Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficit: A Meta-analysis
- First Online:
Decision-making regarding nonoperative versus operative treatment of patients with thoracolumbar burst fractures in the absence of neurologic deficits is controversial. Lack of evidence-based practice may result in patients being treated inappropriately and being exposed to unnecessary adverse consequences.
Using meta-analysis, we therefore compared pain (VAS) and function (Roland Morris Disability Questionnaire) in patients with thoracolumbar burst fractures without neurologic deficit treated nonoperatively and operatively. Secondary outcomes included return to work, radiographic progression of kyphosis, radiographic progression of spinal canal stenosis, complications, cost, and length of hospitalization.
We searched MEDLINE, EMBASE®, and the Cochrane Central Register of Controlled Trials for ‘thoracic fractures’, ‘lumbar fractures’, ‘non-operative’, ‘operative’ and ‘controlled clinical trials’. We established five criteria for inclusion. Data extraction and quality assessment were in accordance with Cochrane Collaboration guidelines. The main analyses were performed on individual patient data from randomized controlled trials. Sensitivity analyses were performed on VAS pain, Roland Morris Disability Questionnaire score, kyphosis, and return to work, including data from nonrandomized controlled trials and using fixed effects meta-analysis. We identified four trials, including two randomized controlled trials consisting of 79 patients (41 with operative treatment and 38 with nonoperative treatment). The mean followups ranged from 24 to 118 months.
We found no between-group differences in baseline pain, kyphosis, and Roland Morris Disability Questionnaire scores. At last followup, there were no between-group differences in pain, Roland Morris Disability Questionnaire scores, and return to work rates. We found an improvement in kyphosis ranging from means of 12.8º to 11º in the operative group, but surgery was associated with higher complication rates and costs.
Operative management of thoracolumbar burst fractures without neurologic deficit may improve residual kyphosis, but does not appear to improve pain or function at an average of 4 years after injury and is associated with higher complication rates and costs.
Level of Evidence
Level II, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.
- 3.Aligizakis A, Katonis P, Stergiopoulos K, Galanakis I, Karabekios S, Hadjipavlou A. Functional outcome of burst fractures of the thoracolumbar spine managed non-operatively, with early ambulation, evaluated using the load sharing classification. Acta Orthop Belg. 2002;68:279–287.PubMedGoogle Scholar
- 7.Bailey CS, Dvorak MF, Thomas KC, Boyd MC, Paquett S, Kwon BK, France J, Gurr KR, Bailey SI, Fisher CG. Comparison of thoracolumbosacral orthosis and no orthosis for the treatment of thoracolumbar burst fractures: interim analysis of a multicenter randomized clinical equivalence trial. J Neurosurg Spine. 2009;11:295–303.PubMedCrossRefGoogle Scholar
- 15.Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]. In Higgins JP, Green S, eds. West Sussex, England: The Cochrane Collaboration; 2008.Google Scholar
- 37.Oprel PP, Tuinebreijer WE, Patka P, den Hartog D. Combined anterior-posterior surgery versus posterior surgery for thoracolumbar burst fractures: a systematic review of the literature. Open Orthop J. 2010;4:93–100.Google Scholar
- 41.Sasso RC, Cotler HB. Posterior instrumentation and fusion for unstable fractures and fracture-dislocations of the thoracic and lumbar spine: a comparative study of three fixation devices in 70 patients. Spine (Phila Pa 1976). 1993;18:450–460.Google Scholar
- 45.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;31:2881–2890.CrossRefGoogle Scholar
- 55.Yi L, Jingping B, Gele J, Baoleri X, Taixiang W. Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit. Cochrane Database Syst Rev. 2006;Oct 18(4):CD005079.Google Scholar