Pain often persists after conservative treatment of some spine fractures

Patients preferred physical therapy, but braces worked better long-term.

While surgeons know of many conservative, non-operative, safe and effective treatments for traumatic thoracolumbar spine fractures, they do not agree on which of them delivers the best outcomes.

In an attempt to find out, F.C. Öner, MD, and his fellow researchers did a prospective randomized study comparing four treatment options for AO type A1 and A2 compression fractures, and two treatment options for AO type 3 burst fractures in neurologically intact patients.

A high percentage of traumatic spinal fracture patients suffer persistent moderate back pain. “As you all know, from past experience and also from recent literature, most compression and stable burst fractures can be treated conservatively,” Öner said at the 2005 Annual Congress of the Spine Society of Europe (EuroSpine 2005). “However, treatment is often poorly defined in different papers, yet they vary from active exercise to strict bed rest for several weeks.”

Treatment options

The study included 133 patients with 158 fractures (130 compression fractures and 28 burst fractures), said Öner, of the University Medical Center Utrecht, the Netherlands. The researchers randomized the compression fracture patients for the following treatments:

physical therapy with postural adjustment and training exercises;
Boston brace for six weeks;
total contact orthosis for six weeks; and
total contract orthosis for 12 weeks.

Patients with burst fractures received total contact orthoses for 12 weeks or Boston braces for 12 weeks, Öner said.

Follow-up came at six weeks, six months, 12 months and a mean endpoint of 4.5 years. The mean long-term follow-up percentage: 75.4%.

The various treatments produced similar results. Researchers found no significant differences between the groups’ Cobb angles at different follow-up points. Investigators found Oswestry Disability Index scores and Visual Analogue Scores comparable at final follow-up, Öner said.

But patients who received physical therapy alone had pain for longer periods. In fact, one patient with an A-3 fracture underwent dorsal fusion after 22 months because of lingering pain and deformity. Patients considered six weeks of brace treatment the least uncomfortable of the four treatment choices, Öner said.

Overall, almost one quarter of all patients had persistent moderate back pain at long-term follow-up, he said. Compared to the incidence of non-specific low back pain in the general population, a high percentage of traumatic spinal fracture patients suffer from persistent back pain, the authors concluded in the abstract.

Still, the study showed that brace therapy may result in less long-term pain than physical therapy alone, Öner said.

“... The physical therapy is preferred by patients but the brace therapy gives the best results,” he said. “So, you can say that there are strong differences in treatment satisfaction between the patients in these groups, and that brace therapy gives less residual pain ... . A full brace in fracture immobilization is better than mere physical therapy.”

For more information:
Öner, FC, Stadhouder, A, Buskens, E, et al. Conservative treatment of thoracolumbar spine fractures: a prospective randomized study of different treatment options. Paper #32. Presented at EuroSpine 2005. Sept. 21-24, 2005. Barcelona, Spain.