Stabilization Of Thoracolumbar Fractures Research Articles

What's New in Spine Surgery.

What's New in Spine Surgery.

One-Year Clinical Outcomes of Minimal-Invasive Dorsal Percutaneous Fixation of Thoracolumbar Spine Fractures.

Introduction: Minimal-invasive instrumentation techniques have become a workhorse in spine surgery and require constant clinical evaluations. We sought to analyze patient-reported outcome measures (PROMs) and clinicopathological characteristics of thoracolumbar fracture stabilizations utilizing a minimal-invasive percutaneous dorsal screw-rod system. Methods: We included all patients with thoracolumbar spine fractures who underwent minimal-invasive percutaneous spine stabilization in our clinics since inception and who have at least 1 year of follow-up data. Clinical characteristics (length of hospital stay (LOS), operation time (OT), and complications), PROMs (preoperative (pre-op), 3-weeks postoperative (post-op), 1-year postoperative: eq5D, COMI, ODI, NRS back pain), and laboratory markers (leucocytes, c-reactive protein (CRP)) were analyzed, finding significant associations between these study variables and PROMs. Results: A total of 68 patients (m: 45.6%; f: 54.4%; mean age: 76.9 ± 13.9) were included. The most common fracture types according to the AO classification were A3 (40.3%) and A4 (40.3%), followed by B2 (7.46%) and B1 (5.97%). The Median American Society of Anesthesiologists (ASA) score was 3 (range: 1–4). Stabilized levels ranged from TH4 to L5 (mean number of targeted levels: 4.25 ± 1.4), with TH10-L2 (12/68) and TH11-L3 (11/68) being the most frequent site of surgery. Mean OT and LOS were 92.2 ± 28.2 min and 14.3 ± 6.9 days, respectively. We observed 9/68 complications (13.2%), mostly involving screw misalignments and loosening. CRP increased from 24.9 ± 33.3 pre-op to 34.8 ± 29.9 post-op (p < 0.001), whereas leucocyte counts remained stable. All PROMs showed a marked significant improvement for both 3-week and 1-year evaluations compared to the preoperative situation. Interestingly, we did not find an impact of OT, LOS, lab markers, complications, and other clinical characteristics on PROMs. Notably, a higher number of stabilized levels did not affect PROMs. Conclusions: Minimal-invasive stabilization of thoracolumbar fractures utilizing a dorsal percutaneous approach resulted in significant PROM outcome improvements, although we observed a complication rate of 13.2% for up to 1 year of follow-up. PROMs were not significantly associated with clinicopathological characteristics, technique-related variables, or the number of targeted levels.

Evidence based spinal surgery or the “journal of anecdotal medicine?” Using qualitative interviews with spinal surgeons to understand how the drivers of orthopaedic decision making can influence the creation and adoption of surgical trial evidence

BackgroundThere is uncertainty regarding the best available treatment for stable thoracolumbar fractures without spinal cord injury. We explore what influences surgical decision making for the treatment of stable thoracolumbar fractures in the UK and discuss the implications of variation in spinal surgical work on the creation and adoption of future evidence. MethodsQualitative semi-structured interviews with 19 spinal surgeons from 13 UK hospitals. Data were collected as part of a mixed methods randomised pilot study (PRESTO). A conceptual framework of drivers of variation in orthopaedic surgical work informed how we analysed and reported our findings. ResultsWe identified various patient, surgeon, organisational and cultural factors to influence surgical decision making and variation in the treatment of stable thoracolumbar fractures. We then use our findings to present the ‘cycle of uncertainty,’ to illustrate how a lack of evidence is a justification for a Randomised Controlled Trial (RCT) and the reason why a trial is not deemed feasible. ConclusionSurgical decision-making is complex, particularly in the absence of robust evidence. The reliance on informal sources to inform decision making and the limited role of evidence, have implications for the likelihood that RCT evidence will be created and/or adopted. To break this cycle of uncertainty we suggest focussing earlier in the research cycle to develop context-specific strategies that are designed to avoid equipoise from deeming future surgical trials unfeasible and high quality evidence being created. This could include separate pieces of implementation research and/or targeted qualitative research conducted prior to RCTs to encourage evidence based surgical decision-making.

