Thoracolumbar burst fractures: Fusion versus nonfusion in surgical treatment .
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2013;1(12):220 PLoS One. 2013 May 21;8(5):e63995. doi: 10.1371/journal.pone.0063995. Print 20134 randomized controlled trials and 1 quasi-randomized controlled trial evaluating the effects of fusion in conjunction with posterior pedicle screw fixation in the treatment of thoracolumbar burst fractures were included in this meta-analysis. The purpose of this review was to determine if additional spinal fusion was advantageous over nonfusion. The pooled data indicated that there were no significant differences between groups in kyphotic angles, vertebral body height, functional outcomes, neurological status, implant failure, or hospital stay. Blood loss and operative time were significantly lower in the nonfusion group.
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
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The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
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Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Burst type fractures in the thoracolumbar spine are characterized by excess kyphosis and neurological deficits. Although non-surgical treatment has been suggested to be effective in patients suffering from a thoracolumbar burst fracture without neurological deficit, surgical treatment allows for the restoration of vertebral height, the correction of the kyphotic angle, increased stability and the decompression of neurostructures. Posterior pedicle screw fixation is a common surgical procedure in the treatment of thoracolumbar burst fractures because of its ability to provide a 3-column stabilization. A number of randomized controlled trials comparing posterior pedicle screw fixation either with or without fusion have recently been conducted, thus giving rise to this meta-analysis.
What was the principal research question?
What are the benefits of adding spinal fusion to posterior pedicel screw fixation in patients suffering from thoracolumbar burst fractures?
- Pooled kyphotic angle data from 3 studies indicated that there was no significant difference between groups in postoperative kyphotic angle (0.14 degrees; 95% CI -0.25 to 0.53; p=0.49), kyphotic angle at last visit (-0.20 degrees; 95% CI -0.85 to 0.45; p=0.55), and lost kyphotic angle (-0.05 degrees; 95% CI -0.63 to 0.53), while 1 study revealed no significant differences between groups in correction of the kyphotic angle (0.40 degrees; 95% CI -2.72 to 3.52; p=0.8). A chi-squared analysis revealed no heterogeneity between studies (p>0.1).
- Pooled vertebral body height (VBH) data from 2 studies indicated that there was no significant difference between groups in postoperative decreased VBH (1.14%; 95% CI -1.32 to 3.60; p=0.36) or decreased VBH at last visit (1.50%; 95% CI -8.99 to 11.98; p=0.78).
- Pooled functional outcome data from 3 studies (all assessed using the Greenough low back outcome scale) indicated that there was no difference in functional outcomes between groups at the last visit (-0.68; 95% CI -3.24 to 1.87; p=0.6).
- Pooled data from 3 studies indicated that there was no difference between groups in neurological status at final follow-up (p=0.794).
- Pooled data from all 4 studies indicated that there was no difference in implant failure rate between the two groups (RR=1.83; 95% CI 0.62 to 5.40; p=0.28). There was no heterogeneity amongst studies (I-squared = 0%; p=0.92).
- Pooled data from all 4 studies indicated that there was a significantly reduced operative time in the nonfusion group (weighted mean difference of 55.04 min; 95% CI 32.80 to 77.28; p<0.0001). There was, however, statistically significant heterogeneity amongst studies (I-squared = 70%; p=0.02).
- Pooled data from 3 trials revealed that the nonfusion group suffered significantly less blood loss compared to the fusion group (weighted mean difference of 189.5 mL; 95% CI 86.5 to 292.5; p=0.0003). There was, however, significant heterogeneity amongst studies (I-squared = 80%; p=0.006).
- Pooled data from 3 trials revealed that there was no significant difference in hospital stay between groups (weighted mean difference of -0.9 days; 95% CI -2.2 to 0.4; p=0.19). There was no heterogeneity amongst studies (I-squared = 0%; p=0.83).
What should I remember most?
There was no significant difference in kyphotic angles, vertebral body height, functional outcomes, neurological status, implant failure, or hospital stay between the fusion and nonfusion groups when combined with posterior pedicle screw fixation in the treatment of thoracolumbar burst fractures. There was, however, significantly decreased operative time and blood loss in the nonfusion group.
How will this affect the care of my patients?
This meta-analysis does not support the treatment of thoracolumbar burst fractures with posterior pedicle screw fixation in conjunction with fusion over nonfusion. This finding should be interpreted with caution, as there was significant heterogeneity amongst studies for certain outcomes. In addition, more than half of the patients included in this meta-analysis did not experience neurological deficit. Therefore, future studies are required to evaluate the effect of non-surgical treatment in patients who are not neurologically intact.
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