Operative versus non-operative treatment for thoracolumbar

burst fractures without neurological deficit (Review)

Yi L, Jingping B, Gele J, Wu T, Baoleri X

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2006, Issue 4
http://www.thecochranelibrary.com

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) i
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Operative versus non-operative treatment for thoracolumbar

burst fractures without neurological deficit

Liao Yi1 , Bai Jingping2 , Jin Gele3, Taixiang Wu4 , XiLin Baoleri5
1 Department of Orthopaedics, The Kelamayi City Central Hospital of Xin Jiang, Kelamayi, China. 2 Department of Orthopaedics,

The Third Affiliated Hospital of Xin Jiang Medical University, Urumqi, China. 3 Department of Orthopaedics, The First Affiliated
Hospital of Xin Jiang Medical University, Urumqi, China. 4 Chinese Cochrane Centre, Chinese EBM Centre, West China Hospital,
Sichuan University, Chengdu, China. 5 Department of Orthopaedics, The Second Affiliated Hospital of Xin Jiang Medical University,
Urumqi, China

Contact address: Liao Yi, Department of Orthopaedics, The Kelamayi City Central Hospital of Xin Jiang, Kelamayi, Xin Jiang, 834000,
China. liaoyi6233005@yahoo.com.cn. liaoyi6233005@hotmail.com.

Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 10 August 2006.

Citation: Yi L, Jingping B, Gele J, Wu T, Baoleri X. Operative versus non-operative treatment for thoracolumbar burst
fractures without neurological deficit. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005079. DOI:
10.1002/14651858.CD005079.pub2.

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
Background
Spinal burst fractures result from the failure of both the anterior and the middle columns of the spine under axial compression loads.
Conservative management is through bed rest, and immobilization with a brace once the acute symptoms have settled. Surgical treatment
involves either anterior or posterior stabilization of the fracture with screws, often with decompression, an operation to remove bone
fragments which have intruded into the vertebral canal.
Objectives
To compare operative with non-operative treatment for thoracolumbar burst fractures without neurological deficit.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (May 2005), the Cochrane Central Register of
Controlled Trials (The Cochrane Library Issue 2, 2005), MEDLINE (January 1966 to April 2005), EMBASE (January 1988 to April
2005), and the Chinese Biomedical Literature Database (CBM) available at http://cbm.imicams.ac.cn (January 1978 to April 2005).
We also searched reference lists of articles, handsearched journals and conference proceedings, and contacted authors where necessary.
Selection criteria
Randomized controlled trials (RCTs) comparing operative with non-operative treatment of thoracolumbar burst fractures without
neurological deficit.
Data collection and analysis
Two review authors assessed trial quality and extracted data independently. Pooling of data was not carried out as only one small, poor
quality trial was included.
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 1
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results

We included one trial comparing operative with non-operative treatment (53 participants).

There was no statistically significant difference in pain and function-related outcomes, rates of return to work, radiographic findings
or average length of hospitalization at final follow up. The rate of complications was higher for the patients treated operatively. The
degree of kyphosis or the percentage of correction lost did not correlate with any clinical symptoms at the time of the final follow up.
Average costs related to hospitalization and treatment in the operative group appeared to be more than in the non-operative group.

Authors’ conclusions

There was no statistically significant difference on the functional outcome two years or more after therapy between operative and non-
operative treatment for thoracolumbar burst fractures without neurological deficit. However, this review was able to include only one
randomized controlled trial with a small sample size and poor quality, which precluded firm conclusions. More research with high
quality trials is needed.

PLAIN LANGUAGE SUMMARY

Comparing conservative treatment with surgery for people with fractures of the spine where fragments of fractured thoracolum-
bar vertebral bodies have protruded into the vertebral canal but not caused any obvious nerve damage

The thoracolumbar vertebral column (T11 to L2) is a common site of spinal injury. Motor vehicle accidents are the commonest cause of
injury, followed by falls and sports-related injuries. Fractures can be associated with acute back pain, limited motion, and swelling at the
fracture site. Pain may not be felt immediately but may begin hours later. If the nerve root or spinal cord is damaged, partial or complete
loss of sensory and motor function in the legs, urinary and fecal incontinence may result. Although many injuries do not cause paralysis
they may leave an unstable spinal segment and later paralysis. People are treated in hospital either conservatively by being placed in
a lying position that reduces strain on that part of the spine followed by fitting a cast or brace and moving around or by surgically
placing instrumentation with screws to stabilize the affected part of the spine. The review authors found only one trial from the US in
which 53 adults with stable thoracolumbar burst fracture were randomized to either wearing a body cast or undergoing surgery. The
people treated conservatively had less pain one to two years later at the last follow-up examination. There was no difference between the
two treatment strategies in the number of people returning to work or with respect to a hunching deformity of the back. The average
duration of hospitalization was not significantly different between groups although the average charges related to hospitalization and
treatment was more in the surgery group and rate of complications was higher. This review was limited by only one small trial being
available for stable burst fractures.