Surgery versus conservative management of stable thoracolumbar fracture: the PRESTO feasibility RCT.

There is informal consensus that simple compression fractures of the body of the thoracolumbar vertebrae between the 10th thoracic vertebra and the second lumbar vertebra without neurological complications can be managed conservatively and that obvious unstable fractures require surgical fixation. However, there is a zone of uncertainty about whether surgical or conservative management is best for stable fractures. To assess the feasibility of a definitive randomised controlled trial comparing surgical fixation with initial conservative management of stable thoracolumbar fractures without spinal cord injury. External randomised feasibility study, qualitative study and national survey. Three NHS hospitals. A feasibility randomised controlled trial using block randomisation, stratified by centre and type of injury (high- or low-energy trauma) to allocate participants 1 : 1 to surgery or conservative treatment; a costing analysis; a national survey of spine surgeons; and a qualitative study with clinicians, recruiting staff and patients. Adults aged ≥ 16 years with a high- or low-energy fracture of the body of a thoracolumbar vertebra between the 10th thoracic vertebra and the second lumbar vertebra, confirmed by radiography, computerised tomography or magnetic resonance imaging, with at least one of the following: kyphotic angle > 20° on weight-bearing radiographs or > 15° on a supine radiograph or on computerised tomography; reduction in vertebral body height of 25%; a fracture line propagating through the posterior wall of the vertebra; involvement of two contiguous vertebrae; or injury to the posterior longitudinal ligament or annulus in addition to the body fracture. Surgical fixation: open spinal surgery (with or without spinal fusion) or minimally invasive stabilisation surgery. Conservative management: mobilisation with or without a brace. Recruitment rate (proportion of eligible participants randomised). Twelve patients were randomised (surgery, n = 8; conservative, n = 4). The proportion of eligible patients recruited was 0.43 (95% confidence interval 0.24 to 0.63) over a combined total of 30.7 recruitment months. Of 211 patients screened, 28 (13.3%) fulfilled the eligibility criteria. Patients in the qualitative study (n = 5) expressed strong preferences for surgical treatment, and identified provision of information about treatment and recovery and when and how they are approached for consent as important. Nineteen surgeons and site staff participated in the qualitative study. Key themes were the lack of clinical consensus regarding the implementation of the eligibility criteria in practice and what constitutes a stable fracture, alongside lack of equipoise regarding treatment. Based on the feasibility study eligibility criteria, 77% (50/65) and 70% (46/66) of surgeons participating in the survey were willing to randomise for high- and low-energy fractures, respectively. Owing to the small number of participants, there is substantial uncertainty around the recruitment rate. A definitive trial is unlikely to be feasible currently, mainly because of the small number of patients meeting the eligibility criteria. The recruitment and follow-up rates were slightly lower than anticipated; however, there is room to increase these based on information gathered and the support within the surgical community for a future trial. Development of consensus regarding the population of interest for a trial. Current Controlled Trials ISRCTN12094890. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 62. See the NIHR Journals Library website for further project information.

Indications and principles of surgical treatment in injuries affecting the thoracolumbar spine

Vertebral fractures are very common and primarily affect the thoracolumbar spine as the result of an isolated injury or in polytrauma patients. The majority of these fractures can be treated non-operatively. Surgical stabilization of thoracolumbar fractures may be indicated after high-energy trauma or in the multiply injured patient. Surgery aims to provide a stable spinal column to allow early mobilization and optimize neurological outcome. This article considers the principles of clinical assessment and decision-making in the surgical management of thoracolumbar fractures. The AO spine thoracolumbar classification system can be used to guide treatment because the choice of surgical strategy depends on the biomechanics of the injury. Most injuries can be stabilized through a posterior approach but anterior column reconstruction can be performed, either as a stand-alone procedure or in order to support a posterior stabilization. The use of minimally invasive techniques is discussed. Interventional spinal technologies for osteoporotic vertebral compression fractures are also considered.

