Thoracolumbar fractures without neurosurgical involvement: surgical or conservative treatment?

The decision whether to treat amyelic thoracolumbar fractures conservatively or by surgical approach depends mainly on radiographic and clinical evaluation of their potential stability. An angle of kyphosis of 20 degrees or more evaluated using the sagittal index (s.i.) described by Farcy et al. in 1990, may be a valid indication for invasine treatment using pedicular systems for correction and stabilization; on the other hand, conservative treatment may be adequate for ensuring satisfactory results in fractures with an angle of less than 20 degrees, which are less likely to become unstable in clinically negative patients. This study confronts the immediate and long-term radiographic and clinical results in 2 groups of patients treated for amyelic thoracolumbar fractures, one treated conservatively, the other surgically; in particular, angle of kyphosis, vertebral compression and clinical conditions (pain and functional impairment) at long-term follow-up were assessed. The study was extended to include an assessment of outcome in relation to the angle of post-traumatic kyphosis in both operated and non-operated patients. Thirty-one patients with a diagnosis of non-neurological thoracolumbar trauma of the segment between D11 and L3 were studied. Twenty patients (group A) were treated conservatively (reduction on Cotrel bed and plaster vest) and 11 (group B) surgically (Diapason instrumentation). The 31 patients were subdivided into 2 groups according to the initial angle of kyphosis calculated using the s.i.: the first consisted of 16 patients (group C) with a s.i. of 20 degrees or more and the other of 15 patients (group D) with a s.i. less than 20 degrees. Six of the 16 group C patients and 5 of the 15 group D patients had been surgically treated. On the basis of the case-material considered, we found that satisfactory short-term radiographic results may be obtained by both conservative and surgical treatment. However, long-term outcome is less favorable in patients treated conservatively because maintainance of the initial improvement of the deformity in the injured segment is not as good as in those treated surgically. This limitation of conservative treatment does not however appear to negatively influence clinical conditions in patients with a s.i. of less than 20 degrees. In other words, although conservative treatment is not as effective as surgery for maintaining radiographic improvement, this does not necessarily signify clinical deterioration in cases with a s.i. of less than 20 degrees in whom the two types of treatment gave similar results.