BACKGROUND L2) is a common site of spinal injury (Denis 1983; McEvoy 1985).
Spinal burst fractures result from failure of both the anterior and It forms a transition zone between the relatively fixed and kyphotic
the middle columns of the spine under axial compression loads, thoracic spine above, and the relatively mobile and lordotic lum-
frequently associated with flexion loading. In the three column bar spine below, which causes stress force to concentrate upon the
theory of spinal stability (Denis 1983), the anterior column is thoracolumbar vertebral column, and predisposes this area to in-
composed of the anterior half of the vertebral body and its adjacent jury (Gertzbein 1992). Motor vehicle accidents are the commonest
soft tissue complex; the middle column consists of the posterior cause of injury, followed by falls and sports-related injuries (Price
half of the vertebral body and soft tissue complex; and the poste- 1994). Thoracolumbar burst fractures account for up to 17% of
rior column is formed by the osseous and ligamentous structures major spinal fractures (Denis 1983). Males are at four times higher
posterior to the vertebral body. risk than females. Other organ system injuries occur in up to 50%
of thoracolumbar trauma patients (Purcell 1981; Weinstein 1988).
The thoracolumbar region, which comprises the eleventh and High-energy injuries associated with paraplegia have a 7% first-
twelfth thoracic, and first and second lumbar vertebrae (T11 to
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 2
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
year mortality rate (Shikata 1990). The incidence of neurological
deficit resulting from thoracolumbar burst fractures is estimated
to be 50% to 60% (Denis 1983; McEvoy 1985).
The clinical features of thoracolumbar fracture include acute back
pain, limited motion, and swelling at the fracture site. Pain may
not be felt immediately, and may begin hours after the injury.
Damage to the nerve root and/or spinal cord from protruding
fragments of vertebral body may result in partial loss of sensory
and motor function in the lower extremity, or in cases of severe
disruption, may produce full paralysis, urinary and fecal inconti-
nence and permanent neurological injury. Characteristic radiolog-
ical findings of the fractures include moderate to marked anterior
wedging of the vertebral body, an increased interpedicular distance
and narrowing of the spinal canal as a result of displacement of
vertebral body fragments. Although many thoracolumbar spinal
injuries do not result in paralysis, they may leave an unstable spinal
segment due to disruption of bony elements and soft tissues. Late
paralysis may result from the residual instability (Denis 1983).
Denis 1983 proposed a classification of thoracolumbar fractures
into four types, based on the three column theory.
(1) Simple anterior wedge/compression fracture.
(2) Burst fracture.
(3) Flexion-distraction injury/seat belt injury.
(4) Fracture-dislocation.
Burst fractures were sub-divided into five fracture patterns.
(1) Fracture of both end plates.
(2) Fracture of the superior end plate (the most common).
(3) Fracture of the inferior end plate (rare).
(4) Burst rotation.
(5) Burst lateral flexion.
In addition, Denis 1983 defined three patterns of instability: first
degree (mechanical), second degree (neurological), or third degree
(mechanical and neurological).
Management options
The goals of treatment for thoracolumbar burst fractures are to
obtain early patient mobilization and a painless, balanced, stable
vertebral column with maximum spine mobility and optimal neu-
rological function (Eskenazi 2000). Basing on the mode and grade
of injury associated with the clinical manifestation, management
strategies include, but are not limited to, the following: (1) con-
servative (non-operative) therapy, (2) isolated posterior stabiliza-
tion (with or without decompression), and (3) isolated anterior
decompression and stabilization (Resnick 1998).
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Non-operative treatments include recumbent bed rest and pos-
tural reduction, followed by casting/bracing with early ambula-
tion. In the traditional conservative management of unstable tho-
racolumbar injuries the patient was confined to bed with great
attention paid to lordotic posture for as long as six to eight weeks
followed by gradual mobilization (Bedbrook 1975). However, this
regimen resulted in mortality rates as high as 90% (Bedbrook
1975). Holdsworth 1970 recommended postural reduction of the
deformity which resulted from the burst fracture, followed by hy-
perextension casting and patient mobilization. This brought on
significantly improved morbidity and mortality rates. Postural re-
duction can produce an indirect decompression of the spinal canal,
and a well-fitted cast or orthosis also may maintain reduction and
prevent deformity, while late neurologic deterioration is uncom-
mon (Cantor 1993; Chow 1996).
Two surgical approaches, posterior and anterior, have been em-
ployed to reduce and stabilize thoracolumbar fractures. Two tech-
niques have utilized the posterior approach. Isolated posterior re-
duction and stabilization (Dickson 1978), using the Harrington
distraction rod system, demonstrated that this technique produced
restoration of vertebral height at the injured level, reduction of
the kyphosis, and spinal canal clearance to some degree. However,
the instrumentation had some drawbacks. It required fixation two
levels caudal (lower) and three levels cephalad (higher) than the
fracture. In addition, it offered only semirigid fixation, thus sup-
plemental external support was often necessary. Over the past ten
and more years, pedicle screw systems have become popular as a
treatment for thoracolumbar burst fractures. They provide rigid,
three-column fixation, and only apply instrumentation to one or
two motion segments. Short segment fixation reduces operative
time and the bulk of internal fixation material, and preserves max-
imal motion of the vertebral column (McKinley 1997). However,
short-segment transpedicular fixation of thoracolumbar burst frac-
tures has been associated with an unacceptable rate of failure, in-
cluding progressive kyphosis, and screw breakage (McLain 1993).
Since it is the anterior and middle columns of the vertebrae which
are mainly involved in thoracolumbar burst fractures, others (Esses
1990; Gertzbein 1992; Okuyama 1996) have argued that anterior
surgery could produce a more complete and reliable decompres-
sion of the canal, and a biomechanically sound reconstruction,
with rigid stabilization that allows early rehabilitation, return to
work, and gainful employment. However, the anterior approach
requires more sophisticated surgical technique. Compared with
the posterior approach, there may be additional adverse effects
such as increased blood loss, prolonged operative and anaesthetic
time, and surgically-induced disturbance of urinary function.
In the last two decades, surgical intervention has largely replaced
conservative treatment in cases of thoracolumbar burst fractures
with neurological deficit. However, there is controversy regarding
treatment for thoracolumbar burst fracture without neurological
deficit (Okuyama 1996). Advocates of conservative treatment cite
cohort studies demonstrating good outcomes, low progression of
3
deformity, less back pain, satisfactory work status, low incidence
of neurological deterioration, progressive bony remodeling and
diminution of canal compromise (Cantor 1993; Chow 1996;
Weinstein 1988). Although some studies argue that the degree
of kyphosis does not correlate to clinical outcomes, others have
demonstrated a relationship between significant deformity (> 30
degrees) and increased pain (Gertzbein 1992; Weinstein 1988).
Although in one study of nonsurgical treatment with poor follow
up, the incidence of late neurological deterioration was 17% (
Denis 1984), others have reported much lower rates between 0%
and 3% (Cantor 1993; Chow 1996; Weinstein 1988).
In conclusion, the decision to treat thoracolumbar burst frac-
tures without neurological deficit operatively or non-operatively
remains controversial. Thus, a systematic review of randomized
controlled trials comparing different methods of treatment for
patients with thoracolumbar burst fractures without neurological
deficit is justified.
OBJECTIVES
To compare the outcomes of non-operative compared with oper-
ative treatment for thoracolumbar burst fractures without neuro-
logical deficit.
METHODS
Criteria for considering studies for this review
Types of studies
Randomized controlled trials and quasi-randomized trials com-
paring non-operative with operative treatment of thoracolumbar
burst fractures without neurological deficit.
Types of participants
Any adult, aged 18 or over, with a radiologically confirmed, re-
cent (less than three weeks) thoracolumbar burst fracture without
neurological deficit.
Types of interventions
Known conservative treatments including recumbency, postural
reduction followed by casting or bracing, and early ambulation.
The comparators were operative treatment, which was either iso-
lated posterior stabilization (with or without decompression), or
isolated anterior decompression and stabilization.
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Types of outcome measures
Primary outcomes
• Proportion of patients who recovered according to self and/
or a clinician’s assessment (e.g. pain assessed by visual analogue
scale (VAS)).
• Proportion of patients who had an improvement in
function measured on a disability or quality of life scale (e.g.
Oswestry Disability Scale and/or Roland Disability Scale).
• Return to work.
• Economic data as available.
• Rate of subsequent surgery.
• The rate of complications: (1) fatal, (2) life threatening, (3)
neurological deterioration, (4) decubitus ulcers, (5) infection, (6)
implant failure.
Secondary outcomes
• Sagittal plane kyphosis.
• The sagittal balance of the patient.
• The degree of canal compromise.
• Correlation between the final amount of kyphosis/canal
compromise and the pain reported or disability.
• The mean duration of hospitalization.
Search methods for identification of studies
We searched the Cochrane Bone, Joint and Muscle Trauma Group
Specialized Register of trials (May 2005), the Cochrane Cen-
tral Register of Controlled Trials (The Cochrane Library Issue 2,
2005), MEDLINE (January 1966 to April 2005), EMBASE (Jan-
uary 1988 to April 2005), and the Chinese Biomedical Literature
Database (CBM) available at http://cbm.imicams.ac.cn (January
1978 to April 2005), and references lists of articles. No language
restrictions was applied. The search concluded in May 2005.
In MEDLINE (OVID) a subject-specific search was combined
with the optimal trial search strategy (Higgins 2005a) (see
Appendix 1), and modified for use in The Cochrane Library
(see Appendix 2), EMBASE (see Appendix 3), and the Chinese
Biomedical Literature database (see Appendix 4).
We handsearched the following conference proceedings: the Amer-
ican Orthopaedic Association Annual Meeting (from 1999 to
2004), North American Spine Society Annual Meeting (from 2000
to 2004), Orthopaedic Trauma Association Annual Meeting (from
1999 to 2004), American Academy of Orthopaedic Surgeons An-
nual Meeting (from 1999 to 2004), final programmes of SICOT
(1996, 1999 and 2002), the British Orthopaedic Association An-
nual Congress (from 2002 to 2004), The International Society
for the Study of the Lumbar Spine and The Spine Society of Aus-
tralia 2004 to 2005: http://abstracts.spinejournal.com (accessed
4
08 June 2006). We also handsearched the following Chinese jour-
nals: Chinese Journal of Traumatology (from 1985 to May 2005),
the Journal of Cervicodynia & Lumbodynia (from 1980 to May
2005), and the China Journal of Orthopaedics and Traumatology
(from 1987 to May 2005).
We tried to identify ongoing and unpublished trials by searching
the following databases: Current Controlled Trials (http://con-
trolled-trials.com), the UK National Research Register (Issue 2,
2005 at http://www.update-software.com/national/search.htm),
Clinical Trials.gov (http://clinicaltrials.gov), and by contact with
authors of relevant trials.
Data collection and analysis
Study selection
Liao Yi (LY) scanned the results of the search, and retrieved the
full articles, for all potentially relevant trials. LY and Bai Jingping
(BJ) independently assessed each of these trials for inclusion and
scrutinized each trial report for multiple publications from the
same data set. We resolved any disagreement through discussion.
We excluded studies that did not meet the inclusion criteria and
stated the reason in the ’Characteristics of excluded studies’ table.
Assessment of methodological quality
LY, BJ, WT, JG and XL assessed the methodological quality of
each trial in terms of generation of allocation sequence, allocation
concealment, blinding, and loss to follow up. For each trial, we
classed each quality components as ’adequate’, ’inadequate’, or
’unclear’ according to Juni 2001. Based on these criteria, studies
were subdivided into one of the following three categories:
A (low risk of bias) - all quality criteria met adequately.
B (moderate risk of bias) - one or more of the quality criteria partly
met.
C (high risk of bias) - one or more of the criteria met inadequately
or not used.
We have displayed this information in an Additional Table (see
Table 1).
Data extraction
LY and BJ independently extracted data using a piloted data ex-
traction form. We extracted data on study characteristics including
methods, participants, interventions, and outcomes. We resolved
any disagreements by referring to the trial report and through dis-
cussion. If data from the trial reports were insufficient or missing,
we contacted the authors for additional information.
Where possible we would extract data to allow an intention-to-
treat analysis (the analysis should include all the participants in the
groups to which they were originally randomly assigned). If the
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
number randomized and the numbers analyzed were inconsistent,
we would calculate the percentage lost to follow up and reported
this information in an additional table. For binary outcomes, we
would record the number of participants experiencing the event in
each group of the trial. For continuous outcomes, for each group
we would extract the arithmetic means and standard deviations.
Data analysis
We planned to pool data from trials if they were sufficiently simi-
lar i.e. we would not combine results of trials with different com-
parator operative treatments. However, as only one RCT met the
criteria we provide a descriptive summary only.
If enough suitable trials for meta-analysis become available in the
future, we will use the following approach:
We will analyze the data using Review Manager (RevMan). We
will compare outcome measures for binary data using relative risks
and we will use the weighted mean difference for continuous data.
Heterogeneity will be tested for using the chi squared statistic, with
significance being set at P < 0.10, and the I2 statistic where a value
greater than 50% may be considered substantial heterogeneity
(Higgins 2003).
Where it is appropriate to pool data but heterogeneity is detected,
we will use the random-effects model. We will explore the potential
sources of heterogeneity using subgroup and sensitivity analyses
as described below. Potential bias will be tested for using the fun-
nel plot or other corrective analytical methods depending on the
number of clinical trials included in the systematic review (Egger
1997).
Subgroup analyses
We would aim to perform subgroup analyses in order to explore
effect size differences in relation to the the type of intervention
and timing.
Reasons for heterogeneity in studies would be explored and, if
necessary, sensitivity analyses would examine the effects of exclud-
ing study subgroups, e.g. those studies with lower methodological
quality.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
Three reports of trials were identified, two in MEDLINE, and
one in The Cochrane Library (the Cochrane Central Register of
Controlled Trials). One was excluded due to methodological flaws
(Shen 2001) (see ’Characteristics of excluded studies’ table). The
5
remaining two reports related to the same trial (Wood 2003) which
was included. This trial compared operative (posterior or ante-
rior arthrodesis and instrumentation) with non-operative treat-
ment (application of a body cast or orthosis) (53 participants) (see
’Characteristics of included studies’ table for details).
Risk of bias in included studies
The randomization method in Wood 2003 is described as a “com-
puter-generated randomization process”. Allocation concealment
and blinding was unclear. Loss to follow up was described in detail,
and the rate was 11% (6/53). However, intention-to-treat analysis
was not used. The methodological quality of the study is therefore
at moderate risk of bias (Higgins 2005b).
Effects of interventions
The included trial contained 53 participants assigned randomly
to the operative or non-operative group; 26 received surgical treat-
ment and 27 were managed conservatively. The operative group
were treated with posterior or anterior arthrodesis and instrumen-
tation, while the non-operative intervention involved the applica-
tion of a body cast or orthosis.
The average duration of follow up was 44 months (minimum 24
months). Four patients (two from each group) were lost to follow
up because they could not be contacted. Two additional patients,
who both came from the non-operative group, died from other
causes unrelated with injuries and interventions before the final
follow up could be performed. Most of outcome measures were
narrated, but a few numerical data could not be provided, such
as tables showing demographic and radiographic data, and de-
tailed patient-reported outcomes and precise complications were
unavailable.
Primary outcomes
Proportion of patients who had recovered according to self
and/or a clinician’s assessment
The proportion of patients who recovered according to self and/
or a clinician’s assessment could not be reported.
The average pain score using a visual analogue scale before treat-
ment of the injury was 6 cm (3 to 9 cm) for the operative group
and 5.8 cm (0 to 9 cm) for the non-operative group. At the last
follow-up examination, the average pain scores were 3.3 cm (0 to
7.5 cm) and 1.9 cm (0 to 9 cm) respectively with no statistically
significant difference found between groups (P = 0.18) .
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Proportion of patients who had an improvement in function
measured on a disability or quality of life scale (Oswestry
Disability Scale and/or Roland Disability Scale)
The proportion of patients who had an improvement in function
measured on a disability or quality of life scale were not described.
The average score on the Oswestry questionnaire at the final fol-
low-up evaluation was 20.8 points (0 to 48 points) for the oper-
ative group and 10.7 points (0 to 52 points) for the conservative
group (where the lower score represents better function).
The average Roland and Morris pre-injury functional disability
scores was 1.9 points (0 to 9 points) for the operative group and
0.7 point (0 to 7 points) for the conservative group. At the time of
the last follow-up examination, the average score was 8.2 points
(0 to 19 points) for the operative group and 3.9 points (0 to 24
points) for the conservative group. The conservative group was
found to have significantly lower pain scores than the operative
group (P = 0.02).
Return to work
Seventeen of the twenty-three patients treated non-operatively
were able to resume work within six months and two returned
between six and twenty four months. Fifteen of them returned to
a similar job, and four returned to a light job.
Ten of the twenty-four patients treated operatively returned to
work within six months after discharge, and four returned to work
between six and twenty four months. Eight of them returned to
a similar job, and seven worked at a less physically demanding
occupation (this included one patient who returned to work more
than twenty four months postoperatively).
Economic data
Among the patients who had an isolated thoracolumbar burst frac-
ture without other substantial trauma requiring specific treatment
during the initial hospitalization, the average charge for hospital-
ization and cast or brace treatment for those treated non-opera-
tively was $11,264 ($4686 to $20,891), while the average charge
per injury for the group treated operatively was approximately
$49,063 ($26,517 to $102,583).
Rate of complications
Adverse events were reported in sixteen participants in the oper-
ative group compared with three in the non-operative treatment
group. However, specific complications were not described.
There was no neurological deterioration regardless of treatment
approach, and neurological examination of all patients was normal
at the time of the final follow up.
6
Secondary outcomes
Sagittal plane kyphosis
In the group managed surgically, the average amount of kyphosis
was 10.1 degrees (-10 degrees to 32 degrees) on admission and 5
degrees (-10 degrees to 25 degrees) at the time of discharge from
the hospital. However, average kyphosis was 13 degrees (-3 degrees
to 42 degrees) at the time of the final follow up.
In the non-operative group, the average amount of kyphosis was
11.3 degrees (-12 degrees to 30 degrees) on admission, 8.8 degrees
(-5.5 degrees to 22 degrees) on discharge from the hospital, and
13.8 degrees (-3 degrees to 28 degrees) at the final follow-up ex-
amination.
At the time of final follow up, no statistically significant difference
was found between the two groups with respect to the sagittal
plane kyphosis (P = 0.6).
Degree of canal compromise
In the operative group, the average midsagittal diameter of the
spinal canal at the level of the fracture on presentation was 39%
(13% to 63%) less than normal, which improved to 22% (0%
to 58%) at the final follow-up examination. In the non-operative
group, the diameter was initially 34% (5% to 75%) less than
normal, which also improved significantly to an average of 19%
(0% to 46%) at the last follow-up examination.
Correlation between the final amount of kyphosis/canal
compromise and the reported pain or disability
There was no correlation between the final amount of kyphosis
and the pain reported (r = 0.22; P = 0.29) or disability according
to the Roland and Morris questionnaire (r = 0.19; P = 0.39) or
the Oswestry questionnaire (r = 0.25; P = 0.27) in the operative
group, or the non-operative group, which was (r = 0.05; P = 0.8),
(r = 0.05; P = 0.8) and (r = 0.3; P = 0.14) respectively.
Mean duration of hospitalization
The mean duration of hospitalization was 7.9 days (range 2 to 17
days) in the non-operative group and 10.7 days (range 6 to 27
days) in the operative group.
DISCUSSION
The trial design in the included trial contained a few defects and
the number of participants was just 53; conclusions must therefore
be made with caution. However, it was possible to draw provisional
conclusions.
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
With the numbers available for the pain and function-related out-
comes, it appears that the non-operative group were performing
better than the operative group with respect to pain either at the
time of presentation or at the final follow up. However, these dif-
ferences were not statistically significant. The rates at which the
patients returned to work were not found to be different between
the groups.
Radiographically, sagittal plane kyphosis showed no statistically
significant difference between the two groups on admission, af-
ter treatment, or after long-term follow up. Both groups initially
showed improvement in the kyphosis after treatment, although
those managed surgically were better; however, much of the cor-
rection was lost gradually during follow-up. Despite these results,
the degree of kyphosis at the time of the final follow up or the
percentage of correction lost did not correlate with any clinical
symptoms. The same is true for the degree of canal compromise.
Although there was no difference in average duration of hospi-
talization between the two groups, the average charges related to
hospitalization and treatment in the operative group were more
than those in the non-operative group. In addition, the rate of
complications was higher for the patients treated surgically, which
was ascribed to the fact that they had undergone an operative in-
tervention. The rate of subsequent surgery and the sagittal balance
of the patient were not stated, but they are common occurrences
after fractures of this kind, regardless of the method of manage-
ment.
There were limitations in the review. As mentioned before, we
could include only one randomized controlled trial and the sample
size was small, which meant we could not draw satisfying and
powerful conclusions. In addition, the small numbers involved
made it impossible to answer some questions; for those managed
surgically, it could not be determined whether an anterior or a
posterior approach was superior. In the non-operative group, we
could not determine whether there is any difference between the
use of a cast and the use of a brace, the length of time that each
should be worn or when and how to begin immobilisation.
Assessor blinding was unclear, and there was 11% loss of follow
up in the trial; these could allow detection and attrition biases.
Participants in the trial had suffered ’stable’ fractures (without pos-
terior osteoligamentous complex injury). These are more com-
mon in the population in which non-operative treatment yielded
acceptable outcomes and the additional benefits of surgery were
questionable.
AUTHORS’ CONCLUSIONS
Implications for practice
There is no statistically significant difference in functional out-
come beyond two years between operative and non-operative treat-
7
ment for stable thoracolumbar burst fractures without neurolog-
ical deficit. The complications rate and overall costs in the oper-
ative group were higher. However, this review involves only one
randomized controlled trial with a small sample size, so the conclu-
sion is short of stringency and its clinical use cannot be supported
on the basis of the trial. The nature of the surgical interventions
made double blinding impossible and there was loss to follow up,
which caused the trial involved to have a moderate risk of bias.
Its randomization procedure was adequate, however, so the results
had still some relevance.
Implications for research