Pragmatic randomised evaluation of stable thoracolumbar fracture treatment outcomes (PRESTO): study protocol for a randomised controlled feasibility trial combined with a qualitative study and survey

BackgroundA thoracolumbar fracture is the most common fracture of the spinal column. Where the fracture is not obviously stable or unstable, the optimal management is uncertain. There are variations between surgeons, treating centres and within the evidence base as to whether surgical or non-surgical approaches should be used. In addition, the boundaries of this zone of uncertainty for stability are unclear.This study has been designed in response to an NIHR HTA commissioning brief to assess the feasibility of undertaking a large-scale trial to evaluate the effectiveness of surgical and non-surgical treatments for thoracolumbar fractures without neurological deficit.MethodsAssessment of feasibility will be addressed through three elements: a randomised external feasibility study, a national survey of surgeons and a qualitative study.The external feasibility study is a pragmatic, parallel-group, randomised controlled trial comparing surgical fixation (intervention) versus non-surgical management (control). Recruitment will take place in three secondary care centres in the UK.The primary outcome is recruitment rate, defined as the proportion of eligible participants who are randomised. Further outcomes related to recruitment, randomisation, drop-out, cross-over, loss to follow-up, completeness of outcome data, study processes and details of the interventions delivered will be collected.The survey of surgeons and qualitative study of clinicians, recruiting staff and patients will enhance the feasibility study, enabling a broad overview of current practice in the field in addition to perceived facilitators and barriers to running a full-scale trial.DiscussionPRESTO is a feasibility study which aims to inform methodology for a definitive trial comparing surgical fixation with non-surgical management for patients with stable thoracolumbar fractures.Trial registrationThe trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN12094890). Date of registration was 22/02/2018 (http://www.isrctn.com/ISRCTN12094890).

A finite element study on posterior short segment fixation combined with unilateral fixation using pedicle screws for stable thoracolumbar fracture.

The objective of this study was to use finite element models to investigate the biomechanics of stable thoracolumbar burst fracture repair using unilateral short-segment fixation and 4 alternate pedicle screw systems.Four posterior pedicle screw systems were compared for unilateral short-segment fixation using finite element models: intermediate bilateral short pedicle screw fixation, intermediate bilateral long pedicle screw fixation, intermediate unilateral short pedicle screw fixation, and intermediate unilateral long pedicle screw fixation. We compared range of motion (ROM), von Mises stresses on the implants, and stress on the intervertebral discs superior and inferior to the injured vertebra during simulated spinal movements.There were no significant differences in ROM, von Mises stress, or intervertebral disc stress among the 4 intermediate pedicle screw fixation techniques for all spinal movements evaluated. In addition, there were no consolidated trends depicting beneficial differences between the short and long screw models, or between the unilateral and bilateral screw models.ROM, von Mises stress, and intervertebral disc stress are the same across the 4, posterior short-segment fixation techniques evaluated using finite element models. The simplest technique—posterior short segment fixation combined with intermediate unilateral short pedicle screw fixation—is a feasible treatment strategy for stable thoracolumbar fracture.

Limitations in clinical outcome after posterior stabilization of thoracolumbar fractures do not correlate with dynamic trunk muscle dysfunction: an ultrasound controlled prospective cohort study

Background and PurposePosterior stabilization of the spine is associated with iatrogenic muscle damage. This is discussed to represent an important cause of postoperative pain, especially in open reduction and fixation. The aim of this study was to visualize muscular changes after open or percutaneous posterior stabilization of traumatic thoracolumbar spine fractures and to investigate whether or not these changes are related to the clinical outcome.MethodsThis prospective cohort study was performed between 05/2012 and 10/2014. A group of posteriorly stabilized patients (study group; SG) with traumatic fractures (AOSpine Type A3 or A4) of the thoracolumbar junction (T11–L2) without neurological deficit were matched to a healthy control group (CG) by age, gender and body mass index. Follow-up: 12 months after surgery. Parameters: muscle size, voluntary muscular activation (VMA) using a standardized ultrasound protocol and standardized questionnaires (VAS Spine Score; ODI; SF-36) were analyzed. Statistics: SPSS (Version 20, 76 Chicago, IL, USA). T test, Chi squared test, analysis of variance and a correlation analysis were performed. Significance level was at p < 0.05.ResultsTwenty-five patients (SG) and 23 control individuals (CG) were included. At follow-up, voluntary muscular activation of the lumbar multifidus (LM) as well as the transverse abdominis muscle (TrA) was diminished in all patients compared to the control group (VMA LM at level L3/4: SG 3.2%; CG 5.1%; p < 0.05; VMA TrA: SG 33.43%; CG 37.84%; p < 0.05). Concomitant interviews revealed health restrictions in all patients when compared with the control group. A correlation between muscle function and clinical outcome could not been demonstrated (rs > 0.07; NS).ConclusionIn surgically treated A3 and A4 fractures, there is continuous muscular deficit 1 year after surgery as documented by ultrasound and clinical control. But, by means of our study we conclude that those muscular deficits alone seem not to be decisive for the clinical outcome 1 year after surgery.

