To The Editor:
We read with great interest the article entitled "Operative compared
with nonoperative treatment of a thoracolumbar burst fracture without
neurological deficit. A prospective, randomized study" (2003;85:773-81) by
Wood et al, and the subsequent discussions by Verlaan et al (2004;86:649-
51) and by Wettstein et al (2004;86:651-2).
The title of the article does not truly represent the content of the
article. This is a very important article which claims credit for being
the only "prospective, randomized study comparing operative and
nonoperative treatment of a thoracolumbar burst fracture in patients
without a neurological deficit". However, the study includes only
`stable' burst fractures without neurological deficit, and concludes that operative treatment provides no
substantial benefit in `stable' burst fracture. The article therefore
should have been titled as a comparison of operative vs. nonoperative
treatment in `stable burst fracture'.
In the absence of neurological deficit, few surgeons recommend surgical
stabilization for stable burst fractures. The real question has been which
fractures are stable and which are not. The present study fails to answer
that question. In the group randomized to surgery there were patients with
little or no kyphosis (range -10 to 32°). Ethically, it is difficult to
justify randomizing these patients to surgery.
Indications for surgery in thoracolumbar burst fractures include
decompression of neural tissue in presence of neurological deficit, or
stabilization in presence of mechanical instability. The diagnostic
criteria for instability in burst fractures are not clear. The
radiological parameters commonly considered for assessment of stability
include kyphotic angle, loss of vertical height of the vertebral body, and
the degree of canal compromise. An absolute kyphosis exceeding 35°1,
relative kyphosis exceeding 20° compared to the adjacent segments, or
sagittal index (SI: a measurement of the kyphotic segmental deformity
corrected for the normal sagittal contour of the spine at the injured
level) exceeding 15°3 have been suggested as indicative of instability.
The canal encroachment exceeding 50%2'4'5 and loss of vertical height of
the vertebral body exceeding 50%2'4 has been suggested as the other
radiological criteria of instability and a predictor of poor prognosis
with nonoperative management. However, these criteria are not universally
accepted, and many clinicians reported good outcome following nonoperative
treatment in all the cases of burst fractures irrespective of these
radiological
parameters. 6,7 There is ample evidence of spontaneous canal remodelling,
and many authors do not accept the degree of canal encroachment as a
criterion for mechanical instability. 7-10
While the original article did not mention thoracolumbar burst
fracture classification scheme, the reply to the letter by Verlaan et al.
mentioned the AO classification system and that the study included type-A3
fractures (compression injury to anterior and middle column and posterior
column intact). In reply to Wettstein et al, the authors proposed that the
involvement of two of three columns does not always constitute an unstable
injury.
In their article, the authors excluded posterior osteoligamentous
injury, since that indicates flexion-distraction injury (AO type-B), or
flexion -rotation /shear injury or fracture dislocation (AO type-C). What
were their criteria of `stable burst fractures' as they mentioned in
materials and conclusion sections of the original article? From their
presented data, it is seen that the upper limit of the kyphosis in both
the groups were 32°. If this was the angle of kyphosis without correction
for segmental lordosis, then all these fractures may be mechanically
stable. The degree of loss of vertebral height has not been presented. Why
were these fractures subjected to operative treatment at all?
As entitled, this important prospective randomized controlled study
promises to answer an important question, but in the absence of the above
data, it is misleading, and disappointing.
Yours truly,
D. K. Sengupta, M.D. E. Truumees, M.D.
J. S. Fischgrund, M.D. L. T. Kurz, M.D.
D. Montgomery, M.D. H. N. Herkowitz, M.D.
Corresponding author:
D. K. Sengupta,
Department of Orthopedics
William Beaumont Hospital
3535 West Thirteen Mile Road, Suite 604
Royal Oak, MI, 48073, USA
dksg@hotmail.com
References
l.Reid DC, Hu R, Davis LA, Saboe LA. The nonoperative treatment of burst
fractures of the thoracolumbar junction. J Trauma. 1988;28:1188-94.
2.Benson DR, Burkus JK, Montesano PX, Sutherland TB, McLain RE Unstable
thoracolumbar and lumbar burst fractures treated with the AO fixateur
interne. JSpinal Disord. 1992;5:335-43.
3.Farcy JP, Weidenbaum M, Glassman SD. Sagittal index in management of
thoracolumbar burst fractures. Spine. 1990;15:958-65.
4.Willen J, Anderson J, Toomoka K, Singer K. The natural history of burst
fractures at the thoracolumbar junction. JSpinal Disord. 1990;3:39-46. 5.
Trafton PG, Boyd CA, Jr. Computed tomography of thoracic and lumbar spine
injuries. J Trauma. 1984;24:506-15.
6.Hartman MB, Chrin AM, Rechtine GR. Non-operative treatment of
thoracolumbar fractures. Paraplegia. 1995;33:73-6.
7.Celebi L, Muratli HH, Dogan O, Yagmurlu MF, Aktekin CN, Bicimoglu A.
[The efficacy of non-operative treatment of burst fractures of the
thoracolumbar vertebrae]. Acta Orthop Traumatol Turc. 2004;38:16-22.
8.de Klerk LW, Fontijne WP, Stijnen T, Braakman R, Tanghe HL, van Linge B.
Spontaneous remodeling of the spinal canal after conservative management
of thoracolumbar burst fractures. Spine. 1998;23:1057-60.
9.Aligizakis A, Katonis P, Stergiopoulos K, Galanakis I, Karabekios S,
Hadjipavlou A. Functional outcome of burst fractures of the thoracolumbar
spine managed non-operatively, with early ambulation, evaluated using the
load sharing classification. Acta Orthop Belg. 2002;68:279-87.
10.Boerger TO, Limb D, Dickson RA. Does 'canal clearance' affect
neurological outcome after thoracolumbar burst fractures? JBone Joint Surg
Br. 2000;82:62935.
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