There is a need for well reported, high quality RCTs using a
study design to assess the effect of operative versus non-operative
treatment for thoracolumbar burst fractures without neurological
REFERENCES
References to studies included in this review
Wood 2003 {published data only}
∗
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.
Journal of Bone and Joint Surgery - American Volume 2003;
85-A(5):773–81. [MEDLINE: 12728024]
Wood KB, Jhanjee R, Buttermann GR, Garvey TA, Kane
RS, Sechreist VF. Operative versus nonoperative treatment
of thoracolumbar burst fractures without neurological
deficit [abstract]. American Academy of Orthopaedic
Surgeons 68th Annual Meeting. 2001 Feb 27-Mar 4; San
Francisco (CA).
References to studies excluded from this review
Shen 2001 {published data only}
Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus
posterior fixation for thoracolumbar junction burst fractures
without neurologic deficit. Spine 2001;26(9):1038–45.
[MEDLINE: 11337622]
Additional references
Bedbrook 1975
Bedbrook GM. Treatment of thoracolumbar dislocation and
fractures with paraplegia. Clinical Orthopaedics and Related
Research 1975;(112):27–43. [MEDLINE: 1192644]
Cantor 1993
Cantor JB, Lebwohl NH, Garvey T, Eismont FJ.
Nonoperative management of stable thoracolumbar burst
fractures with early ambulation and bracing. Spine 1993;18
(8):971–6. [MEDLINE: 8367784]
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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
deficit, which assures high internal validity. These studies should
be conducted as randomized controlled trials with adequate ran-
domization procedure, allocation concealment, blinding of out-
come assessors and adequate handling of any attrition (by means
of reporting any losses to follow up and by performing intention-
to-treat analyses).
ACKNOWLEDGEMENTS
We thank Janet Wale, Peter Herbison, Rajan Madhok and Jeremy
Fairbank for their comments on the review. We also thank Marc
Swiontkowski for helpful comments on the protocol. We are also
grateful to Lesley Gillespie and Lindsey Shaw of the Cochrane
Bone, Joint and Muscle Trauma Group.
Chow 1996
Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown
CW, Donaldson DH. Functional outcome of thoracolumbar
burst fractures managed with hyperextension casting or
bracing and early mobilization. Spine 1996;21(18):2170–5.
[MEDLINE: 8893445]
Denis 1983
Denis F. The three column spine and its significance in the
classification of acute thoracolumbar spinal injuries. Spine
1983;8(8):817–31. [MEDLINE: 6670016]
Denis 1984
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. Clinical Orthopaedics and Related Research 1984;
(189):142–9. [MEDLINE: 6478691]
Dickson 1978
Dickson JH, Harrington PR, Erwin WD. Results of
reduction and stabilization of the severely fractured thoracic
and lumbar spine. The Journal of Bone and Joint Surgery.
American Volume 1978;60(6):799–805. [MEDLINE:
701314]
Egger 1997
Egger M, Smith GD, Schneider M, Minder C. Bias in
meta-analysis detected by a simple, graphical test. BMJ
1997;315:629–34.
Eskenazi 2000
Eskenazi MS, Bendo JA, Spivak JM. Thoracolumbar
spine trauma: evaluation and management. Current
Opinion in Orthopaedics 2000;11(3):176–85. [:
00001433–200006000–00004]
Esses 1990
Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical
treatment for burst fractures. Spine 1990;15(7):667–73.
[MEDLINE: 2218713]
8
Gertzbein 1992
Gertzbein SD. Scoliosis Research Society. Multicenter spine
fracture study. Spine 1992;17(5):528–40. [MEDLINE:
1621152]
Higgins 2003
Higgins JP, Thompson SG, Deeks JJ, Altman DG.
Measuring inconsistency in meta-analyses. BMJ 2003;372:
557–60.
Higgins 2005a
Higgins JPT, Green S, editors. Highly sensitive search
strategies for identifying reports of randomized controlled
trials in MEDLINE. Cochrane Handbook for Systematic
Reviews of Interventions 4.2.4 [updated March 2005];
Appendix 5b. In: The Cochrane Library, Issue 2, 2005.
Chichester, UK: John Wiley & Sons, Ltd.
Higgins 2005b
Higgins JPT, Green S, editors. Assessment of study
quality. Cochrane Handbook for Systematic Reviews of
Interventions 4.2.4 [updated March 2005]; Section 6. In:
The Cochrane Library, Issue 2, 2005. Chichester, UK: John
Wiley & Sons, Ltd.
Holdsworth 1970
Holdsworth F. Fractures, dislocations, and fracture-
dislocations of the spine. The Journal of Bone and
Joint Surgery. American volume 1970;52(8):1534–51.
[MEDLINE: 5483077]
Juni 2001
Juni P, Altman DG, Egger M. Systematic reviews in health
care: Assessing the quality of clinical trials. BMJ 2001;323
(7303):42–6.
McEvoy 1985
McEvoy RD, Bradford DS. The management of burst
fractures of the thoracic and lumbar spine. Experience in 53
patients. Spine 1985;10(7):631–7. [MEDLINE: 4071272]
McKinley 1997
McKinley TO, McLain RF, Yerby SA, Sarigul-Klijn N,
Smith TS. The effect of pedicle morphometry on pedicle
screw loading. A synthetic model. Spine 1997;22(3):
246–52. [MEDLINE: 9051885]
Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review)
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McLain 1993
McLain RF, Sparling E, Benson DR. Early failure of
short-segment pedicle instrumentation for thoracolumbar
fractures. A preliminary report. The Journal of Bone
and Joint Surgery. American volume 1993;75(2):162–7.
[MEDLINE: 8423176]
Okuyama 1996
Okuyama K, Abe E, Chiba M, Ishikawa N, Sato K.
Outcome of anterior decompression and stabilization for
thoracolumbar unstable burst fractures in the absence of
neurologic deficits. Spine 1996;21(5):620–5. [MEDLINE:
8852319]
Price 1994
Price C, Makintubee S, Herndon W, Istre GR. Epidemiology
of traumatic spinal cord injury and acute hospitalization and
rehabilitation charges for spinal cord injuries in Oklahoma,
1988-1990. American Journal of Epidemiology 1994;139(1):
37–47. [MEDLINE: 8296773]
Purcell 1981
Purcell GA, Markolf KL, Dawson EG. Twelfth thoracic-
first lumbar vertebral mechanical stability of fractures after
Harrington-rod instrumentation. The Journal of Bone
and Joint Surgery. American volume 1981;63(1):71–8.
[MEDLINE: 7451528]
Resnick 1998
Resnick DK, Benzel EC. Lateral extracavitary approach
for thoracic and thoracolumbar spine trauma: operative
complications. Neurosurgery 1998;43(4):796–802.
[MEDLINE: 9766306]
Shikata 1990
Shikata J, Yamamuro T, Iida H, Shimizu K, Yoshikawa J.
Surgical treatment for paraplegia resulting from vertebral
fractures in senile osteoporosis. Spine 1990;15(6):485–9.
[MEDLINE: 2402688]
Weinstein 1988
Weinstein JN, Collalto P, Lehmann TR. Thoracolumbar
“burst” fractures treated conservatively: a long-term follow-
up. Spine 1988;13(1):33–8. [MEDLINE: 3381135]
∗
Indicates the major publication for the study
9
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Wood 2003

