- Department of Surgery, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
- Division of Trauma, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
- Division of Plastic Surgery, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
- Division of Neurosurgery, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
- Department of Radiology, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
- Division of Plastic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
Division of Neurosurgery, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
DOI:10.4103/sni.sni_336_17Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Jarvis W. Walters, Tammy R. Kopelman, Arpan A. Patel, Patrick J. O’Neill, Poya Hedayati, Paola G. Pieri, Sydney J. Vail, Salvatore C. Lettieri, Iman Feiz-Erfan. Closed therapy of thoracic and lumbar vertebral body fractures in trauma patients. 20-Nov-2017;8:283
How to cite this URL: Jarvis W. Walters, Tammy R. Kopelman, Arpan A. Patel, Patrick J. O’Neill, Poya Hedayati, Paola G. Pieri, Sydney J. Vail, Salvatore C. Lettieri, Iman Feiz-Erfan. Closed therapy of thoracic and lumbar vertebral body fractures in trauma patients. 20-Nov-2017;8:283. Available from: http://surgicalneurologyint.com/surgicalint-articles/closed-therapy-of-thoracic-and-lumbar-vertebral-body-fractures-in-trauma-patients/
Background:The failure rate for the closed/non-surgical treatment of thoracic and lumbar vertebral body fractures (TLVBF) in trauma patients has not been adequately evaluated utilizing computed tomography (CT) studies.
Methods:From 2007 to 2008, consecutive trauma patients, who met inclusion criteria, with a CT diagnosis of acute TLVBF undergoing closed treatment were assessed. The failure rates for closed therapy, at 3 months post-trauma, were defined by progressive deformity, vertebral body collapse, or symptomatic/asymptomatic pseudarthrosis. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification was utilized to classify the fractures (groups A1 and non-A1 fractures) and were successively followed with CT studies.
Results:There were 54 patients with 91 fractures included in the study; 66 were A1 fractures, and 25 were non-A1 fractures. All had rigid bracing applied with flat and upright X-ray films performed to rule out instability. None had sustained spinal cord injuries. Thirteen patients (24%) failed closed therapy [e.g. 13 failed fractures (14%) out of 91 total fractures]. Five failed radiographically only (asymptomatic), and eight failed radiographically and clinically (symptomatic). A1 fractures had a 4.5% failure rate, while non-A1 fractures failed at a rate of 40%.
Conclusion:Failure of closed therapy for TLVBF in the trauma population is not insignificant. Non-A1 fractures had a much higher failure rate when compared to A1 fractures. We recommend close follow-up particularly of non-A1 fractures treated in closed fashion using successive CT studies.
Keywords: Computed tomography, fracture, failure, lumbar, vertebral body fracture, thoracic
Spinal injuries in the trauma population are detected in 23.2% of cases.[
Between 2007 and 2008, trauma patients with a computed tomography (CT) diagnosis of acute TLVBF undergoing closed treatment by senior author with minimum follow-up of 3 months, or failure of treatment, were consecutively evaluated. The bracing was adjusted to the level of fracture and included thoracolumbosacral orthosis (TLSO). For high thoracic injuries halo immobilization was applied.
The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification was applied to classify the body fractures into A1 and non-A1 fractures. The fractures were followed using CT imaging up to 3 months after initial treatment. The failure with closed therapy was defined as progressive deformity greater than 50% of the initial sagittal or coronal angulation [
A 69 year old male was involved in a motor cycle accident and suffered from a 2 column thoracic 6 fracture AO type B (a). He was braced but at 6 weeks time imaging revealed significant progression of post traumatic kyphotic deformity (b). Surgery was offered, but he refused since he was asymptomatic. He was followed up elsewhere and kept in brace for a total of 9 months. At 2 years after injury he remained asymptomatic
A 71 year old male involved in a motor vehicle accident suffered from an lumbar 3 burst fracture AO type A3 (a). He was placed in a TLSO. At 3 months follow up, patient was asymptomatic. Imaging revealed significant collapse of the fracture (b). He was removed out of brace and had no further clinical complaints at 6 months follow up
A 22 year old male was involved in a motor cycle accident and suffered from a lumbar 1 fracture AO type A2 (a). He was treated in a TLSO brace for 4.5 months but disclosed pseudo-arthrosis of the fractured vertebral body on imaging (b). Due to ongoing mechanical back pain he was fused operatively at an outside facility closer to his home and did well on follow up at 11 months
Statistical methods of analysis
The Chi-square test was applied for statistical analysis. A P value of 0.05 or lesser was considered statistically significant, and a P value of 0.001 or lesser was considered statistically highly significant. Institutional review board approval was obtained for this study.
A total of 54 patients, harboring 91 vertebral body fractures, (31 male, 23 female; mean age 44 years), who survived the initial injury and had sufficient follow-up were enrolled consecutively. The mechanism of injury included motorized vehicle accidents (N = 35), falls (N = 12), auto versus pedestrian (N = 3) and other mechanisms (N = 4) [
Clinical failures; Symptomatic patients
All eight patients (61.5%) with symptomatic clinical failure complained of back pain without neurological deficit. One underwent pedicle screw fixation for pseudoarthrosis of the fracture with pain relief following surgery. The remainder were treated conservatively. One was referred for percutaneous cement injection for progressive body collapse, but was not felt to be a good candidate for the procedure on consultation.
Without failure of closed management
In the cohort of patients without failure of closed management (N = 41) five patients (12%) were complaining of persistent back pain without neurological deficits; all of them were managed conservatively. There was a highly significant association between healed fractures and absence of back pain, when comparing them to non-healed fractures and pain freedom (P = 0.0001).