Muscular changes after minimally invasive versus open spinal stabilization of thoracolumbar fractures: A literature review.

This review addressed the question of whether minimally invasive surgery after traumatic thoracolumbar spine fractures can reduce paraspinal muscle injury, limit changes in muscular structure and function, and lead to better functional outcome. Special emphasis was given to studies using imaging techniques or electromyography to evaluate the lumbar multifidus muscle structure and function. The authors searched the literature in the PubMed/Medline, EMBASE, by cross-referencing and additional hand search. Included were comparative studies between conventional open and minimally invasive or percutaneous surgical approaches. Twelve studies were included. The literature review supports the assumption that minimally invasive surgery preserves muscles for the early post-operative period, even though the level of evidence is still low. The correlation of changes in muscular structure to pain, strength, disability, and quality of life remains ambiguous and should be addressed in further studies with a focus on the surgical approach.

Microcirculation in open vs. minimally invasive dorsal stabilization of thoracolumbar fractures

Standard open and percutaneous minimally invasive surgical procedures co-exist in the treatment of fractures of the thoracolumbar spine. Shorter skin incisions just above the pedicles are used in minimally invasive procedures. Full-length skin incisions and invasive preparations are applied in the standard open approach. While both methods show equivalent rates of intraoperative surgical complications and comparable clinical and radiological outcomes, blood loss and operation time have shown to be decreased in minimally invasive treatment. However, no study so far has investigated differences in microcirculation. This study hypothesized less impairment of microcirculation in the minimally invasive approach compared to the open approach and an improvement of microcirculation over time. A prospective cohort study was conducted using non-invasive laser-Doppler spectrophotometry (an O2C “oxygen to see” device) for measurement of cutaneous and subcutaneous blood oxygenation (SO2), haemoglobin concentration (Hb), and blood flow at depths of 2, 8, and 15 mm at six locations on the skin. Measurements were performed before surgery, 8 and 24 h after surgery, and 2, 4, 7, 12 and 20 days after surgery, however the number of patients measured decreased towards the later time points. Forty patients were included in the study, 20 with each approach (18 females and 22 males). Pair-wise comparison of the types of surgical procedure for each measurement point revealed a significantly higher flow value in the minimally invasive group at one of the measurement points located between the incisions (P = .041). The point-wise analyses of SO2 and Hb did not show significant differences between the approaches. In conclusion, significantly albeit moderately higher flow values could be found in minimally invasive procedures compared to open operations of thoracolumbar fractures in the area of skin that is spared by the incisions.

The Relationship between Superior Disc-Endplate Complex Injury and Correction Loss in Young Adult Patients with Thoracolumbar Stable Burst Fracture.

BackgroundTo determine the relationship between superior disc-endplate complex injury and correction loss after surgery in a group of young adult patients with a stable thoracolumbar burst fracture.MethodsThe study group was comprised of young adult patients who had undergone short-segment posterior fixation and bone grafting under the diagnosis of a stable thoracolumbar burst fracture from March 2008 to February 2014. Follow-up was available for more than 1 year. Before surgery, magnetic resonance imaging was performed to determine injury to the anterior longitudinal ligament, posterior longitudinal ligament, and superior and inferior intervertebral discs and endplates. Correction loss was evaluated by the Cobb angle, intervertebral disc height, upper intervertebral disc angle, vertebral wedge angle, and vertebral body height.ResultsNo significant relation was noted between correction loss and an injury to the anterior longitudinal ligament, posterior longitudinal ligament, inferior intervertebral disc/endplate, and fracture site, whereas an injury to the superior endplate alone and superior disc-endplate complex showed a significant association. Specifically, a superior intervertebral disc-endplate complex injury showed statistically significant relation to postoperative changes in Cobb angle (p = 0.026) and vertebral wedge angle (p = 0.047).ConclusionsA superior intervertebral disc-endplate complex injury may have an influence on the prognosis after short-segment fixation in young adult patients with a stable thoracolumbar burst fracture.