Methods Randomized controlled trial.

Randomization method: computer-generated randomization
process.
Blinding: unclear.
Lost to follow up: 6 at a minimum of two years (mean 44 months)

Participants Participants: 53 (gender and age not stated).

Minneapolis, Minnesota;
thoracolumbar burst fracture without neurological deficit

Interventions Intervention: application of a body cast or orthosis.

Control: posterior or anterior arthrodesis and instrumentation

Outcomes 10 cm visual-analog scale.

Roland and the modified Morris disability questionnaire.
Oswestry back-pain questionnaire.
Short Form-36 (SF-36) health survey.
Kyphosis.
Degree of canal compromise.
Length of hospitalization.
Cost of treatment.
Rate of return to work.
Complications

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Shen 2001 Seven participants assigned to the operative group refused surgery and were reassigned to the non-operative group.
Three participants in the non-operative group did not complete the two-year study period and were excluded. This
study was excluded as the randomisation of patients was inadequate

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 10
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES
This review has no analyses.

ADDITIONAL TABLES
Table 1. Methodological quality of included studies

Quality components Wood 2003

Generation of allocation sequence: Adequate: computer-generated randomization process

adequate or unclear or inadequate

Allocation concealment: Unclear

adequate or unclear or inadequate

Blinding: Unclear
adequate or unclear or inadequate

Loss to follow up: There is loss to follow-up but intention-to-treat analysis is not
adequate or unclear or inadequate used at the time of statistics management

Scales: B

APPENDICES

Appendix 1. Search strategy for MEDLINE

MEDLINE (OVID)

1. exp Spinal Injuries/

2. Thoracic Vertebrae/
3. Lumbar Vertebrae/
4. or/2-3
5. and/1,4
6. burst.tw.
7. and/5-6
8. (thoracolumbar or thoraco lumbar).tw.
9. ((burst adj5 (fract$ or injur$)) or (compression adj5 (fract$ or injur$))).tw.
10. and/8-9
11. or/7,10
12. randomized controlled trial.pt.
13. controlled clinical trial.pt.

