Thoracolumbar Burst Fracture Without Neurologic Deficit - Rationale for Operative Treatment Albert J.M. Yee, M.D.

, MSc, FRCSC Sunnybrook Spine, Sunnybrook & Women's College Health Sciences Centre, Assistant Professor, Department of Surgery, University of Toronto Toronto, ON Like other aspects in the management of spinal trauma patients (e.g., timing of surgical decompression in spinal cord injury), there is controversy regarding operative treatment for thoracolumbar burst fracture without deficit. Advocates of nonoperative treatment cite cohort studies demonstrating good outcomes, low progression of deformity, low incidence of neurologic deterioration, progressive bony remodeling and diminution of canal compromise 4,10,13,14,17. Although some studies argue that the degree of kyphosis does not correlate to clinical outcomes, others have demonstrated a relationship between significant deformity (>30) and increased pain 6,14 . Late neurologic deterioration occurs infrequently, with rates reported between 0-3% 1,7,9,14, although in one study with poor follow-up, the incidence was 17% 3

There are several studies comparing Figure 1. What is a 'stable' burst fracture? operative versus nonoperative treatment for thoracolumbar burst fractures without neurologic deficit 11,16. In a study by Shen et al, they prospectively followed 80 patients with isolated single level thoracolumbar burst fractures without neurologic injury11. Although patients were initially randomized (n=83), there was crossover in their study (7 patients randomized to surgical group refused A. Axial CT image of B. Axial CT image of surgery and reassigned to nonsurgical Patient A Patient B group). Their surgical group (n=33) demonstrating disrupted stabilized with posterior short-segment facet joints fixation reported improved early pain relief (up to three months) and better Greenough Low Back Outcome scores to six months. The operative group reported one case of superficial infection and two cases of screw breakage. They reported some loss in kyphosis correction (mean initial correction 17) following posterior segmental fixation, however, the surgical group had a better maintenance of sagittal plane balance when compared to the nonoperative group. Functional outcome at two years was not significantly different comparing the two groups. More recently, Wood et al randomized 47 consecutive patients with what they considered 'stable' burst fractures to nonoperative or operative (anterior or posterior arthrodesis) treatment 16. Posterior or anterior arthrodesis was performed in 24 patients with an average initial fracture kyphosis of 10.1 and initial canal compromise of 39%. Significant limitations of this RCT includes the sample size (n=24 in the operative group with two different surgical approaches), and a follow-up of < 80%. The authors concluded that operative treatment provided no major long-term advantage (mean 3.5 years)

compared to nonoperative treatment. However, patients with a 'stable' fracture configuration (without significant collapse, kyphosis, or posterior element complex injury) are more likely the population where nonoperative treatment yields acceptable outcomes and the additional benefits of surgery are questionable. A valid comparison of Wood's study to that of Shen et al is difficult due to differences in inclusion criteria and patient heterogeneity as highlighted by a greater mean initial kyphosis in the study by Shen et al (21 and 23 in their nonsurgical and surgical groups, respectively) 11. Because of aforementioned study limitations, I would consider the studies of Shen and Wood to provide Class II evidence. Conceptually, conventional spinal surgery is indicated for primarily three considerations: decompression of neurologic compression, spinal stabilization, and correction (or prevention) of unacceptable deformity. As such, the arguments for operative treatment of thoracolumbar burst fracture in neurologically intact patients revolve around issues of what one would consider either stable and/or acceptable deformity (Figure 1)2. Determining the 'personality of the fracture' is important in guiding treatment decisions. My relative indications for considering operative treatment include those patients with what I consider to be 'unstable' burst fracture patterns (>50 collapse, >25-30 kyphosis, >50 canal compromise, posterior element complex injury as manifested by PLL disruption, facet fracture/joint incongruity; Figure 1B). In isolation, I do not consider a vertical laminar fracture, transverse or spinous process fractures to constitute significant posterior complex injuries 12. It is my opinion that unstable fracture patterns (e.g., Denis type D) warrant consideration for surgery to provide stability, assist with early pain relief and subsequent rehabilitation 8,15. The risk of neurologic deterioration is related in part to fracture severity with increased risk in burst fracture patterns having a component of rotation 5. In multiply injured trauma patients, surgical stabilization will obviate the need for an orthosis, assist with nursing care and potentially facilitate early mobility. If patients are managed nonoperatively, I routinely obtain initial upright lumbar spine plain films and follow patients closely over the first several weeks. If there is evidence to counter the initial conclusion of fracture 'stability' (i.e., significant progressive collapse, facet subluxation and kyphosis), I would discuss with these patients the consideration of surgical stabilization. In conclusion, it is my opinion that there are arguments to be made for the surgical treatment of thoracolumbar burst fractures in neurologically intact patients. Not all such burst fractures have the same personality and properly conducted prospective multicentre randomized studies are required to validate the current clinical notion of 'stable' versus 'unstable' burst fracture and to define which patients would benefit from early surgical intervention. References 1. Cantor J.B., Lebwohl N.H., Garvey T., and Eismont F.J. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine, 18(8): 971-6, 1993. 2. Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop, (189): 65-76, 1984. 3. Denis F., Armstrong G.W., Searls K., and Matta L. Acute thoracolumbar burst fractures

