Artikel
Does operative or non-operative treatment achieve better results in A3 and A4 spinal fractures without neurological deficit? Systematic literature review with meta-analysis
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Autoren
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Frank Kandziora
- BG Unfallklinik Frankfurt am Main, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Germany
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Maarten Spruit
- St Maartenskliniek, Nijmegen, Netherlands
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Roger Härtl
- NY Presbyterian Hospital - Weill Cornell Medical College, New York, United States
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Paul Heini
- Klinik Sonnenhof - Wirbelsäulenchirurgie, Bern, Switzerland
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Jean Ouellet
- Shriners Hospital, McGill University Health Center Dept of Surgery, Montreal, Canada
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Robert McGuire
- University of Mississippi Medical Center, Department of Orthopedics and Rehab, Jackson, United States
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Vasiliki Kalampoki
- AO Foundation, Clinical Investigation and Documentation (AOCID), Dübendorf , Switzerland
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Elke Rometsch
- AO Foundation, Clinical Investigation and Documentation (AOCID), Dübendorf , Switzerland
| Veröffentlicht: | 10. Oktober 2016 |
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Gliederung
Text
Objectives: Burst fractures of the thoracolumbar (TL) spine are frequent and approximately half of the patients maintain full neurological function.
Whilst general consensus exists that in less severe fractures (A0-A2 according to the AOSpine classification) conservative treatment is indicated and that very severe fractures (B and C type) as well as patients with neurological compromise should be treated surgically, the optimal treatment strategy for patients with incomplete (A3) and complete (A4) TL burst fractures without neurological deficit remains controversial.
Thus, a systematic literature search was carried out to collate the clinical evidence on the different treatment modalities with the aim of performing a meta-analysis.
Methods: Two searches were performed in PubMed and the Web of Science. Eligibility criteria included a minimum group size of 20 patients, A3 or A4 fractures according to the AOSpine classification, minimum follow-up (FU) of 12 months, presentation of clinical outcomes, and publication date from 2000 on. Publications on fractures caused by diminished bone density or neoplastic disease were excluded. Clinical and radiological outcome data were collected on standardized forms.
For all studies directly comparing operative to non-operative treatment, the standardized mean differences (SMD) for disability and pain were calculated based on the Roland Morris Disability Questionnaire (RMDQ) and the Low Back Outcome Score (LBOS) for disability and pain VAS for pain.
Methodological quality and risk of bias and publication bias were assessed.
Results and Conclusion: From a total of 1929 initial matches, 12 were deemed eligible. Four of these directly compared surgical to conservative treatment.
A comparative analysis of radiological results was not possible due to a lack of uniform reporting.
The differences in clinical outcomes at FU were small, both between studies and between treatment groups. Eight of 10 treatment groups reported mean RMDQs from 3 to 4.4 and 9 of 13 treatment groups reported pain VAS from 1 to 2.
The SMD was 0.00 (95% CI -0.072, 0.72) for disability and -0.05 (95% CI -0.91, 0.81) for pain.
The methodological quality assessment scores were high in 9 of 12 studies, the highest risk of bias was found for "comparability", and no evidence of publication bias was revealed.
This review did not reveal any difference in disability or pain outcomes between operative and non-operative treatment of A3 and A4 TL fractures in neurologically intact patients. Notwithstanding, the available scores have been developed and validated for degenerative diseases; thus, their suitability in trauma may be questionable. The available data did not allow comparing radiological data due to a lack of uniform reporting. Specific and uniform outcome parameters need to be defined and enforced for the evaluation of TL trauma.
