|Year : 2020 | Volume
| Issue : 1 | Page : 79-85
Outcome of nonoperative management of thoracolumbar burst fractures without neurological deficits – An analysis
Madan Mohan Sahoo1, Satyajeet Ray2, Prasanta Mahato1, Udit Sourav Sahoo1, Tapas Kumar Panigrahi1
1 Department of Orthopaedics, S.C.B. Medical College and Hospital, Cuttack, Odisha, India
2 Department of Orthopedics, S.C.B. Medical College, Cuttack, Odisha, India
|Date of Submission||02-Jan-2020|
|Date of Acceptance||23-Apr-2020|
|Date of Web Publication||26-Jun-2020|
Dr. Satyajeet Ray
C/O - Dr. A. K. Ray, Friends Colony, BK Road, Cuttack - 753 001, Odisha
Source of Support: None, Conflict of Interest: None
Study Design: This was a prospective cohort study. Background: Despite being common injury, management of thoracolumbar burst fractures without neurological deficit remains an enigma. Proponents of surgery showed the debatable advantages of canal clearance, better kyphosis correction, and prevention of neurological deterioration. This study aims to review the outcome of conservative management in these injuries. Materials and Methods: Thirty adult patients of burst fractures of the thoracolumbar spine without neurological deficits, kyphosis angle of <30°, and doubtful posterior ligamentous complex (PLC) lesions irrespective of loss of vertebral body heights were managed with bed rest and spinal bracing with an average follow-up period of 25 months. Results: Radiologically, the kyphosis angle changed from an average of 17.9° at initial presentation to 21.3° in the final follow-up. We also observed an improvement of mean kyphosis angle of 2.6° in 23% of our patients. Anterior vertebral body compression (AVC) percentage, which was 40.83% initially after injury, increased to 44.09% at the final follow-up. Five patients (16.6%) had initial AVC of more than 50% and 10 (33%) had doubtful PLC injuries. The functional outcome scores at the final follow-up using median values of the Visual Analog Scale, Oswestry Disability Index, and Roland-Morris Score were 2, 15%, and 6, respectively. There was no progression of neurological deficit in any case. Conclusion: Thoracolumbar spine burst fractures without neurological deficits can be managed conservatively with good functional outcome without any significant increase in kyphosis or neurological deterioration eliminating risks and cost associated with surgery.
Keywords: Burst fracture, nonoperative management, spinal injury
|How to cite this article:|
Sahoo MM, Ray S, Mahato P, Sahoo US, Panigrahi TK. Outcome of nonoperative management of thoracolumbar burst fractures without neurological deficits – An analysis. J Orthop Traumatol Rehabil 2020;12:79-85
|How to cite this URL:|
Sahoo MM, Ray S, Mahato P, Sahoo US, Panigrahi TK. Outcome of nonoperative management of thoracolumbar burst fractures without neurological deficits – An analysis. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Jul 6];12:79-85. Available from: http://www.jotr.in/text.asp?2020/12/1/79/287711
| Introduction|| |
Burst fractures are very common, involving nearly 10%–20% of all thoracolumbar spine injuries,, and thus leaving a high burden of disease in society. Despite being such common, the management of these fractures in the thoracolumbar segment of the spine still remains in a state of clinical equipoise largely due to controversies in defining spinal stability. Although there is no controversy on the need for surgery in patients with progressive neurological loss, unstable fractures with complete neurological loss, or patients with polytrauma requiring fixation for early and easier rehabilitation, till today there is no consensus regarding the management of burst fractures with intact neurology or stable fractures with fixed neurological deficit, which comprise the majority of thoracolumbar injuries. In various studies, proponents of surgery have shown some debatable advantages such as direct decompression with canal clearance and better kyphosis correction, which are essential for stabilizing neurology and reducing pain.,, On the other hand, various studies and two large meta-analyses have shown no differences in functional outcomes at initial and at the final follow-up between patients managed nonoperatively and operatively.,,,,,, Even some studies have reported better functional outcome and less pain in conservative group in comparison with operative., In this present prospective case series, we have evaluated the functional and radiologic outcomes of conservative treatment in thoracolumbar burst fracture without any neurological deficit.
| Materials and Methods|| |
This study was conducted in clinicoradiologically diagnosed cases of thoracolumbar spine burst fractures without any neurological deficit during a period of 3 years from July 2016 to June 2019 in our institute. The study was also cleared by our institutional ethics committee before trial. A total of 37 cases of thoracolumbar spine burst fracture were selected for this procedure. Demographic data collected at the time of admission included age, sex, smoking habits, employment status, medical comorbidities, and any preexisting spinal pathologies. Patients included in this series were radiologically diagnosed burst fractures of the thoracolumbar spine without any neurological deficit presenting within 3 weeks of injury after obtaining verbal consent from them. Patients with head injury, polytrauma, especially with lower-limb injuries, fractures with kyphosis angle of more than 300, pathological fractures, and history of previous spinal surgery were excluded from the study.
All patients clinically suspected of spinal injury were admitted, and standard anteroposterior (AP) and lateral radiographs in supine position were taken. Neurological evaluation was done to ensure any deficit clinically. The degree of pain was assessed by a 10-cm line Visual Analog Scale before they received treatment. The patients also completed a modification of the 25-item questionnaire on spinal disability described by Roland and Morris to assess any thoracolumbar dysfunction that they may have had before the injury. After diagnosing the presence of burst fracture [Figure 1] in the thoracolumbar region, the patients were immobilized in bed and weight-bearing was strictly avoided.
Back care for prevention of bed sore was maintained with the use of air bed and change of posture every 3–4 h. Indwelling catheter was not required routinely, and per-rectal enema was administered at times for constipation. All the patients included in the study were investigated thoroughly with routine blood investigations to rule out any associated medical comorbidities.
Plain AP and lateral radiographs at supine position were taken on admission. The following parameters were manually measured on lateral radiograph by two independent examiners. The anterior vertebral body compression (AVC) percentage according to Willen's method [Figure 2]a and the degree of kyphosis at the fracture site [Figure 2]b were calculated.
|Figure 2: (a) Anterior vertebral body compression measurements. (b) Cobb's angle measurement|
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AP view X-ray was observed for any increase of interpedicular distance, malalignments, lateral translation, and vertical fracture components in the vertebral body, pedicle, and lamina.
Computed tomography (CT) scans of the affected region along with screening of the whole spine was done to see posterior wall breach and retropulsion of body fragments into the spinal canal, thereby confirming our diagnosis [Figure 3]a and [Figure 3]b. CT and X-ray were also evaluated to see any widening of the interspinous space, diastasis and subluxation of the facet joints, and translation or rotation of the vertebral body as indirect identifiers of posterior ligamentous complex (PLC) injury. Magnetic resonance imaging (MRI) was obtained in each patient to see the status of cord and detect any associated PLC injuries. Intact PLC was defined as no visible change in the MRI signal, while PLC injury was considered as MRI signal change with or without evidence of full discontinuity.
|Figure 3: (a) Axial computed tomography scan. (b) Three-dimensional computed tomography reconstruction|
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The duration of hospitalization ranged from 3 to 7 days. No patient required transfer to any rehabilitation centers. Patients were discharged with advice of continued bed rest, strict avoidance of sitting, and standing with advices of back care for the prevention of bedsore which were demonstrated to them during their hospital stay.
After about 1 month in subsequent follow-up, patients were fitted in a thoraco-lumbo-sacral orthosis. Standing in an erect position and ambulation were permitted. The brace was worn for about 6–8 months depending on radiological healing of fractures. While wearing the brace, patients were taught isometric exercises to help maintain the condition of trunk muscles. After removal of the brace, the patients were allowed to return to their original job. The patients were followed up for clinical and radiological assessments at monthly interval for 6 months and then every 6 months thereafter. Kyphosis and loss of anterior height of the vertebral body were calculated according to the Cobb's method and Willen method, respectively. At the final follow-up, standing flexion, and extension, lateral view radiographs were taken to detect any instability of the injured area of the spine. The secondary outcomes included pain, disability, and overall health measures, return to their previous occupation. Pain was evaluated at baseline and during all follow-up visits using the Visual Analog Scale (VAS), scaled from 0 (no pain) to 10 (worst imaginable pain) for back pain. Disability was evaluated at 6-month follow-up visit by the revised Oswestry Disability Index (ODI), scaled from 0 (no disability) to 100 (crippling disability), and by the Roland-Morris (RM) Disability Score. At the final follow-up, they were asked about return to their previous occupation. Whether they could continue working in their previous job without any added discomfort or required to change to a new lighter job? Patients were also monitored for adverse events including need for surgery due to neurological deterioration or in-hospital medical complication.
| Results|| |
Out of total 37 patients, 30 were available for the final follow-up. Seven patients could not be followed up in our hospital. On telephonic conversation, four of them preferred for checkup in their local hospitals. They were ambulatory and performing their routine daily activities at an average of 8 months following injury. Two of them could not be contacted over phone. One patient died of preexisting cardiac disease around 3 months after the spinal injury.
