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Debate About Optimal Care for Spinal Fractures

Treatment for spinal fractures may be operative (surgery) or nonoperative (conservative care). Research comparing these two treatment methods is very limited. It's difficult to compare the results between these two interventions. For one thing, surgeons use different methods to classify the injury.

And patient populations vary considerably. More serious injuries are often treated surgically creating a bias in favor of one treatment over another. The question has been raised as to whether or not surgery is really needed just because the injury is more severe. Some experts have suggested that the long-term results wouldn't be any different between operative and nonoperative care.

In this study, differences in results between operative and nonoperative patients with traumatic thoracic or lumbar spine fractures are reported. Measures of outcome included quality of life, residual pain, and neurologic recovery. Work status was also reviewed.

Patients were treated at one of two surgery centers. One center only performs surgery in unusual cases. All other patients are treated conservatively without surgery. The second center has adopted a more aggressive approach. Surgery is done on anyone with unstable or neurologically involved fractures.

Conservative care consisted of bed rest and/or a plaster cast until fracture healing occurred. Alternately, the surgical group had a stabilization and fusion operation of the fractured segment. After the operation, everyone wore a protective brace called a thoracic-lumbar-sacral orthosis (TLSO).

All things considered, patients in the two groups were very similar. The main difference was the larger number of men in both groups but especially in the operative group. Results were assessed using two well-known surveys of health status. The complication rate was high (20 per cent) but equal between the two groups. Types of problems varied from infection to bowel paralysis.

Pain and disability were also equal between the two groups. Health-related quality of life was also comparable from one group to the other. Patients in both groups who had neurologic involvement had the worst results.

Women in both groups tended to have lower scores in terms of physical and mental function. The reason for this was not clear. Osteoporosis and a stiffer spine in women may account for some of the differences between the sexes.

And finally, patients in the operative group had a shorter rehab period and faster earlier return to work date. Even with the higher costs related to surgery, operative care was still more cost-effective than nonoperative care. This factor alone might tip the scales in favor of operative therapy for traumatic spinal fractures.

References: Agnita Stadhouder, MD, et al. Traumatic Thoracic and Lumbar Spinal Fractures: Operative and Nonoperative Treatment. In Spine. April 20, 2008. Vol. 33. No. 9. Pp. 1006-1017.

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