Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit

  • Review
  • Intervention

Authors


Abstract

Background

Spinal burst fractures result from the failure of both the anterior and the middle columns of the spine under axial compression loads. Conservative management is through bed rest, and immobilization with a brace once the acute symptoms have settled. Surgical treatment involves either anterior or posterior stabilization of the fracture with screws, often with decompression, an operation to remove bone fragments which have intruded into the vertebral canal.

Objectives

To compare operative with non-operative treatment for thoracolumbar burst fractures without neurological deficit.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (May 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005), MEDLINE (January 1966 to April 2005), EMBASE (January 1988 to April 2005), and the Chinese Biomedical Literature Database (CBM) available at http://cbm.imicams.ac.cn (January 1978 to April 2005). We also searched reference lists of articles, handsearched journals and conference proceedings, and contacted authors where necessary.

Selection criteria

Randomized controlled trials (RCTs) comparing operative with non-operative treatment of thoracolumbar burst fractures without neurological deficit.

Data collection and analysis

Two review authors assessed trial quality and extracted data independently. Pooling of data was not carried out as only one small, poor quality trial was included.

Main results

We included one trial comparing operative with non-operative treatment (53 participants).

There was no statistically significant difference in pain and function-related outcomes, rates of return to work, radiographic findings or average length of hospitalization at final follow up. The rate of complications was higher for the patients treated operatively. The degree of kyphosis or the percentage of correction lost did not correlate with any clinical symptoms at the time of the final follow up. Average costs related to hospitalization and treatment in the operative group appeared to be more than in the non-operative group.

Authors' conclusions

There was no statistically significant difference on the functional outcome two years or more after therapy between operative and non-operative treatment for thoracolumbar burst fractures without neurological deficit. However, this review was able to include only one randomized controlled trial with a small sample size and poor quality, which precluded firm conclusions. More research with high quality trials is needed.

Plain language summary

Comparing conservative treatment with surgery for people with fractures of the spine where fragments of fractured thoracolumbar vertebral bodies have protruded into the vertebral canal but not caused any obvious nerve damage

The thoracolumbar vertebral column (T11 to L2) is a common site of spinal injury. Motor vehicle accidents are the commonest cause of injury, followed by falls and sports-related injuries. Fractures can be associated with acute back pain, limited motion, and swelling at the fracture site. Pain may not be felt immediately but may begin hours later. If the nerve root or spinal cord is damaged, partial or complete loss of sensory and motor function in the legs, urinary and fecal incontinence may result. Although many injuries do not cause paralysis they may leave an unstable spinal segment and later paralysis. People are treated in hospital either conservatively by being placed in a lying position that reduces strain on that part of the spine followed by fitting a cast or brace and moving around or by surgically placing instrumentation with screws to stabilize the affected part of the spine. The review authors found only one trial from the US in which 53 adults with stable thoracolumbar burst fracture were randomized to either wearing a body cast or undergoing surgery. The people treated conservatively had less pain one to two years later at the last follow-up examination. There was no difference between the two treatment strategies in the number of people returning to work or with respect to a hunching deformity of the back. The average duration of hospitalization was not significantly different between groups although the average charges related to hospitalization and treatment was more in the surgery group and rate of complications was higher. This review was limited by only one small trial being available for stable burst fractures.

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