Bracing After Surgical Stabilization of Thoracolumbar Fractures: A Systematic Review of Evidence, Indications, and Practices

The role of spinal orthotic braces after surgical stabilization is not clearly defined. We systematically reviewed the published literature to determine patterns of practice, indications, and current evidence for the use of orthotic braces after surgical thoracolumbar fracture stabilization. A search was performed for publications including descriptions of postoperative management and outcomes after surgical stabilization of thoracolumbar injuries. Differences between wearing versus not wearing a postoperative brace were examined with regard to loss of deformity correction, pain, return to previous work activity, functional improvement, instrumentation failure rate, pseudoarthrosis, and the percentage of reported complications. This search yielded 76 pertinent studies. Postoperative bracing (POB) was adopted in 62 studies for a median wear time of 13.3 weeks. No significant differences in terms of pain, return to work, Frankel score improvement, or instrumentation failure were found between the POB and non-POB groups. Loss of surgical kyphotic reduction was slightly greater in the POB group (4.79° vs. 3.77°; P < 0.001). The overall complication rate was also higher in the POB group (16.3% vs. 11.9%; P < 0.01). The pseudoarthrosis rate was lower in the braced group (2.4% vs. 6.0%; P < 0.001). Most surgeons use braces for 3 months after surgical thoracolumbar fracture stabilization. Given the lack of clinical or biomechanical evidence for this, and the additional costs and potential discomfort to patients, further investigation is warranted to determine when and if POB for surgically stabilized thoracolumbar fractures is indicated. Controlled studies should include a careful analysis of pseudoarthrosis and complication rates.

Risk Factors and Compression and Kyphosis Rates after 1 Year in Patients with AO type A Thoracic, Thoracolumbar, and Lumbar Fractures Treated Conservatively.

Conservative treatment is a frequently used treatment modality for traumatic thoracolumbar fractures. However, not many studies evaluating radiological and clinical results of conservative treatment are found. The aim of this study was to determine the risk factors, and compression and kyphosis rates after 1 year in patients with AO type A thoracic, thoracolumbar, and lumbar fractures treated conservatively. Radiological and clinical results of 79 thoracolumbar fractures in 57 patients, who were treated conservatively, were evaluated one year after trauma. Fractures were classified according to thoracolumbar injury classification and severity (TLICS) score and AO spinal trauma classification system. Compression rate, wedge and kyphosis angles, and sagittal index were calculated in early and late periods after trauma. Female/male ratio was 25/32, and mean age was 41.7±16.7 years. They were followed for 15.2±4.9 months. Mean compression rates were 19.6% and 25.2%; wedge angles were 10.1 and 12.7 degrees; kyphosis angles were 5.82 and 8.9 degrees; and sagittal indexes were 8.01 and 10.13 in all patients just after trauma and after one year, respectively. Fractures in older patients ( > 60 years of age) and in patients with osteopenia or osteoporosis, located in the thoracolumbar junction, AO type A2 and A3 fractures, and solitary fractures had higher compression and kyphosis rates at last follow-up. Early mobilization without bed rest for stable thoracolumbar fractures according to the TLICS system is a good treatment option, and radiological and clinical results are usually acceptable. However, fractures in patients older than 60 years, those with osteoporosis or osteopenia, fractures located in the thoracolumbar junction, solitary fractures, and fractures in AO type A2 or A3, are more inclined to increase in compression and kyphosis and may require a closer follow-up.

The long-term efficacy of pedicular screw fixation at patients suffering from thoracolumbar burst fractures without neurological deficit.

