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Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficit: A Meta-analysis

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Clinical Orthopaedics and Related Research®

Abstract

Background

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.

Purpose

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.

Methods

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.

Results

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.

Conclusions

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.

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Authors and Affiliations

  1. South West Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia

    Sonali R. Gnanenthiran MBBS, Sam Adie BSc(Med), MBBS, MSpMed MPH & Ian A. Harris MBBS, MMed(Clin Epid), PhD, FRACS(Orth)

  2. Whitlam Orthopaedic Research Centre, Liverpool Hospital, Liverpool, NSW, Australia

    Sonali R. Gnanenthiran MBBS, Sam Adie BSc(Med), MBBS, MSpMed MPH & Ian A. Harris MBBS, MMed(Clin Epid), PhD, FRACS(Orth)

  3. PO Box 906, Caringbah, NSW, 2229, Australia

    Ian A. Harris MBBS, MMed(Clin Epid), PhD, FRACS(Orth)

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  1. Sonali R. Gnanenthiran MBBS
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  2. Sam Adie BSc(Med), MBBS, MSpMed MPH
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  3. Ian A. Harris MBBS, MMed(Clin Epid), PhD, FRACS(Orth)
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Correspondence to Ian A. Harris MBBS, MMed(Clin Epid), PhD, FRACS(Orth).

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Gnanenthiran, S.R., Adie, S. & Harris, I.A. Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficit: A Meta-analysis. Clin Orthop Relat Res 470, 567–577 (2012). https://doi.org/10.1007/s11999-011-2157-7

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