in the absence of neurologic deficit. A comparison between operative and nonoperative treatment. Clin Orthop, (189): 142-9, 1984. 4. Fidler M.W. Remodelling of the spinal canal after burst fracture. A prospective study of two cases. J Bone Joint Surg Br, 70(5): 730-2, 1988. 5. Gertzbein S.D. Neurologic deterioration in patients with thoracic and lumbar fractures after admission to the hospital. Spine, 19(15): 1723-5, 1994. 6. Gertzbein S.D. Scoliosis Research Society. Multicenter spine fracture study. Spine, 17(5): 528-40, 1992. 7. Mumford J., Weinstein J.N., Spratt K.F., and Goel V.K. Thoracolumbar burst fractures. The clinical efficacy and outcome of nonoperative management. Spine, 18(8): 955-70, 1993. 8. Okuyama K., Abe E., Chiba M., Ishikawa N., and Sato K. Outcome of anterior decompression and stabilization for thoracolumbar unstable burst fractures in the absence of neurologic deficits. Spine, 21(5): 620-5, 1996. 9. Reid D.C., Hu R., Davis L.A., and Saboe L.A. The nonoperative treatment of burst fractures of the thoracolumbar junction. J Trauma, 28(8) 1188-94, 1988. 10. Scapinelli R., and Candiotto S. Spontaneous remodeling of the spinal canal after burst fractures of the low thoracic and lumbar region. J Spinal Disord, 8(6) 486-93, 1995. 11. Shen W.J., Liu T.J., and Shen Y.S. Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine, 26(9) 1038-45, 2001. 12. Shen W.J., and Shen Y.S. Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit. Spine, 24(4) 412-5, 1999. 13. Weinstein J.N., Collalto P., and Lehmann T.R. Long-term follow-up of nonoperatively treated thoracolumbar spine fractures. J Orthop Trauma, 1(2) 152-9, 1987. 14. Weinstein J.N., Collalto P., and Lehmann T.R. Thoracolumbar "burst" fractures treated conservatively a long-term follow-up. Spine, 13(1) 33-8, 1988. 15. Willen J., Anderson J., Toomoka K., and Singer K. The natural history of burst fractures at the thoracolumbar junction. J Spinal Disord, 3(1) 39-46, 1990. 16. Wood K., Butterman G., Mehbod A., Garvey T., Jhanjee R., and Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am, 85-A(5) 773-81, 2003. 17. Yazici M., Atilla B., Tepe S., and Calisir A. Spinal canal remodeling in burst fractures of

the thoracolumbar spine a computerized tomographic comparison between operative and nonoperative treatment. J Spinal Disord, 9(5) 409-13, 1996