported less disability. Final scores on the SF-36 and Oswestry questionnaires were similar for the two groups, although certain trends favored those treated without surgery. Complications were more frequent in the operative group.<b>CONCLUSION: </b>We found that operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with nonoperative treatment.
STUDY DESIGN: A prospective clinical trial was conducted.
OBJECTIVE: To compare the results of nonoperative treatment versus short-segment posterior fixation using pedicle screws.
SUMMARY OF BACKGROUND DATA: A previous study showed that nonoperative treatment with early mobilization produced good results, even when the posterior column was involved.
METHODS: This study involved 80 patients. Inclusion criteria required the following: neurologically intact patient, single-level closed burst fracture involving T11-L2, no fracture dislocations or pedicle fractures, age of 18 to 65 years (nonpathologic adult), and no other major organ system or musculoskeletal injuries. Patients in the nonoperative group (n = 47) were allowed activity to the point of pain tolerance beginning on the day of injury using a hyperextension brace. Patients in the operative group (n = 33) underwent three-level, (one above, one at fracture level, and one below) fixation using VSP or TSRH instrumentation. The follow-up period was 2 years.
RESULTS: The surgical group had less pain up to 3 months and a better Greenough Low Back Outcome Score up to 6 months, but the outcome was similar afterward. No neurologic deficit in any patient. In the nonoperative group, the kyphosis angle worsened by 4 degrees, and the retropulsion decreased from 34% to 15%. In the operative group, there was one case of superficial infection and two cases of broken screws. The kyphosis angle was improved initially by 17 degrees, but this was gradually lost. Hospital charges were four times higher in the operative group.
CONCLUSIONS: Short-segment posterior fixation provides partial kyphosis correction and earlier pain relief, but the functional outcome at 2 years is similar. Early activity to the point of pain tolerance can be safely allowed.
BACKGROUND: Both surgery and recumbency have been adopted in the treatment of spinal fractures. Herein we present the indications for each, and our experience with thoracolumbar junction (T12, L1 and L2) burst fractures.
METHODS: Sixty-eight patients with thoracolumbar burst fractures were treated operatively in 36 cases, and nonoperatively in 32 with recumbency for 1-6 weeks. Treatment was based on clinical and radiological criteria. Eighty-one percent of the recumbency patients, but only 14% of the surgical patients were intact on admission. Patients were followed for a mean+/-SD of 9+/-10 months in the recumbency group, and 21+/-21 months in the surgical group.
RESULTS: Neurological improvement and progressive angular deformity occurred in both groups. The cost of recumbency in our patients was nearly half that of those who required surgery, though the length of hospitalization between the two groups was similar at 1 month +/-2 weeks.
CONCLUSION: The above study emphasizes that the selection of operative versus nonoperative treatment in burst fractures should not be random but based on clinical as well as radiological criteria. Recumbency is favored in patients who are intact, with angular deformity less than 20 degrees , a residual spinal canal greater than 50% of normal, and an anterior body height exceeding 50% of the posterior height. Surgical intervention is generally indicated in patients with partial neurological deficit, and those with severe instability.