Objectives:Treatment of choice at stable burst fracture is still a matter of debate. The aim of this study is assessment of health-related quality of life (HRQOL) regarding short form-36 (SF-36) and its correlation with kyphosis in patients affected by thoracolumbar burst fracture without neurological deficit undergoing posterior short segment pedicular screw fixation.Materials and Methods:Twenty patients with thoracolumbar burst fractures without neurological deficits, meeting our criteria were enrolled in this study. The patients underwent short segment pedicular screw fixation. After 2 years of follow-up, the outcome assessment was performed with evaluating HRQOL; SF-36. The mean ± standard deviation was measured at each eight category of SF-36 and compared with normative values of Iran. The correlation of Cobb angle and body pain was analyzed by linear regression.Results:The study detected reduced quality of life (QOL), with total mean of 49.7 ± 14 and physical function grade of 61.2 ± 22 which was significantly lower than Iran normative reported as 85.9 ± 19. Fifty percent still suffered from moderate to severe pain and Cobb angle had no statistically significant correlation with body pain.Conclusions:It seems that surgical treatment could not improve pain related disability of patients with stable thoracolumbar burst fracture at long term follow up.

Multidisciplinary Development of Bracing Protocol for Stable Thoracolumbar Fractures

There are no evidence-based guidelines to direct the use of bracing for patients with stable thoracolumbar fractures. A recent randomized controlled trial suggested there was no measurable benefit to using a custom made thoracolumbar spine orthosis (c-TLSO) for stable thoracolumbar burst fractures. Given the high cost of c-TLSO, we convened a multidisciplinary committee to develop guidelines about appropriate brace use and to seek out effective, less costly bracing options. Our goals were to reduce the unnecessary bracing with a c-TLSO.

Clinical and radiological outcomes of conservative treatment after stable post-traumatic thoracolumbar fractures in elderly: Is it really best option for all elderly patients?

ObjectiveThe purpose of this study was to research the effectiveness of conservative treatment of stable post-traumatic thoracolumbar vertebral fractures in elderly patients.MethodsThe study included 21 elderly patients (13 females, 8 males) with post-traumatic thoracolumbar compression fracture who were treated with a brace. Fractures without any trauma history, pathological fractures, patients younger than 60 years old and patients with no malignancy history were excluded from study. Neurological examination and posterior ligamentous complex (PLC) were intact in all patients. Radiological parameters and pain scores were recorded in regular follow-up.ResultsThe mean age and follow-up were 71.3 years (range, 60–84 years) and 20.1 months (range, 12–26 months) respectively. During follow-up, 4 patients had significant height loss resulting in kyphotic deformity and intractable pain. There was a significant increase in the local kyphosis angle (p = 0.001) and height loss percentage (p = 0.017). At the final follow-up, the mean Denis Score of pain was 1.62 ± 0.74.ConclusionAlthough there is wide acceptance of conservative treatment of post-traumatic stable thoracolumbar fracture with intact PCL according to the Thoracolumbar Injury Classification and Severity Score (TLICS), elderly female patients with a post-traumatic compression fracture in the junctional region are at great risk of conservative treatment failure. These patients should be well-informed about the possible complications and poor results of conservative treatment, and surgical treatment should be considered in selective cases with the informed consent of the patients.

Long-term results still favor nonoperative treatment of stable thoracolumbar burst fractures: commentary on an article by Kirkham B. Wood, MD, et al.: "Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective randomized study with follow-up at sixteen to twenty-two years".

Burst fractures of the thoracolumbar spine are common, but no consensus has been reached as to the best treatment. Although all burst fractures are characterized by the common finding of retropulsion of the posterior vertebral body wall into the spinal canal, burst fractures vary in severity with respect to amount of comminution, canal narrowing, associated neurologic deficit, and involvement of posterior structures. The latter structures are of primary importance in defining stability. To determine the best treatment, the authors conducted a randomized clinical trial from 1992 to 1998 in which they compared the outcomes of forty-seven patients who received either surgical or nonoperative treatment of a stable thoracolumbar burst fracture. This type of fracture has an intact posterior osteoligamentous complex. Nonoperative care consisted of bracing or casting. The surgical group was treated by anterior corpectomy and fusion with a plate or short-segment (two to four-level) posterior pedicle-screw instrumentation and arthrodesis. The …

Efficacy of Simotang oral liquid for treatment of gastrointestinal dysfunction after stable thoracolumbar fractures

Efficacy of Simotang oral liquid for treatment of gastrointestinal dysfunction after stable thoracolumbar fractures

The Relationship between the Progression of Kyphosis in Stable Thoracolumbar Fractures and Magnetic Resonance Imaging Findings.

