Comparison Between Surgical and Conservative Treatment for AOSpine Type A3 and A4 Thoracolumbar Fractures without Neurological Deficit: Prospective Observational Cohort Study

Abstract

Objective To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit.

Methods Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up.

Results Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p > 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p > 0.05), quality of life (EQ-5D), and return to work (DWS).

Conclusion Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.

Keywords

internal fixation fracture - spinal fractures - treatment outcome - conservative treatment

Financial Support

This study had financial and logistical support from AOSpine Latin America.

Multicenter work developed at the Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, PR and the Hospital Cristo Redentor, Porto Alegre, RS, Brazil.

Publication History

Received: 23 October 2021

Accepted: 28 April 2022

Article published online:
24 March 2023

• Referências

• 1 Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am 2003; 85 (05) 773-781
• 2 Jansson KA, Blomqvist P, Svedmark P. et al. Thoracolumbar vertebral fractures in Sweden: an analysis of 13,496 patients admitted to hospital. Eur J Epidemiol 2010; 25 (06) 431-437
• 3 Vaccaro AR, Oner C, Kepler CK. et al; AOSpine Spinal Cord Injury & Trauma Knowledge Forum. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine 2013; 38 (23) 2028-2037
• 4 Siebenga J, Leferink VJ, Segers MJ. et al. Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment. Spine 2006; 31 (25) 2881-2890
• 5 Post RB, van der Sluis CK, Leferink VJ, Dijkstra PU, ten Duis HJ. Nonoperatively treated type A spinal fractures: mid-term versus long-term functional outcome. Int Orthop 2009; 33 (04) 1055-1060
• 6 Vorlat P, Leirs G, Tajdar F, Hulsmans H, De Boeck H, Vaes P. Predictors of Recovery After Conservative Treatment of AO-Type A Thoracolumbar Spine Fractures Without Neurological Deficit. Spine 2018; 43 (02) 141-147
• 7 Pehlivanoglu T, Akgul T, Bayram S. et al. Conservative Versus Operative Treatment of Stable Thoracolumbar Burst Fractures in Neurologically Intact Patients: Is There Any Difference Regarding the Clinical and Radiographic Outcomes?. Spine 2020; 45 (07) 452-458
• 8 Wood KB, Buttermann GR, Phukan R. et al. 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; 97 (01) 3-9
• 9 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; (04) CD005079
• 10 Rometsch E, Spruit M, Härtl R. et al. Does Operative or Nonoperative Treatment Achieve Better Results in A3 and A4 Spinal Fractures Without Neurological Deficit?: Systematic Literature Review With Meta-Analysis. Global Spine J 2017; 7 (04) 350-372
• 11 Butler JS, Walsh A, O'Byrne J. Functional outcome of burst fractures of the first lumbar vertebra managed surgically and conservatively. Int Orthop 2005; 29 (01) 51-54
• 12 Rajasekaran S. Thoracolumbar burst fractures without neurological deficit: the role for conservative treatment. Eur Spine J 2010; 19 (Suppl. 01) S40-S47
• 13 Aebi M. Classification of thoracolumbar fractures and dislocations. Eur Spine J 2010; 19 (Suppl. 01) S2-S7
• 14 Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 2001; 26 (09) 1038-1045
• 15 Rabb CH, Hoh DJ, Anderson PA. et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Operative Versus Nonoperative Treatment. Neurosurgery 2019; 84 (01) E50-E52
• 16 Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993; 18 (08) 971-976
• 17 Bailey CS, Dvorak MF, Thomas KC. et al. 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 (03) 295-303
• 18 Bailey CS, Urquhart JC, Dvorak MF. et al. Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial. Spine J 2014; 14 (11) 2557-2564
• 19 Breivik H, Borchgrevink PC, Allen SM. et al. Assessment of pain. Br J Anaesth 2008; 101 (01) 17-24
• 20 Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983; 8 (02) 141-144
• 21 EuroQol Group. EuroQol–a new facility for the measurement of health-related quality of life. Health Policy 1990; 16 (03) 199-208
• 22 Haywood KL, Garratt AM, Fitzpatrick R. Quality of life in older people: a structured review of generic self-assessed health instruments. Qual Life Res 2005; 14 (07) 1651-1668
• 23 Denis F, Armstrong GW, Searls K, Matta L. Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment. Clin Orthop Relat Res 1984; (189) 142-149
• 24 Sadatsune DA, Costa PP, Caffaro MF, Umeta RS, Meves R, Avanzi O. Thoracolumbar burst fracture: correlation between kyphosis and function after surgical treatment. Rev Bras Ortop 2015; 47 (04) 474-478