The Michel Benoist and Robert Mulholland yearly European Spine Journal review

Abstract

This year has produced a great number of excellent papers that should have a significant effect on our approach to and management of a wide diversity of spinal problems. I hope that my comments on each paper will cause people to read or reread them. Do not just skim the abstract, as inevitably abstracts have to summarize the whole paper, and important conclusions in the paper itself may not surface in the abstract. An important contribution that the European Spine Journal makes to surgical education and the daily practise of spinal surgery is the review article. They mainly deal with extreme topical issues. This year I particularly enjoyed those, which dealt with the nonoperative treatment of thoracolumbar burst fractures, Scheuermann’s disease, adult scoliosis, and clinical studies in spinal surgery. Despite reviewing some 2,700 references, and selecting some 17 eligible studies for review, the authors van der Roer et al. [27] claim that there was no scientifically sound evidence from high-quality randomized trials comparing the effectiveness of operative or conservative treatment of unstable traumatic thoracolumbar fractures, because such studies had not been done. However, this is a paper that deserves close study, as although it was my impression from the paper that the surgically treated had less pain in the long term, the lack of any clear difference may make surgeons considering surgery or not, to weigh both surgical factors and nonsurgical factors more carefully. Will a patient with a scar on his back and a plate perhaps extending to L3 be as good in the long term compared with a patient with a satisfactorily healed single segment in some kyphosis? What is the social and psychological effect of having had a major operation on the spine, and the possibility of another operation to remove the plate? The paper, which follows this review is by Agus et al. [3]. Although the study was performed with only 35 patients, the follow-up was for 6 years, and it was an excellent analysis of the results of treating conservatively, unstable burst fractures, which were neurologically intact. They discuss the concept of instability and using the Denis classification, treated both 2 column and 3 column fractures, but without facet fracture or facet dislocation. The short time of hospitalisation, only 3–8 days, and the use of bracing for comfort, not for maintenance of position, and the lack of any indication in the final results that kyphosis was a factor in clinical result, all rather undermines the usual suggested reasons for surgical intervention in unstable fractures. There was an increasing deformity at final follow-up, of kyphosis, and anterior and posterior vertebral height loss, but this does not affect the result, and as others have commented canal compromise dropped from around 45% average to 20% average, in both 2 and 3 column fractures. It would seem reasonable that in any general orthopaedic setting, without specialist spinal surgeons, a strong case can be made for conservative treatment of these fractures, as in relatively inexperienced hands surgery has the potential for significant complications.