Thoracolumbar Burst Fractures Study Comparing Surgical Versus Non-surgical Treatment

Thoracolumbar Burst Fractures (AOSpine A3, A4) in Neurologically Intact Patients: An Observational, Multicenter Cohort Study Comparing Surgical Versus Non-surgical Treatment

Thoracolumbar (TL) burst fractures in neurologically intact patients account for approximately 45% of all TL spine injuries. Despite being common fractures, there is significant variability in treatment recommendations encompassing surgery and non-surgical treatment options. The controversy regarding optimal treatment for these injuries is fueled by several studies which suggest a potential benefit to surgical treatment in the realm of patient satisfaction, and the overall socio-economic burden of treatment while other studies demonstrate improved outcomes and lower morbidity with non-surgical treatment. This study aims to perform a prospective cohort analysis investigating the clinical outcome of various treatment alternatives for patients with A3/A4 fractures in the thoracolumbar region. A cost-effectiveness analysis will also be performed to identify costs and benefits of each treatment option. More specifically a sub-group analysis will be performed for this group of patients, which have equipoise in regards to patients treatment, as decided by a blinded review panel.

Study Overview

• Status: Completed
• Conditions: Thoracolumbar Burst Fracture

Detailed Description

208 subjects (i.e., 137 per surgical group; 71 per conservative group) with TL burst fractures AOSpine classification type A3 or A4 without neurological deficit as defined in the inclusion/exclusion criteria, and with or without suspected Posterior Ligament Complex (PLC) injury (M1) from T10 to L2, will be enrolled in a prospective multicenter cohort study. Patients may have an associated B injury, but must have an A3 or A4. Patients will be monitored prospectively for patient reported, clinical and radiologic outcomes, over a period of 2 years post-treatment. Specifically a patient diary will measure the Oswestry Disability Index (ODI), and employment information (indirect costs questionnaire) every second week until 6 months post-treatment. Diary will continue every second month until 2 years post-treatment. All interventions/examinations are considered as standard of care.

• Study Type: Observational
• Enrollment (Actual): 213

Contacts and Locations

Study Locations

• Australia
  • Melbourne, Australia, 3004
    • Alfred Health operating through the Alfred hospital
• Canada
  • Québec, Canada, 1401
    • Hopital l'Enfant-Jesus, CHU de Quebec
  • Vancouver, Canada, V5z1M9
    • Vancouver General Hospital
• Egypt
  • Assiut, Egypt, 71526
    • Assiut university hospitals
• Greece
  • Kifisiá, Greece, 145 61
    • KAT Hospital
• India
  • Coimbatore, India, 641011
    • Ganga Hospital
• Netherlands
  • Utrecht, Netherlands, 3508 AB
    • UMC Utrecht
• Romania
  • Iasi, Romania
    • Clinical Hospital "Prof. N.Oblu"
• Spain
  • Marbella, Spain, 29603
    • Hospital Universitario Costa Del Sol
• Switzerland
  • Bern, Switzerland, 3010
    • Inselspital, University of Bern
• United States
  • California
    • San Diego, California, United States, 92093
      • University of California, San Diego Medical Center
  • New York
    • East Syracuse, New York, United States, 13057
      • SUNY Upstate
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19107
      • Thomas Jefferson University
  • West Virginia
    • Morgantown, West Virginia, United States, 26506-9496
      • West Virginia University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients with thoracolumbar burst fractures

Description

Inclusion Criteria:

• Skeletally mature, age 18 to 65 years old inclusive
• Diagnosis of AO type A3 or A4 fractures on a CT scan with or without a suspected PLC injury (M1) from T10 to L2.
• Patients may have an associated B injury, but must have an A3 or A4.
• TLICS Score between 2-5 inclusive
• Acute fracture - diagnosis and treatment within 10 days of injury
• Ability to understand the content of the patient information / informed consent form
• Willingness and ability to participate in the clinical investigation including imaging and FU procedures
• Investigation according to the Clinical Investigation Plan (CIP)
• Signed and dated IRB/EC-approved written informed consent

Exclusion Criteria:

• Any neurological deficit associated with the fracture. Absence of neurological deficit will be determined with the International Standards for Neurological Classification of Spinal Cord Injury (ISNC SCI). It will be documented the status "E" (neurologically intact/normal) of the patient.
• Spontaneous fractures due to pathologic processes or neoplasia
• Head injuries causing inability to cooperate during hospital admission
• Open or penetrating spinal lesion (e.g. due to gun, stab, or projectile)
• Prior spinal surgeries in thoracic or lumbar spine
• Additional musculoskeletal, head or other injuries which would preclude rapid mobilization
• Multiple trauma or Injury Severity Score (ISS) > 16
• Other co-morbidities precluding the patient to be considered as a surgical or non-surgical candidate, i.e. burns, dementia, BMI > 40, etc.
• Any severe systemic medical disease that would exclude the patient to be a potential candidate for surgery
• Prisoner
• Participation in any other medical device or medicinal product study within the previous month that could influence the results of the present study
• Recent history of substance abuse (i.e., recreational drugs, alcohol) that would preclude reliable assessment.
• Pregnancy or women planning to conceive within the study period