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 11
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

14. Randomized Controlled Trials/

15. Random Allocation/
16. Double-Blind Method/
17. Single-Blind Method/
18. or/12-17
19. Animal/ not Human/
20. 18 not 19
21. clinical trial.pt.
22. exp Clinical Trials/
23. (clinic$ adj25 trial$).tw.
24. ((singl$ or doubl$ or trebl$ or tripl$) adj (mask$ or blind$)).tw.
25. Placebos/
26. placebo$.tw.
27. random$.tw.
28. Research Design/
29. (latin adj square).tw.
30. or/21-29
31. 30 not 19
32. 31 not 20
33. Comparative Study/
34. exp Evaluation Studies/
35. Follow-Up Studies/
36. Prospective Studies/
37. (control$ or prospectiv$ or volunteer$).tw.
38. Cross-Over Studies/
39. or/33-38
40. 39 not 19
41. 40 not (20 or 32)
42. or/20,32,41
43. and/11,20
44. and/11,32
45. and/11,41
46. or/43-45

Appendix 2. Search strategy for The Cochrane Library

The Cochrane Library

#1. SPINAL INJURIES explode tree 1 (MeSH)

#2. LUMBAR VERTEBRAE single term (MeSH)
#3. THORACIC VERTEBRAE single term (MeSH)
#4. (#2 or #3)
#5. (#1 and #4)
#6. (burst or compression)
#7. (#5 and #6)
#8. (thoracolumbar or (thoraco next lumbar))

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 12
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

#9. ((burst near fract*) or (burst near injur*) or (compression near fract*))
#10. (#8 and #9)
#11. (#7 or #10)

Appendix 3. Search strategy for EMBASE

EMBASE (OVID)

1. Spine Fracture/ or Spine Injury/

2. Vertebral Fracture/
3. or/1-2
4. Thoracolumbar Spine/
5. and/3-4
6. burst.tw.
7. and/5-6
8. (thoracolumbar or thoraco lumbar).tw.
9. (burst adj5 (fract$ or injur$)).tw.
10. and/8-9
11. or/7,10
12. exp Randomized Controlled trial/
13. exp Double Blind Procedure/
14. exp Single Blind Procedure/
15. exp Crossover Procedure/
16. Controlled Study/
17. or/12-16
18. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.
19. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
20. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
21. (cross?over$ or (cross adj1 over$)).tw.
22. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$
or group$)).tw.
23. or/18-22
24. or/17,23
25. limit 24 to human
26. and/11,25

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 13
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Appendix 4. Search strategy for the Chinese Biomedical Literature database

CBM Database

1. exp Spinal Injuries/

2. Thoracic Vertebrae/
3. Lumbar Vertebrae/
4. or/2-3
5. and/1,4
6. burst.tw.
7. and/5-6
8. (thoracolumbar or thoraco lumbar).tw.
9. ((burst and (fract? or injur?)) or (compression and (fract? or injur?))).tw.
10. and/8-9
11. or/7,10
12. randomized controlled trial.pt.
13. controlled clinical trial.pt.
14. Randomized Controlled Trials/
15. Random Allocation/
16. Double-Blind Method/
17. Single-Blind Method/
18. or/12-17
19. Animal/ and not Human/
20. 18 and not 19
21. clinical trial.pt.
22. exp Clinical Trials/
23. (clinic? and trial?).tw.
24. ((singl? or doubl? or trebl? or tripl?) and (mask? or blind?)).tw.
25. Placebos/
26. placebo?.tw.
27. random?.tw.
28. Research Design/
29. (latin and square).tw.
30. or/21-29
31. 30 and not 19
32. 31 and not 20
33. Comparative Study/
34. exp Evaluation Studies/
35. Follow-Up Studies/
36. Prospective Studies/
37. (control? or prospectiv? or volunteer?).tw.
38. Cross-Over Studies/
39. or/33-38
40. 39 and not 19
41. 40 and not (20 or 32)
42. or/20,32,41
43. and/11,20
44. and/11,32
45. and/11,41
46. or/43-45

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 14
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
WHAT’S NEW
Last assessed as up-to-date: 10 August 2006.

Date Event Description

11 September 2008 Amended Converted to new review format.

HISTORY
Protocol first published: Issue 1, 2005
Review first published: Issue 4, 2006

CONTRIBUTIONS OF AUTHORS
Liao Yi: protocol development, searching for trials, quality assessment of trials, data extraction, data analysis, review development.
Bai Jingping: searching for trials, quality assessment of trials, data extraction, data analysis.
Wu Taixiang: quality assessment of trials, statistical advice.
Jin Gele: quality assessment of trials.
XiLin Baoleri: quality assessment of trials.

DECLARATIONS OF INTEREST
None known.

SOURCES OF SUPPORT

Internal sources
• Xin Jiang Medical University, China.

External sources
• No sources of support supplied

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 15
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
INDEX TERMS

Medical Subject Headings (MeSH)

Fracture Fixation [∗ methods]; Lumbar Vertebrae [∗ injuries]; Spinal Fractures [surgery; ∗ therapy]; Thoracic Vertebrae [∗ injuries]

MeSH check words

Humans

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit (Review) 16
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.