Does Operative or Nonoperative Treatment Achieve Better Results in A3 and A4 Spinal Fractures Without Neurological Deficit?: Systematic Literature Review With Meta-Analysis

Abstract

Study design: Systematic literature review with meta-analysis.

Objective: Thoracolumbar (TL) fractures can be treated conservatively or surgically. Especially, the treatment strategy for incomplete and complete TL burst fractures (A3 and A4, AOSpine classification) in neurologically intact patients remains controversial. The aim of this work was to collate the clinical evidence on the respective treatment modalities.

Methods: Searches were performed in PubMed and the Web of Science. Clinical and radiological outcome data were collected. For studies comparing operative with nonoperative treatment, the standardized mean differences (SMD) for disability and pain were calculated and methodological quality and risk of bias were assessed.

Results: From 1929 initial matches, 12 were eligible. Four of these compared surgical with conservative treatment. A comparative analysis of radiological results was not possible due to a lack of uniform reporting. Differences in clinical outcomes at follow-up were small, both between studies and between treatment groups. The SMD was 0.00 (95% CI -0.072, 0.72) for disability and -0.05 (95% CI -0.91, 0.81) for pain. Methodological quality was high in most studies and no evidence of publication bias was revealed.

Conclusions: We did not find differences in disability or pain outcomes between operative and nonoperative 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. Specific and uniform outcome parameters need to be defined and enforced for the evaluation of TL trauma.

Keywords: A3 and A4 spinal fractures; AOSpine classification; conservative therapy; functional outcome; meta-analysis; neurologically intact patients; surgical therapy; thoracolumbar burst fractures.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Three authors (Elke Rometsch, Brigitte Sandra Gallo-Kopf, and Vasiliki Kalampoki) are employees of AO Foundation in the Department of Clinical Investigation and Documentation (AOCID). Concerning the work under consideration, Frank Kandziora has received travel support and honorary for board meetings by AO Spine. Financial activities outside the submitted work within the preceding 36 months are reported by Maarten Spruit for his activities as Chairman of AO TK Spine, by Frank Kandziora for his activities as a consultant for DePuy-Synthes, Siemens, and Silony, by Roger Härtl for his activities as a consultant for Brainlab, Lanx, Depuy-Synthes and AOSpine, and by Robert Alton McGuire for review of medical records for Rehab, Inc.

Figures

Figure 1.

Study inclusion flow diagram.

Figure 2.

Standardized mean difference for disability combined with Newcastle-Ottawa Scale for bias rating.

Figure 3.

Standardized mean difference for pain combined with Newcastle-Ottawa Scale for bias rating.

Figure 4.

Results and treatment group sizes of all studies reporting Roland Morris Disability Questionnaire (RMDQ) presented in the order of methodological quality. X and Ο represent the RMDQ mean values and the bars represent the standard deviation.

Figure 5.

Results and treatment group sizes of all studies reporting pain visual analog scale (VAS) presented in the order of methodological quality. X and Ο represent the pain VAS mean values and the bars represent the standard deviation (as far as reported).