Session IV - Spine
Fri., 10/8/04 Spine & Pelvis, Paper #26, 4:26 pm
Comparison of Health Related Quality of Life in Patients with Burst Fractures Treated Surgically or Non-Surgically
Purpose: The purpose of this prospective study on thoracolumbar burst fractures without neurologic deficit was to compare nonoperative treatment with surgical treatment in terms of radiologic and functional outcomes by using the SF-36 questionnaire.
Methods: Twenty-eight consecutive patients with thoracolumbar (T11-L2) burst fractures without neurologic compromise were included. Of these, three were lost to follow-up. For all other patients, direct radiographs, CT scan, and MRI were used to confirm burst type and to document the integrity of the posterior ligamentous complex (PLC). Exclusion criteria were neurologic compromise, Glasgow coma scale score of <14, and type C-1 fractures. Patients were assigned into two treatment groups solely on the basis of the integrity of the PLC. The absolute degree of kyphosis, canal encroachment, anterior loss of body height, interspinous process distance, or fracture of posterior bony structures was not taken into consideration in assignment. Group A included 15 patients with intact PLC (type A-3). They were treated by closed reduction and cast immobilization under conscious sedation and allowed to mobilize the next day. Casts were removed at the end of the 3rd month with no further stabilization. Group B included 10 patients with disrupted PLC (type B-1). They were treated with posterior three-level instrumentation (two above, one below). Radiographic analyses included measurement of preoperative, postoperative, and follow-up local kyphosis angles (LKA). All patients completed validated SF-36 questionnaires at the latest follow-up. Statistical evaluation was performed with use of the Student's t-test, Wilcoxon signed-rank test, Pearson correlation coefficient and chi-square analysis. The level of significance was set at P <0.05.
Results: All patients were observed for more than 2 years (average, 33 months, range, 24 to 66). The two groups were not significantly different in terms of age, sex, cause of trauma, site of fractures, duration of follow-up and preoperative kyphosis. In group A, the mean pretreatment LKA of 16.5° ± 9° was corrected to 5° ± 10° but deteriorated to 17° ± 7° at the final follow-up. In group B, mean preoperative LKA was 18° ± 10°. It was corrected to &4° ± 7° postoperatively but deteriorated to 1° ± 3° at the final follow-up. The difference between the groups in terms of residual kyphosis was significant (P = 0.001). No significant differences were observed between the two groups in physical functioning (70 ± 23 vs. 75 ± 17; P = 0.727), role physical (79 ± 35 vs. 62 ± 46; P = 0.432), role-emotional (50 ± 36 vs. 62 ± 33; P = 0.401), vitality (57 ± 25 vs. 49 ± 22; P = 0.368), social functioning (65 ± 21 vs. 71 ± 23; P = 0.505), pain index (65 ± 20 vs. 65 ± 17; P = 0.907), general health perceptions (52.5 ± 15 vs. 57.5 ± 26; P = 0.534) and mental health index (67 ± 19 vs. 61 ± 21; P = 0459). There was no correlation between the magnitude of residual kyphosis and any of the parameters of SF-36 (P >0.05). The rate of complications and additional procedures were higher in group B (one deep infection necessitating three additional surgical interventions, one screw close to the aorta necessitating one surgical intervention, one donor site pain after graft harvesting) than group A (no complications). There was no significant difference between the two groups in terms of the time to return to work (mean 3.5 months vs. 3.3 months; P = 0.645).
Conclusions: Our results are consistent with the results of previous studies of nonoperative treatment of burst fractures. It appears that these patients end up with a deformity similar to that at the time of presentation. Therefore, radiologic results are better in the operated group in spite of the presence of a more severe injury, with the type of posterior instrumentation used.
However, the results of this study demonstrate that, at least in the moderate-term follow-up, residual kyphosis is not correlated with the functional outcome as determined by SF-36. In the longer-term follow-up, whether the functional results will deteriorate in general or whether there will be measurable differences between the groups remains an open question.
Significance: This study has demonstrated that: