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Thoracolumbar burst fracture debate addresses classification, prevention of kyphotic deformity
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ISTANBUL — In a Debate Forum on conservative vs. surgical management of traumatic thoracolumbar junction burst fractures at the EFORT Congress, Ahmet Alanay, MD, of Ankara, Turkey, debated Frank Kandziora, MD, PhD, of Frankfurt, Germany, about the dilemmas orthopaedic spine surgeons encounter with these cases.
"This is a fracture that should be treated conservatively," Alanay said.
Ahmet Alanay
Kandziora said some of the ongoing debate over appropriate care of these fractures is because burst fracture is an umbrella term.
"Studies show a lack of evidence for one treatment, but these studies have no long-term follow-up," Kandziora said.
Alanay discussed the challenges of thoracolumbar junction burst fractures that are important in the selection of an appropriate treatment option, but noted many of these fractures can be adequately addressed with bracing or casting.
Alanay said it is a myth that canal clearance was a real problem with these fractures.
Alanay reviewed the patient-centric literature results to support his contention that good patient outcomes can frequently be attained with conservative treatment.
"We see several papers with satisfactory outcomes," including one by Wood and colleagues published in 2003, he said.
Alanay said his experience and that reported in the literature show few complications with conservative management of thoracolumbar burst fractures.
"If you looked at the conservative care series, we do not have that many complications," although complication rates can be as high as 15% for surgery, in some instances, and later revisions may be required with those procedures, he said.
Frank Kandziora
The balance of Kandziora’s argument addressed the fact that published studies include inhomogeneous groups of patients, and many of the studies are greatly underpowered. Additionally, there are no validated trauma-specific clinical scores on a par with the Oswestry Low Back Disability Index or the SF-36 for the spine, he said.
"We simply do not know what we are measuring with these scores at all," he said.
Kandziora shared some insights into how surgeons in Germany manage these patients effectively with standing radiographs that show more kyphotic deformity than films made with the patient laying down. Those differences in kyphotic angle measurement can be critical, he said.
He discussed the role that the re-evaluation of patients 6 months or more after surgery can play in deciding if anterior thoracoscopic stabilization is required or when to attempt implant removal.
Burst fractures are not as controversial as they seem, Kandziora said.
"It is just a lack of detailed evaluation and treatment," he said.
References:
Alanay A. Conservative management.
Kandziora F. Surgical management.
Both presented at: EFORT Congress; 5-8 June 2013; Istanbul.
Wood K. J Bone Joint Surg Am. 2003; 85:773-781.
Disclosures: Alanay is a consultant and speaker and receives funds for travel from Medtronic. Kandziora has no relevant financial disclosures.