Variation in the Management of Thoracolumbar Trauma and Postoperative Infection

Kepler, Christopher K.; Vroome, Colin; Goldfarb, Matthew; Nyirjesy, Sarah; Millhouse, Paul W.; Lonjon, Guillaume; Koerner, John D.; Vialle, Luiz Roberto; Vaccaro, Alexander R.

doi:10.1097/bsd.0000000000000224

Cited by 9 publications

(4 citation statements)

References 32 publications

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“…Additionally, certain injuries, including TL-spine burst fractures without neurological deficit, can often be managed non-operatively. 83,84 Moreover, a recent multicenter prospective randomized study in Canada revealed no benefit in short-or long-term outcomes in terms of pain relief or disability assessment in patients with incomplete TL-spine burst fractures treated with orthotic bracing versus no bracing. 85,86 Surgical intervention or orthotics traditionally define what constitutes a "clinically significant" injury.…”

Section: Discussionmentioning

confidence: 99%

Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging

VandenBerg

Cullison

Fowler

et al. 2019

The Journal of Emergency Medicine

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Background: Delayed diagnoses of unstable thoracolumbar-spine (TL-spine) fractures can result in neurological deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging.Objectives: Quantifying the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients.Methods: A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2×2 tables, were duplicates, not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios. Results:In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for the detection of TL-spine fractures with plain

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Section: Discussionmentioning

confidence: 99%

Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging

VandenBerg

Cullison

Fowler

et al. 2019

The Journal of Emergency Medicine

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“…An essential role of the orthosis in the healing process of these injuries has never been proven, which explains the current subjective use in postoperative care. 2 3 The beneficial effect can only be scientifically tested by randomising groups between the use and no use of an orthosis. To our best knowledge, this is the first prospective randomised study on the use of postoperative orthoses.…”

Section: Discussionmentioning

confidence: 99%

Is postoperative bracing after pedicle screw fixation of spine fractures necessary? Study protocol of the ORNOT study: a randomised controlled multicentre trial

et al. 2018

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IntroductionThe most common surgical treatment of traumatic spine fractures is through a posterior approach using pedicle screws and rods. Postoperative treatment protocols including the use of postoperative orthoses however differ between hospitals and surgeons. A three-point hyperextension orthosis is designed to support proper posture and unload the anterior column. Some motion remains when wearing an orthosis, and its main value in postoperative treatment is therefore believed to be pain relief and patient confidence. This could consequently shorten recovery time. On the other hand, an orthosis could also lead to muscle weakness and slow down recovery. Any orthosis-related complications might also be avoided. Additionally, recent studies on conservative fracture treatment show no difference in radiological outcomes with or without an orthosis. To date, no randomised studies have been performed on the use of postoperative orthoses.Methods and analysisPatients undergoing posterior fixation with pedicle screws for a traumatic thoracolumbar fracture (T7–L4) will be included in this randomised controlled multicentre non-inferiority trial. Forty-six patients will be randomised 1:1 to one of the two parallel groups; one group will wear a postoperative orthosis for 6 weeks followed by 6 weeks of weaning and one group will not wear an orthosis. The primary outcome is pain at 6 weeks reported on the Numerical Rating Scale. Secondary outcomes consist of pain on other moments, analgesic use, complications and length of hospital stay, quality of life (EuroQuol 5 Dimensions), back pain-related function (Oswestry Disability Index) and radiological outcomes with a follow-up of 1 year. Orthosis compliance is monitored weekly in the orthosis group.Ethics and disseminationThe institutional review board (METc VUmc) approved this study on 11 October 2016 under case number 2016.389. After completion of the trial, the results will be offered to an international scientific journal for peer-reviewed publication.Trial registration number NCT03097081 and NTR6285; Pre-results.

