Operative Compared with Nonoperative treatment of a Thoracolumbar Burst Fracture Without Neurological Deficit



J Bone and Joint Surgery 2003;85-A:773-781

To our knowledge, a prospective, randomized study comparing operative and nonoperative treatment of a thoracolumbar burst fracture in patients without a neurological deficit has never been performed. Our hypothesis was that operative treatment would lead to superior long-term clinical outcomes.

We found that operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with nonoperative treatment.

The patients who were managed with a thoracolumbosacral orthosis were placed with the spine in hyperextension to reduce the kyphosis and were fitted with a molded plaster cast that was then converted to an encompassing plastic jacket. No thigh extensions or shoulder straps were used. Patients wore the brace for twenty-four hours a day; however, they were allowed to remove it to take a shower with no bending or twisting.

The present investigation is the first prospective, randomized study, as far as we know, to compare operative and nonoperative treatment of neurologically intact patients with a burst fracture of the thoracolumbar junction (T10 to L2).

Radiographic examination demonstrated no significant differences between the two groups with respect to the fracture kyphosis on admission, after treatment, or after long-term follow-up.

A noteworthy finding was that, although no significant difference between the two groups was found with respect to the average length of hospitalization, the average charges related to hospitalization and treatment in the operative group were more than four times greater than those in the nonoperative group.

The complication rate is in agreement with those reported in numerous other studies on both operative1-4 and nonoperative treatment.5-10 Our experience, especially with the operatively treated group, may have been influenced, in some cases, by the high rate of smokers in the group (67% compared with 17% of those treated nonoperatively). However, while nine of the sixteen smokers in the operative group reported complications, seven of the eight nonsmokers also reported some form of complication.

In conclusion, we believe, on the basis of the results in the present study, that operative treatment of patients who have a stable thoracolumbar burst fracture and are neurologically intact provides no substantial benefit compared with nonoperative treatment with a cast and/or brace.


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