Commentary & Perspective

Commentary & Perspective on
"Operative Compared with Nonoperative Treatment of a Thoracolumbar Burst Fracture without Neurological Deficit. A Prospective, Randomized Study"
by K. Wood, MD, et al.

Commentary & Perspective by
Frank J. Eismont, MD*,
Department of Orthopaedics and Rehabilitation,
University of Miami School of Medicine, Miami, FL

Wood et al. are to be commended for performing a prospective, randomized study comparing operative and nonoperative treatment of thoracolumbar burst fractures in patients without a neurological deficit.

On the basis of retrospective data, it was reported that as many as 20% of neurologically normal patients with burst fractures treated nonoperatively would develop neurologic deterioration¹. Clinicians at that time advocated operative treatment of most burst fractures with 20% to 25% of canal compromise. Over time, as experience suggested that certain patients who received nonoperative treatment of thoracolumbar burst fractures were not neurologically compromised, the degree of canal compromise that indicated operative treatment was raised to 30%, and then to 40%, 50%, and increasingly greater percentages. From 1988 to 1990, a prospective study was carried out at our institution² in which neurologically normal patients with stable burst fractures were treated nonoperatively regardless of the degree of canal compromise. Good results were obtained with use of thoracolumbosacral orthoses (TLSO braces) and early ambulation.

In this study, Wood et al. have further refined the evaluation of patients with burst fractures that are treated nonoperatively and also have directly compared the results of nonoperative treatment with those of operative treatment. The authors found that the results of operative treatment were not significantly better in terms of final kyphosis, improvement in canal compromise, and pain rated with a visual analog pain scale. The results were substantially better for the nonoperative group regarding final functional disability. Results in the nonoperative group were also better than those in the operative group in several other areas, which were not statistically evaluated, including return to work at six months (74% vs. 42%), cost (approximate averages of $11,000 vs. $49,000), and complications (13% of patients vs. 67% of patients). In addition, six patients in the operative group had a second operation for removal of instrumentation (Appendix).

The strength of this paper lies in the prospective and randomized study design used in the comparison of nonoperative and operative treatment of burst fractures. The enrollment of fifty-three patients and the 89% follow-up at a minimum of two years (average duration of follow-up, 44 months) is outstanding. One weakness of the study design is the unblinded final evaluations, which were performed by the treating physicians rather than by a professional unaware of the treatment rendered. Another weakness of this study is that, even though patients were prospectively randomized to either of the two treatment groups by computer, there were two persistent biases inherent in the patient demographics of the two groups. The smoking status of the patients was significantly different between the two groups, with 17% of the nonoperative group and 66% of the operative group being smokers (p less than 0.01). There was also a large difference in the number of patients covered by Workers' Compensation—4% of the nonoperative group and 29% of the operative group. (Appendix, Tables E-1 and E-2). Unfortunately, both smokers and patients who receive Workers' Compensation tend to have poorer results after most types of spine treatment, so that even though the patients were randomized in this study, there was inherent bias against surgical treatment.

Despite these criticisms, this is still an excellent study comparing the outcomes of operative and nonoperative treatment of thoracolumbar burst fractures in patients who are neurologically intact.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817-31.
2. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine. 1993;18:971-6.