Study DesignRetrospective study.PurposeTo investigate the relation between the progression of kyphotic deformity and magnetic resonance imaging (MRI) findings in conservatively treated stable thoracolumbar fractures.Overview of LiteratureWhen treated conservatively, excessive progression of kyphotic deformity and vertebral compression can emerge during follow-up. We sought to identify predictors of vertebral body deformation using MR images.MethodsThe presence in MR images of anterior longitudinal ligament (AL) or posterior longitudinal ligament (PL) injury, superior or inferior endplate disruption, superior or inferior disc injury in fractured vertebral bodies, the existence of low signal intensity on T2 weighted images, and bone edema of intravertebral bodies were assessed.ResultsThe presence of superior endplate disruption and a higher level of bone edema were found to cause the progressions of kyphotic angle (KA), wedge angle (WA), and anterior vertebral compression (AVC) rate. When AL or superior disc injury was observed, only KA increased meaningfully. When low signal intensity was present on T2 weighted images WA and AVC increased significantly, but PL injury, inferior endplate disruption, and inferior disc injury showed no notable correlation with kyphotic deformity progression. The risk factors found to be associated with an increase of KA to >5° were AL injury, superior endplate disruption, superior disc injury, and a bone edema level of over 1/3, and their associated risks versus no injury cases were 14.1, 3.7, 6.8, and 10.4-fold, respectively.ConclusionsAL injury, superior endplate and disc injury, or a high level of bone edema, were critical factors that determine kyphotic deformity progression.

A Pilot Evaluation of the Role of Bracing in Stable Thoracolumbar Burst Fractures Without Neurological Deficit

Prospective, 2-center, observer-blinded, randomized controlled trial. Investigate clinical and radiologic outcomes of bracing versus no-bracing in the treatment of stable thoracolumbar burst fractures. Management of thoracolumbar burst fractures depends upon clinical presentation of neurological deficit and radiographic features of fracture severity. Neurologically intact patients with mild deformity and biomechanical stability may be treated with conservative therapy. Patients with stable (AO type A3), single level, thoracolumbar burst fractures between T12 and L2 with no neurological deficit were randomized to nonoperative treatment with a customized thoracolumbosacral orthosis (TLSO) or no-brace. Self-reported clinical outcomes of pain, disability, and health-related quality of life, and radiographic outcomes of kyphotic progression and loss of vertebral height, assessed by 2 independent reviewers blinded to treatment group, were measured at 6 months follow-up. Twenty-three consecutive eligible patients were included (TLSO: n=12; no-brace: n=11). There were no between-group differences regarding level of injury (P=0.75) and baseline spine geometry including fractional canal compromise (P=0.49), anterior loss of vertebral body height (P=0.28), and sagittal Cobb angle (P=0.13). In-hospital stay was significantly shorter in the no-brace group (mean: 2.8±3.0 d) compared with the TLSO group (mean: 6.3±2.1 d; P=0.004). At follow-up there were no differences in anterior loss of vertebral body height (TLSO: 12.5%±10.2% vs. no-brace: 11.9%±8.1%; P=0.88), kyphotic progression (TLSO: 5.3±4.4 degrees vs. no-brace 5.2±3.6 degrees; P=0.93), adverse events, or self-reported clinical outcomes. Neurologically intact patients with stable thoracolumbar burst fractures treated with or without bracing had similar radiographic and clinical outcomes at 6 months follow-up. The no-brace group had shorter in-hospital lengths of stay. Conservative therapy involving early mobilization without brace immobilization may be warranted. Further studies with a larger series of patients and longer follow-up are required for conclusive findings.