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Average 3.9 of 46 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
In patients with a stable thoracolumbar burst fracture and no neurologic deficits, operative treatment has what long term outcome when compared to nonoperative management.
Improved sagittal balance
Decreased pain scores
Improved return to work status
Increased disability and complications
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Although a very controversial topic, evidence supports in patients with stable thoracolumbar burst fracture without neurologic deficits, there is no advantages to surgical treatment.
Wood et al performed the first radomized control trial comparing operative versus nonoperative treatment of thoracolumbar burst fractures in patients with no neurological deficits. They found no major long-term advantages with operative treatment, and increased disability and complications with operative treatment.
Gnanenthiran et al performed a meta-analysis to look at nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit. At final follow up they found no between-group differences in pain, Roland Morris Disability Questionnaire scores, and return to work rates.
Agus et al found that regardless of the number of columns involved, nonoperative treatment led to satisfactory results with no neurologic deterioration in their cohort of 29 patients. They conclude that nonoperative treatment is a viable option in patients with intact two- and three-column-injured Denis-types A, B and C thoracolumbar burst fractures.
Wood K, Buttermann G, Butterman G, Mehbod A, Garvey T, Jhanjee R, Sechriest V
J Bone Joint Surg Am. 2003 May;85-A(5):773-81. PMID: 12728024 (Link to Abstract)
Wood, JBJS 2003
Gnanenthiran SR, Adie S, Harris IA.
Clin Orthop Relat Res. 2012 Feb;470(2):567-77. Epub 2011 Nov 5. PMID: 22057820 (Link to Abstract)
Gnanenthiran, CORR 2012
Ağuş H, Kayali C, Arslantaş M.
Eur Spine J. 2005 Aug;14(6):536-40. Epub 2004 May 28. PMID: 15168239 (Link to Abstract)
Ağuş, ESPNJ 2005
Please rate question.
Average 3.0 of 38 Ratings
You are seeing a 68-year-old female who fell out of her second story apartment window. She complains of severe low back pain and right buttock pain. Her neurologic exam shows she is an ASIA E. Imaging shows a L3 burst fracture with 10 degrees of kyphosis, 30% loss of vertebral body height, and retropulsion of bone with 20% occlusion of the spinal canal. There is no evidence of edema in posterior ligament complex on MRI. What is the most appropriate treatment?
Spinal traction with bedrest for a minimum of 6 weeks
Spinal orthosis and early mobilization as tolerated
Laminectomy and lateral recess decompression
Laminectomy and 4 level posterior instrumented fusion
Anterior corpectomy with decompression and staged 4 level posterior instrumented fusion
The clinical presentation is consistent with a lumbar burst fracture in a patient who is neurologically intact and has no evidence of radiographic instability. Spinal orthosis and early mobilization is the most appropriate treatment.
Butler et al. retrospectively reviewed 14 cases of L5 isolated burst fractures without neurological defect (10 nonoperative and 4 operative treatment). The nonoperative group showed superior radiographic (coronal/sagittal balance) and clinical results including pain, work restrictions, and overall satisfaction.
Seybold et al. conducted a retrospective review of 42 patients treated for burst fractures of L3,4, or L5 with and without neurological deficit and found that no patient showed neurological deterioration, regardless of method of treatment. Patients with L3 fractures tended to loose sagittal balance height without change in patient related functional outcome. The overall ability to return to work and achieve good to excellent results did not differ in the patient cohorts. In addition, the rate of repeat surgery was 41% in the surgical cohort, suggesting that surgical management may actually be detrimental to the long term spine health of the patient.
Butler JS, Fitzpatrick P, Ni Mhaolain AM, Synnott K, O'Byrne JM
Spine. 2007 Feb;32(4):443-7. PMID: 17304135 (Link to Abstract)
Butler, SPINE 2007
Seybold EA, Sweeney CA, Fredrickson BE, Warhold LG, Bernini PM
Spine. 1999 Oct;24(20):2154-61. PMID: 10543015 (Link to Abstract)
Seybold, SPINE 1999
Average 3.0 of 27 Ratings
In a neurologically intact patient with the injury pattern shown in Figure A, B and C, what is the advantage of surgical treatment compared to early mobilization in a thoracolumbosacral orthosis?
Decreased kyphosis over time
Decreased residual back pain
Lower cost of hospitalization
Earlier return to work
No advantage - equivalent clinical outcomes
The clinical presentation is consistent with a thoracolumbar burst fracture. Because the patient is neurologically intact and there is no evidence of injury to the posterior ligament complex (PLC), there is no benefit to surgical management over nonoperative treatment with a TLSO.
Indications for surgery for a thoracolumbar burst fracture include neurologic deficts with active compression of the neural elemenents and spinal instability in the sagittal plane. Sagittal plane stability is partially provided by the posterior tension band construct, known as the posterior ligamentous complex. Injury to this structure can be seen in bony avulsions of the spinous process (bony chance fx), increased interspinous distance, or signal intensity of the soft tissues on MRI showing ligament injury.
Wood et al. performed the first randomized control trial comparing operative versus nonoperative treatment of thoracolumbar burst fractures in patients with no neurological deficits. They found no major long-term advantages with operative treatment, and increased disability and complications with operative treatment.
Gnanenthiran et al. performed a meta-analysis to look at nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit. At final follow up they found no between-group differences in pain, Roland Morris Disability Questionnaire scores, and return to work rates.
Thomas et al. performed a meta analysis of the literature. The authors obtained evidence for both operative and nonoperative treatment approaches. They found no scientific evidence linking posttraumatic kyphosis to clinical outcomes.
Yi et al. also did a review of the literature and Cochrane Database with an objective to compare operative with non-operative treatment for thoracolumbar burst fractures without neurological deficit. They found 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.
Figure A and B show sagittal and axial CT scan images of a thoracolumbar burst fracture with minimal resultant kyphosis and minimal canal compromise. Figure C shows a sagittal image from an MRI of the same patient with no evidence of PLC disruption.
Answer 1-4: There is no difference in kyphosis, residual back pain, cost of hospitalization and return to work between operative and non-operative approaches.
Thomas KC, Bailey CS, Dvorak MF, Kwon B, Fisher C.
J Neurosurg Spine. 2006 May;4(5):351-8. PMID: 16703901 (Link to Abstract)
Yi L, Jingping B, Gele J, Baoleri X, Taixiang W.
Cochrane Database Syst Rev. 2006;(4):CD005079. Epub 2006 Oct 18. PMID: 17054237 (Link to Abstract)
Yi, COCHD 2006
Average 4.0 of 16 Ratings
A 32-year-old male sustained an L4 burst fracture in a car accident five days ago. On initial presentation he was neurologically intact and treated in a thoracolumbar orthosis. In the last two days he has noticed increasing difficulty voiding, decreased perianal sensation, and weakness to ankle plantar flexion. Radiographs, computed tomography, and magnetic resonance imaging are shown in Figures A through D. What is the most appropriate next step in treatment?
Spinal dose corticosteroids with inpatient observation
A decompressive lumbar laminectomy without fusion
Percutaneous posterior instrumented stabilization from L2 to L5 with indirect decompression via distraction ligamentotaxis
Anterior decompresssion with strut grafting followed by posterior instrumentation
This patient is presenting with cauda equina syndrome following a lumbar burst fracture that was initially treated nonoperatively. Urgent anterior decompression with strut grafting is indicated followed by instrumented stabilization, which can be done with posterior instrumentation.
Treatment in most patients with thoracolumbar fractures who are neurologically intact is non-surgical. Surgery is indicated for unstable fracture patterns and/or neurologic deficits, especially if they are progressive. This includes CES, progressive neurological deficits, and evidence of injury to the posterior ligament complex (PLC).
Clohisy et al studied twenty-two patients with incomplete neurologic deficits after thoracolumbar junction fractures that were treated by anterior decompression and stabilization. In their series, no patients had any deterioration in neurologic function after surgery. The authors found that early anterior decompression for traumatic injuries at the thoracolumbar junction was associated with improved rates of neurologic recovery when compared to late decompression. Those who were treated within 48 hours of injury recovered more function then those who were treated at greater than 48 hours.
Krengel et al studied 14 patients who underwent stabilization for acute compression fractures at the thoracolumbar junction with neurologic deficits. 12 of the patients underwent initial posterior instrumentation and fusion, one of whom subsequently had an anterior decompression. Two patients had initial anterior decompression and fusion. Both patients later had posterior instrumentation and fusion to treat progressive deformity. Average neurologic improvement was 2.2 Frankel grades per patient, lower extremity motor index improved from an average of 7 to 44. Again, it was concluded that early surgical reduction, stabilization, and decompression is safe and improves neurologic recovery in comparison to historical controls treated by postural reduction or late surgical intervention.
Illustration A shows the postoperative radiographs of a combined anterior-posterior decompression and stabilization procedure.
Answers 1 & 2: Because this patient has acute symptoms of cauda equina syndrome, urgent decompression within 48 hours is indicated. Therefore EMG, steroids, and observation are not appropriate.
Answer 3: This patient has anterior retropulsed bone causing severe compression of the thecal sac. A posterior laminectomy would not provide adequate decompression, and an anterior decompression with a L4 corpectomy and strut grafting is the only way to ensure an adequate decompression.
