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Journal Club: JBJS 2015 – Operative compared with non-operative treatment of a thoracolumbar burst fracture without neurologic deficit

Wood KB, Buttermann GR, Phukan R, Harrod CC, Mehbod A, Shannon B, Bono CM,Harris MB. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am. 2015 Jan7;97(1):3-9. doi: 10.2106/JBJS.N.00226. PubMed PMID: 25568388.

Background:

  • Is some controversy over optimal management of neurologically intact burst fx.
  • This study is a long-term follow-up of a previous RCT comparing operative vs non-op treatment of neurologically intact burst fractures.
    • Previous study showed no difference between the two except increased hospital costs and risks of complications in the surgically treated group (median f/u 44 months).
  • This study examines the outcomes at 15-20 year follow-up. Hypothesis is will be no difference between the groups

Methods

  • RCT- 47 patients enrolled between 1992 and 1998 and randomized to non-op tx with cast or brace or operative treatment.
    • Inclusion criteria- 18-66 years with burst fracture of TL region (T10-L2) on imaging, no neurologic compromise, presenting within 3 weeks of injury, no medical problems (including cancer, infection, bleeding disorder, or skin disease) that would prohibit one treatment over the other. Patients could have other compression fx’s and be enrolled as long as the compression fractures did not require treatment
    • Unblinded study
  • Patients treated with 1-5 days of bed rest followed by:
    • Non-op group- cast for 8 weeks and orthosis for 4 weeks or orthosis for 12 weeks
    • Operative group- posterior short segment fusion or anterior fibular and rib strut arthrodesis with lateral instrumentation
  • Radiographic characteristics of the fracture as well as work status, medication use, and other spine issues were collected. At 2,4, and 16022 yr follow-up, VAS score, Rolland and Morris questionnaire, Oswestry index, and SF 36 scores collected

Results:

  • 78-79% follow-up at mean of 18.6 years. Operative and non-operative groups were similar in characteristics
  • Average kyphosis of operatively treated group was 13 deg (5-42). No correlation between amount of kyphosis and results on validated indices. Average kyphosis for non-op group was 19 deg (10-29). No correlation between kyphosis and pain or function
  • 64% of operative patients and 70% of non-operative patients had degenerative finding to the segment immediately caudal to the involved segment at final follow-up (no significant difference). 75% of operative patients and 55% of non-op patients had extension of disc degeneration further to other caudal segments (significant difference)
  • At final long-term follow-up, operatively treated patients had significantly higher VAS scores (4 vs 1.5), Rolland and Morris scores (7 vs 1), Oswestry (20 v 2), and 6 of the 8 SF 36 categories.
    • Operative groups had no change in scores over the years while non-op group had significant improvement in Roland and Morris scores.
  • No neuro deficits in either group. 47% of operative group vs 72% of non-op group were working at final follow-up. 3 operative patients and no non-operative patients were taking regular narcotics

Strengths

  • Randomized trial with long-term follow-up and accepted loss of follow-up. Use of validated measures and radiographs

Weaknesses

  • May have been underpowered with loss of some patients to truly detect differences in pain and disability between groups

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