Review Question - QID 498

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.

Incorrect Answers:
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.