Traumatic vertebral body fractures of the thoracic and lumbar spine can successfully be managed nonoperatively.[
The presence of failure of closed therapy for TLVBF may be associated with development of back pain. In the failure group of 13 patients 61.5% complained of back pain, in contrast to only 12% in the nonfailure group. In the present literature there are conflicting data to prove that non-healing or deformity of TLVBF are more frequently associated with pain.[
For future studies, it will be important to evaluate the method of nonoperative therapies. Only then can we implement guidelines for more accurate stratifications of therapies for patients with TLVBF.
We were able to safely and successfully treat the majority of patients with traumatic TLVBF in closed fashion with bracing; none suffered significant or permanent neurological damage, and only a single patient underwent operative therapy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors would like to thank Ocean C Feiz-Erfan for her help in the preparation of this manuscript.
1. Alanay A, Yazici M, Acaroglu E, Turhan E, Cila A, Surat A. Course of nonsurgical management of burst fractures with intact posterior ligamentous complex: An MRI study. Spine (Phila Pa 1976). 2004. 29: 2425-31
2. Bailey CS, Dvorak MF, Thomas KC, Boyd MC, Paquett S, Kwon BK. Comparison of thoracolumbosacral orthosis and no orthosis for the treatment of thoracolumbar burst fractures: Interim analysis of a multicenter randomized clinical equivalence trial. J Neurosurgery Spine. 2009. 11: 295-303
3. Bohler L. Conservative treatment of fractures of the thoracic and lumbar spine. Z Unfallmed Berufskr. 1972. 65: 100-4
4. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine. 1993. 18: 971-6
5. Cooper C, Dunham CM, Rodriguez A. Falls and major injuries are risk factors for thoracolumbar fractures: Cognitive impairment and multiple injuries impede the detection of back pain and tenderness. J Trauma Acute Care Surg. 1995. 38: 692-6
6. Dai LY, Jiang LS, Jiang SD. Conservative treatment of thoracolumbar burst fractures: A long-term follow-up results with special reference to the load sharing classification. Spine (Phila Pa 1976). 2008. 33: 2536-44
7. Denis F, Armstrong G, Searls K, Matta L. Acute thoracolumbar burst fractures in the absence of neurologic deficit A comparison between operative and nonoperative treatment. Clin Orthop. 1984. 189: 142-9
8. Folman Y, Gepstein R. Late outcome of nonoperative management of thoracolumbar vertebral wedge fractures. J Orthop Trauma. 2003. 17: 190-2
9. Hitchon PW, Torner JC, Haddad SF, Follett KA. Management options in thoracolumbar burst fractures. Surg Neurol. 1998. 49: 619-27
10. Joaquim AF, Daubs MD, Lawrence BD, Brodke DS, Cendes F, Tedeschi H. Retrospective evaluation of the validity of the thoracolumbar injury classification system in 458 consecutively treated patients. Spine J. 2013. 13: 1760-5
11. Krompinger WJ, Fredrickson BE, Mino DE, Yuan HA. Conservative treatment of fractures of the thoracic and lumbar spine. Orthop Clin North Am. 1986. 17: 161-70
12. Mohanty S, Venkatram N. Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise?. Spinal Cord. 2002. 40: 295-
13. Moller A, Hasserius R, Redlund-Johnell I, Ohlin A, Karlsson MK. Nonoperatively treated burst fractures of the thoracic and lumbar spine in adults: A 23-to 41-year follow-up. Spine J. 2007. 7: 701-7
14. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br. 1949. 31B: 376-94
15. Ohana N, Sheinis D, Rath E, Sasson A, Atar D. Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine.: A retrospective study comparing the radiographic results between early ambulation with and without lumbar orthosis?. Clin Spine Surg. 2000. 13: 305-8
16. Pirouzmand F. Epidemiological trends of spine and spinal cord injuries in the largest Canadian adult trauma center from 1986 to 2006. J Neurosurgery Spine. 2010. 12: 131-40
17. Shen W, Shen Y. Nonsurgical treatment of Three-Column thoracolumbar junction burst fractures without neurologic deficit. Spine. 1999. 24: 412-5
18. Siebenga J, Leferink VJ, Segers MJ, Elzinga MJ, Bakker FC, Haarman HJ. Treatment of traumatic thoracolumbar spine fractures: A multicenter prospective randomized study of operative versus nonsurgical treatment. Spine (Phila Pa 1976). 2006. 31: 2881-90
19. Stadhouder A, Buskens E, Vergroesen DA, Fidler MW, de Nies F, Oner FC. Nonoperative treatment of thoracic and lumbar spine fractures: A prospective randomized study of different treatment options. J Orthop Trauma. 2009. 23: 588-94
20. Tropiano P, Huang RC, Louis CA, Poitout DG, Louis RP. Functional and radiographic outcome of thoracolumbar and lumbar burst fractures managed by closed orthopaedic reduction and casting. Spine (Phila Pa 1976). 2003. 28: 2459-65
21. Weninger P, Schultz A, Hertz H. Conservative management of thoracolumbar and lumbar spine compression and burst fractures: Functional and radiographic outcomes in 136 cases treated by closed reduction and casting. Arch Orthop Trauma Surg. 2009. 129: 207-19
22. Weinstein JN, Collalto P, Lehmann TR. Thoracolumbar “burst” fractures treated conservatively: A long-term follow-up. Spine. 1988. 13: 33-8
23. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study. JBJS. 2003. 85: 773-81