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“…Stability is a key factor in the determination of fracture treatment. Kepler et al 7 list the fracture types, in order of increasing instability, as compression, burst, flexion-distraction and fracture-dislocation.…”

Section: Stabilitymentioning

confidence: 99%

Surgery versus conservative management of stable thoracolumbar fracture: the PRESTO feasibility RCT

Cook

Scantlebury

Booth

et al. 2021

Health Technol Assess

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Background There is informal consensus that simple compression fractures of the body of the thoracolumbar vertebrae between the 10th thoracic vertebra and the second lumbar vertebra without neurological complications can be managed conservatively and that obvious unstable fractures require surgical fixation. However, there is a zone of uncertainty about whether surgical or conservative management is best for stable fractures. Objectives To assess the feasibility of a definitive randomised controlled trial comparing surgical fixation with initial conservative management of stable thoracolumbar fractures without spinal cord injury. Design External randomised feasibility study, qualitative study and national survey. Setting Three NHS hospitals. Methods A feasibility randomised controlled trial using block randomisation, stratified by centre and type of injury (high- or low-energy trauma) to allocate participants 1 : 1 to surgery or conservative treatment; a costing analysis; a national survey of spine surgeons; and a qualitative study with clinicians, recruiting staff and patients. Participants Adults aged ≥ 16 years with a high- or low-energy fracture of the body of a thoracolumbar vertebra between the 10th thoracic vertebra and the second lumbar vertebra, confirmed by radiography, computerised tomography or magnetic resonance imaging, with at least one of the following: kyphotic angle > 20° on weight-bearing radiographs or > 15° on a supine radiograph or on computerised tomography; reduction in vertebral body height of 25%; a fracture line propagating through the posterior wall of the vertebra; involvement of two contiguous vertebrae; or injury to the posterior longitudinal ligament or annulus in addition to the body fracture. Interventions Surgical fixation: open spinal surgery (with or without spinal fusion) or minimally invasive stabilisation surgery. Conservative management: mobilisation with or without a brace. Main outcome measure Recruitment rate (proportion of eligible participants randomised). Results Twelve patients were randomised (surgery, n = 8; conservative, n = 4). The proportion of eligible patients recruited was 0.43 (95% confidence interval 0.24 to 0.63) over a combined total of 30.7 recruitment months. Of 211 patients screened, 28 (13.3%) fulfilled the eligibility criteria. Patients in the qualitative study (n = 5) expressed strong preferences for surgical treatment, and identified provision of information about treatment and recovery and when and how they are approached for consent as important. Nineteen surgeons and site staff participated in the qualitative study. Key themes were the lack of clinical consensus regarding the implementation of the eligibility criteria in practice and what constitutes a stable fracture, alongside lack of equipoise regarding treatment. Based on the feasibility study eligibility criteria, 77% (50/65) and 70% (46/66) of surgeons participating in the survey were willing to randomise for high- and low-energy fractures, respectively. Limitations Owing to the small number of participants, there is substantial uncertainty around the recruitment rate. Conclusions A definitive trial is unlikely to be feasible currently, mainly because of the small number of patients meeting the eligibility criteria. The recruitment and follow-up rates were slightly lower than anticipated; however, there is room to increase these based on information gathered and the support within the surgical community for a future trial. Future work Development of consensus regarding the population of interest for a trial. Trial registration Current Controlled Trials ISRCTN12094890. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 62. See the NIHR Journals Library website for further project information.

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Variation in the Management of Thoracolumbar Trauma and Postoperative Infection

Abstract: There is lack of consensus regarding the appropriate management of thoracolumbar fractures. In the future, multicenter prospective studies are necessary to establish guidelines for the management of thoracolumbar fractures.

Cited by 9 publications

References 32 publications

Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging

Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging

Is postoperative bracing after pedicle screw fixation of spine fractures necessary? Study protocol of the ORNOT study: a randomised controlled multicentre trial

Surgery versus conservative management of stable thoracolumbar fracture: the PRESTO feasibility RCT

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