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Surgical treatment; Several surgical treatments exist to treat the fractures included in the study. The following section describes the different surgical treatment modalities in more detail Approaches: Open short segment surgical fixation (1 level above and below the fracture level) with or without posterior decompression; Open long segment posterior fixation (2 or more levels above, 2 or more levels below) with or without posterior decompression; Posterior short or long fixation with posterolateral corpectomy and reconstruction; Anterior alone instrumentation; Combined Anterior Posterior (AP) instrumentation; Percutaneous posterior fixation combined with anterior instrumentation; Percutaneous posterior fixation with or without vertebroplasty
Non-surgical treatment; Non-surgical treatment is defined as bed rest followed by immobilization with: Custom-molded or prefabricated total body contact thoracolumbosacral orthosis (TLSO); Thermoplastic removable brace; Jewett hyperextension braces; Anterior hyperextension brace (ASH); Taylor-Knight brace; Plaster of Paris (POP)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Oswestry Disability Index (ODI)	ODI within the first year after surgical or non-surgical treatment using time to event analysis	1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
AOSpine Patient Reported Outcome Spine Trauma (AOSpine Prost)	AOSpine PROST consists of 19 questions on aspects of functioning such as personal care, traveling, and emotional functioning after the accident causing the spinal injury. Each item has a 0-100 numeric rating scale, supported by smileys at both ends of the ruler. It is important to realize that 0 indicates a level at which the patient is non-functional and 100 indicates the level before the accident, no matter how well or poorly the patient functioned before the accident.	2 years
Quality of life EQ5D-3L	The EuroQoL-5D (EQ-5D) is a standardized instrument that was designed for self-completion. It has five items (mobility, self-care, usual activities, pain / discomfort and anxiety / depression) with a three-point categorical response scale (1 = no problems, 2 = some / moderate problems, 3 = extreme problems) where the patient's current health status will be assessed.	2 years
Numeric Pain Rating Scale (NPRS)	The NPRS measures the subjective intensity of pain. The patient is asked to make a pain rating, corresponding to his/her experienced pain.	2 years
Spine Adverse Events Severity System (SAVES)	The SAVES is a prospective adverse event (AE) recording instrument. The AEs are defined as any unexpected or undesirable events occurring as a result of spinal surgery, and a complication as a disease or disorder, which, as a consequence of a surgical procedure, that will negatively affect the outcome of a patient.	2 years
overall satisfaction with the treatment	The overall satisfaction with treatment questionnaire contents one question regarding the satisfaction with the results of the recent treatment of the spine injury with a rating system from extremely satisfied (1) to not sure/no opinion (8)	2 years
Non-surgical treatment failure rate	Failure rate of conservative treatment will be assessed during this study. Non-surgical treatment failure is defined as necessity of surgery after non-surgical treatment.	2 years
Surgical treatment failure rate	Surgical treatment failure is defined as necessity of an additional surgery after the primary surgical treatment.	2 years
indirect cost questionnaire	The indirect cost questionnaire assesses the personal situation of the patient at his workplace regarding to health, support, and their financial income statement	2 years
Validation of AO TL Classification System aided by the analysis of CT scans	The participating clinics will upload the clinical data (de-identified X-rays, CT, MRI images) on a secure web-based platform. AOSpine Knowledge Forum Trauma Steering committee members, blinded to the diagnosis made in the study, will analyze the different images to validate the different TL fractures type A3 or A4 with or without PLC injury according to the new AOSpine TL Classification System.	2 years

Collaborators and Investigators

• Sponsor: AO Innovation Translation Center
• Collaborators: AO Foundation, AO Spine
• Investigators: Principal Investigator: Marcel Dvorak, MD, Vancouver General Hospital

Publications and helpful links

Helpful Links

• Sponsor's website

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2016
• Primary Completion (Actual): December 31, 2021
• Study Completion (Actual): December 31, 2021

Study Registration Dates

• First Submitted: May 23, 2016
• First Submitted That Met QC Criteria: July 7, 2016
• First Posted (Estimate): July 11, 2016

Study Record Updates

• Last Update Posted (Estimate): January 9, 2023
• Last Update Submitted That Met QC Criteria: January 6, 2023
• Last Verified: January 1, 2023

More Information

Terms related to this study

• Keywords: Conservative treatment; Surgical treatment; Thoracolumbar spine; Burst fractures; Thoracic or lumbar vertebrae
• Additional Relevant MeSH Terms: Wounds and Injuries; Fractures, Bone
• Other Study ID Numbers: Spine_TL-A3-A4

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No