The average follow-up period was 25 months (range, 19 –35 months). Age varied from 18 to 56 years, mean age being 35 years. The age distribution showed an increased incidence in relatively younger patients with the highest incidence between 30 and 39 years (30%) with a male preponderance in 26 patients (87%). The mechanism of injury included road traffic accidents in 14 (46%), fall from height in 8 (27%), recreational trauma in 2 (7%), and workplace injury due to fall of heavy objects in 6 patients (20%). Fracture distribution according to vertebral level showed L1 being the most commonly involved vertebra in 14 (47%) patients [Table 1].
The mean initial percentage of AVC was 40.83%, ranging from 24.6% to 56.1%. At the final follow-up, the mean percentage was 44.09%, ranging from 16.6% to 64.6%, and the mean increase of AVC at the last follow-up was 3.21%, which was not very significant. The mean Cobb's angle at the time of injury was 18.37° (range, 12.5°–25.6°). At the final follow-up, the average angle was 21.5° (range, 14.3°–28.9°), with a mean increase of kyphotic angle of 2.6°, which was also not very significant [Figure 4]a and [Figure 4]b. Interestingly, we have found an improvement of Cobb's angle in seven patients (23%) ranging from 0.8° to 2.4° [Figure 5]a and [Figure 5]b. Although there was a progression of overall radiologic deformity, neurological deterioration was not seen in any of the 30 patients. Spinal stability measured radiologically with standing flexion and extension lateral view at the final follow-up showed no instability. In MRI, we found hyperintense lesions over PLC area in T2 sequence without evidence of complete discontinuity in 10 patients (33%) [Figure 6].
|Figure 4: (a) Pretreatment and (b) posttreatment radiograph, showing increased kyphosis|
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|Figure 5: (a) Pretreatment and (b) posttreatment radiograph, showing improvement of kyphosis angle|
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|Figure 6: T2 magnetic resonance imaging showing doubtful posterior ligamentous complex injury (white arrow)|
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The initial median VAS score, which measured 8 (range, 6–10), came out to be 2 (range, 1–5) on the final follow-up. The initial median Roland and Morris Score was 20 (range, 18–24). There was a significant improvement in this score, with the final median score of 6 (range 0–15). The median score on the Oswestry questionnaire at the long-term follow-up evaluation was 15% (range, 8%–44%). All patients except two showed complete recovery and were able to return to their previous work with near-normal range of back movement.
There were no adverse events with regard to patients requiring surgical intervention, neurological deterioration, or in-hospital medical complications such as bedsore, urinary tract infections, or ileus. Two patients were unable to return to their previous working condition, so they changed their job.
| Discussion|| |
Till date, there is still considerable controversy regarding the stability in vertebral burst fractures, which does not have any specific criteria or definition. There are various classification systems, where a specifc anatomical structure was given more importance. For example, in Denis and McAfee et al classification, middle column was given importance. In McCormack et al load sharing classification, the fracture pattern was emphasised. Similarly in Magerl et al and TLICS, the integrity of PLC was the important deciding factor. However, they have their own shortcomings, i.e., Denis, McCormack et al(Load sharing), and AO/ Magerl et al, have not considered neurological status and none were validated by randomized clinical trials nor they have considered the stabilizing effect of paraspinal muscles and the natural healing of ligamentous structures.
Although various biomechanical studies have identified the integrity of PLC as an indicator of mechanical stability,, it has been difficult to confirm the structural integrity of PLC from a clinical and imaging perspective. Results of studies also suggest that MRI may not be as accurate in defining PLC integrity as suggested by previous studies, with a high sensitivity but low specificity., Hence, the clinical studies remain the cornerstone of forming guidelines in these kinds of fracture treatment. In our study, we have found similar results with signal enhancement in T2 sequence without any specific discontinuation, which suggests an incomplete injury to the PLC. In spite of these findings, there were no other indicators of instability, i.e., neurological deterioration or any significant deformity which can impede full functional return.