Answer 4: Although one might argue posterior percutaneous pedicle screws instrumentation with distraction may provide indirect decompression through ligamentotaxis, due to the severity of the neurologic symptoms and degree of anterior compression, this approach would not be appropriate for this patient.
Clohisy JC, Akbarnia BA, Bucholz RD, Burkus JK, Backer RJ.
Spine (Phila Pa 1976). 1992 Aug;17(8 Suppl):S325-30. PMID: 1523520 (Link to Abstract)
Clohisy, SPINE 1992
Krengel WF 3rd, Anderson PA, Henley MB.
Spine (Phila Pa 1976). 1993 Oct 15;18(14):2080-7. PMID: 8272964 (Link to Abstract)
Krengel, SPINE 1993
Average 3.0 of 21 Ratings
A 32-year-old man presents to the emergency department after sustaining a L1 burst fracture in a fall. A careful neurologic exam shows he is an ASIA E. MRI shows mild vertebral retropulsion with 10% central canal stenosis and no evidence of injury to the posterior ligament complex. Which of the following is true regarding surgical decompression and fixation when compared to nonoperative treatment with bracing?
Patients treated with surgery return to work earlier.
Patients treated with surgery have decreased pain scores.
Patients treated with surgery have increased complication rates.
Patients treated with surgery have improved final SF-36 scores.
All of the above
The clinical presentation is consistent for a stable thoracolumbar burst fracture with no neurological deficits. New studies have shown 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, but does have an increased complication rate.
The thoracolumbar injury classification and severity score (TLICS) was developed to address deficits in reliability and prognostic accuracy of historical classification systems. TLICS is based on three characteristics: (1) injury morphology, (2) integrity of the posterior ligamentous complex and (3) patient neurologic status. TLICS allows determination of which injuries are stable and its reliability has been validated.
Wood et al performed a prospective, randomized trial in which the authors found: 1) no significant difference between the two groups with respect to return to work. 2) The average pain scores at the time of the latest follow-up were similar for both groups. 3) At the time of the final follow-up, those who were treated nonoperatively reported less disability. 4) Final scores on the SF-36 and Oswestry questionnaires were similar for the two groups. 5) Complications were more frequent in the operative group.
Mumford et al looked at the clinical outcome and efficacy of closed management of thoracolumbar burst fractures in patients with no neurological deficits. They found nonoperative management as the preferred treatment in these circumstances.
Illustration A shows the point system used in the TLICS classification scheme. Patients scoring less than 4 are managed without surgery. Patients scoring more than 4 are managed operatively. Patients with a score of 4 can be managed either operatively or nonoperatively.
Answers 1, 2, 4, 5: Surgery does not add benefit in stable thoracolumbar burst fractures without neurologic deficit.
Verlaan JJ, Oner FC.
J Bone Joint Surg Am. 2004 Mar;86-A(3):649-50; author reply 650-1. PMID: 14996901 (Link to Abstract)
Verlaan, JBJS 2004
Mumford J, Weinstein JN, Spratt KF, Goel VK.
Spine (Phila Pa 1976). 1993 Jun 15;18(8):955-70. PMID: 8367783 (Link to Abstract)
Mumford, SPINE 1993
Average 3.0 of 20 Ratings
Treatment Decisions in Thoracolumbar Trauma: Operative or Non-operative? was pre...
Thoracolumbar Spine Approaches was presented by D. Kojo Hamilton, M.D. at the Se...
HPI - Pt fell from tree about 30 feet while intoxicated. On arrival was moving b/l extremities. Injuries include
1. L1 and L3 burst fx
2. type 1 hangman's fx
3. non-displaced fx of posterior arch of C6
4. R proximal humerus fx
5. left distal radius fx
6. nonoperative subdural hemorrhage.
After 2 days in hospital went into DTs and went into respiratory distress. Pt has pneumothrax and chest tube was placed. Pt was intubated to protect airway due to agitated state. Sedation required. Pt developed right lobe pneumonia, possibly from aspiration.
Orthopaedic spine consulted after pt intubated and sedated. While very difficult to determine examine, pt appeared to have slowly increasing weakness on bilateral lower extremity. During state of agitation initially would bring knees off bed. This was slowly lost over course of several days. Difficulty to tell if it was due to a systemic process (sedation, mental status changes) or due to stenosis at L3.
Would you perform operative L3 decompression +/- stabilization on this patient at this time (mental status changes, likely progressive weakness but unreliable exam)?
HPI - S/P snowmobile accident. C/O severe LBP, R leg pain, parasthesia and weakness.
What would be your choice of treatment?