Controversies in the management of thoracolumbar burst fractures

Introduction

The classification of thoracolumbar burst fractures requires continuous evolution (1,2). This is best encapsulated by the fact that the most widely used classification system, the AO Spine Thoracolumbar Injury Classification and severity score, provides ambivalent recommendations in particularly difficult clinical situations when it is most needed (1,3). For example, a neurologically intact patient with a burst fracture and suspected posterior ligamentous complex injury scores an intermediate four points which does not determine whether operative or non-operative intervention is favoured, thereby neglecting to provide a clear recommendation to the treating clinician. This represents an area of clinical equipoise currently under investigation (4,5). With this score, it is left up to the clinician to evaluate whether conservative or operative management is appropriate taking into account patient factors. If operative management is determined necessary, then short segment posterior fixation of thoracolumbar burst fractures is a commonly selected approach (6).

We aim to provide an overview of the controversies in both non-operative and operative management of patients with thoracolumbar burst fractures to facilitate understanding of the complexities involved in decision making. This highlights the need for a universal classification system and treatment algorithm to enable efficient patient care.

Discussion

Proponents of conservative management of neurologically intact patients who sustain thoracolumbar burst fractures argue that radiographic improvement post-traumatic kyphotic deformity does not translate into clinically superior functional outcomes (7-9). Seybold et al. noted this in 1999 after finding equivalence of operative and non-operative management in 42 patients with lumbar fractures utilizing the Dallas Pain Questionnaire as the primary outcome measure (10). This was corroborated by Tisot et al. who also astutely noted there was no statistically significant correlation between kyphosis or spinal canal with quality of life measured by the 36-Item Short Form Survey (SF-36) questionnaire on follow-up (11-13). For this reason, Wallace et al. found clinical and radiographic outcomes were similar regardless of whether an orthosis was utilized in the management of thoracolumbar burst fractures (14-17). Weinstein et al. shared this sentiment that non-surgical management is a safe and effective treatment option (18).

As a diametrically opposite viewpoint, Sharif et al. noted that operative management may possess the theoretical advantages of facilitating earlier mobilization, reduced medical complications such as pneumonia or thrombotic events as well as earlier discharge from hospital (16,17,19). Denis et al. advocated for operative management based upon this tenet (20). The argument for early mobilization and avoidance of recumbency and its associated medical complications was also the foundation of Jacobs et al. positing that operative management was favourable (21). This is again the paradigm and equilibrium of weighing up the immediate perioperative surgical risk against delayed consequences of surgical stabilization highlighted by Dai et al. (6,22).

On superficial inspection Erichsen et al. found the contrary and that posterior stabilization resulted in no significant difference in loss of kyphosis angle over time between anterior and posterior stabilization (23). Kocis et al. support this and championed percutaneous fixation of A3 and A4 fractures (24). What is important to recognize is that this cohort of patients included the less severe morphology of A3 fractures. What is important to recognize is that this cohort of patients included the less severe morphology of A3 fractures exclusively (23,25).

Consequently, Morrissey et al. acknowledge that complete burst fractures could even be considered for a combined anterior and posterior approach (26). More invasive stabilization methods such as the anterolateral approach for more unstable fractures have also been described by Hammad et al. (27). Given shorter duration of surgery is preferable, Kumar et al. have also concluded that minimally invasive percutaneous short segment pedicle fixation is safe and reduced Oswestry Disability Index (ODI) compared to open techniques (28). This was supported in the World Federation of Neurosurgical Societies (WFNS) guidelines with an index screw at the fracture level also increasing construct strength if possible (19).

In contrast, Siebenga et al. determined in their multi-centre randomized controlled trial comparing management of type A thoracolumbar fractures that the single endplate A3 morphology is best treated with surgical stabilization (29). The amount of reduction of kyphosis was superior to that achieved by Wood et al., perhaps reflective of an evolution of surgical technique to bisegmental pedicle screws rather than screw hook fixation (29,30). Moreover, there was an earlier return to work compared to the conservatively treated group (29). It is important to note that there has been no definitive evidence that kyphotic correction correlates to functional outcome. For example, proactive participation with rehabilitation programs immediately after surgery and the possible improved health-related quality of life following stabilization of the fracture (31). Pehlivanoglu et al. also examined 45 neurologically intact patients with A3 or A4 burst fractures with a mean follow-up of 63.1 months who underwent short segment posterior stabilization (32). The radiographic outcomes were superior than with orthosis use but there was no significant difference in quality of life (32).

Rabb et al. have astutely warned, in the presence of non-superiority of surgical intervention, that conservative management in the first instance before resorting to operative management as required is an option (33-35). Indeed, even major large scale reviews such as the WFNS recommendations by Sharif et al. or the Cochrane reviews by Abudou et al. report that known factors such as age and comorbidities predict worse outcomes (7,19). Despite this, there is no conclusive advice regarding the ideal management of thoracolumbar burst fractures in neurologically intact patients (7,19). However, this is not to state that absence of evidence is evidence of absence. Poignantly, studies have demonstrated nil significant difference in ODI at baseline or ODI improvement within 1 year after baseline or injury between surgical management and non-surgical management for patients with either A3 or A4 fractures (2,36).

Cho and Kim furthered this by determining that non-contiguous fracture groups requiring long segments fixation experienced poorer functional outcomes (37). It was Tian et al. who argued fusion was not necessary with posterior pedicle screws (38). For this reason, Aono et al. argued that risk factors for kyphosis include degree of disc destruction and damage to the endplate but that short segment fixation is viable in most cases as was supported by Jamali et al. who found a mean hospital stay of only 4.6 days after short segment instrumentation (39). Scheer et al. in their comprehensive review of 23 studies advocated for posterior approaches being less invasive and therefore carrying a lower risk of complications than anterior or combined approaches (40). Bailey et al. conducted a multicentre randomized controlled trial of 96 patients with A3 burst fractures treated with and without an orthosis. For this single endplate injury, only 6 patients required surgery eventually due to inability to adequately mobilise as a consequence of mechanical pain (41).

Unfortunately, such trials may be limited by ethical dilemmas given allocating a frail high risk patient to surgical intervention cannot be justified (42-45). Similarly, true randomization to sham surgery also exposes patients to risk of a general anaesthetic of identical duration. We argue that there is a role for surgery in A3 and A4 fractures and suggest there may be a role for standardization of treatment at a high volume trauma centre to minimise fluctuating outcomes for these patients. In the interim, we advocate for holistic clinical decision making to be based upon individual patient factors whilst taking into consideration fracture morphology. For example, traditional tenets of spine trauma would suggest that a patient who sustains a hyperextension fracture in the setting of diffuse idiopathic skeletal hyperostosis is unstable and requires surgical fixation. However, a trial of conservative management with or without orthosis would also be reasonable in an elderly comorbid patient without any neurological deficit. Equally a young athlete who sustains a thoracolumbar burst fracture may warrant early fixation and consideration of removal of hardware in a premeditated fashion 12 months later.

Conclusions

Patients with traumatic thoracolumbar burst fractures should be assessed on an individual basis specific to fracture morphology, extent of ligamentous injury and degree of neurological deficit consistent with the AO Spine Thoracolumbar Injury Classification System. It is useful that a standardized classification system has been established to enable multi-centre trials to be conducted in the future to continue the global healthcare of patients who sustain these injuries. However, greater nuances in the management of these patients are still required with a more specific classification system translating into a validated quantitative management algorithm.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Surgical Journal. The article has undergone external peer review.

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-59/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-59/coif). B.T.S.K. serves as an unpaid editorial board member of AME Surgical Journal from May 2024 to June 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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