In this present study, patients belong to relatively adult age group, with a range of 18–56 years and a mean age of 36. This study shows a preponderance of dorsolumbar spine burst fractures in the second, third, and fourth decades with the highest percentage in the third decade (30%) which correlates with the other studies.,,,,
A much-discussed subject in literature is, how the deformity progresses and what will be the subsequent impact clinically. In patients treated conservatively with braces or hyperextension cast and early ambulation, the range of kyphosis progression has been observed to be from 1° to 8° in previous studies.,,,, In most of the patients, kyphosis progression occurred in the initial days after injury and without any further progression thereafter as it gradually stabilizes. Although surgical management has shown a better correction of the deformity in the immediate postoperative period,, the kyphosis gradually reappears in the rehabilitative phase with the final kyphosis often being similar or even increased up to 8°–12° in some cases.,,,, In our study, we have found that there was an overall increase in radiological deformity, with a mean loss of correction of AVC being 3.21% and a mean increase in kyphosis angle of 2.6°, which was not very significant. Interestingly, we have found an improvement of Cobb's angle in seven patients (23% of our cases) who had a mean improvement of 1.84°, which was not found in other literatures. This radiological picture showing improvement of kyphosis may probably be related to prolonged bed rest for 1 month with complete avoidance of weight-bearing. This long period of bed rest was duly accompanied with proper back care with care of bowel and bladder and regular range of motion exercises of extremity joints taught to the patient and attendants during their hospital stays.
Traditionally, loss of anterior vertebral body height of more than 50% served as a radiographic indicator of unstable burst fractures in various studies,,, and described as a contraindication to conservative treatment, whereas others found no such correlation., We have also found similar results where eight patients (27%) had a loss of anterior vertebral body height of >50%, but neither they did suffer from any instability in the final follow-up nor had any significant progression of deformity.
Stable neurological injury without progression in a burst fracture occurs primarily due to a variety of mechanical factors, such as rapid cord compression, acute distraction, acceleration or deceleration with shearing, transection, or penetration, and depends on the nature of injury, which occurs at the time of the accident. There is also no concrete evidence that retropulsion of the fragments causing canal compromise can give rise to symptomatic spinal stenosis in the future., In contrast, different studies show that the retropulsed fragments can gradually resorb with remodeling of the canal and increase in canal diameter.,,, Interestingly, one study has shown that the higher the amount of initial canal compromise, the better is the remodeling. The neurological deterioration has been rarely found except in one where neurological deterioration was seen in 6 out of 29 patients in the final follow-up. However, in our study, we have found no neurological deterioration in any of our patients.
The relationship of posttraumatic kyphosis with back pain and functional limitations is a matter of debate. It has been postulated that thoracolumbar kyphosis, compensated by lumbar hyperlordosis, can lead to early degenerative changes of facet joints and pain. However, some studies also indicate that there is no direct relationship of kyphosis with back pain or functional impairment., Although radiological results may be better in the operative group only for a limited period, no significant difference in the final outcome has been observed in comparison with the nonoperative groups., Interestingly, in the study of Wood et al., conservatively managed group was found to have significantly lower pain scores than the operative group. Similarly, in a comparative study, Resch et al. found that all patients in the nonoperative group remained satisfied, but 15% of the surgical group were dissatisfied with the outcome.
On functional evaluation, we also found similar results. There was a significant improvement in VAS, ODI, and RM scores. All except two patients returned to their previous activity.
The disadvantages of surgery with a wide variety of complications such as anesthetic risks, postoperative infection, intraoperative dural tears, pseudoarthrosis, failure of instrumentation, prolonged hospital stays, higher costs, and sometimes need for secondary surgery to remove implants could also be avoided in our series.,,,,,,,
The limitations of our study are small sample and relatively shorter period of follow-up. A longer follow-up could have demonstrated any further progression of kyphosis/collapse, the appearance of canal clearance, and total functional restoration. Therefore, we are continuing the study further. Another limitation of our review is the choice of target outcome parameters. We relied on the most commonly used clinical outcome scores which are prone to subjective errors and need to be validated.
| Conclusion|| |
Our study shows that thoracolumbar burst fractures with doubtful PLC injuries irrespective of vertebral body height without any neurological deficits can successfully be treated by simple conservative methods of bed rest and braces. Considering the complications and cost factor of surgical methods, conservative management is quite safe and effective in view of function, neurology, and radiological outcome.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]