Meta-analysis
ACE Report #10016

Fusion not necessary in addition to fixation of thoracolumbar burst fractures


Study Type:Meta-analysis/Systematic Review
OE Level Evidence:1
Journal Level of Evidence:N/A

Is fusion necessary for thoracolumbar burst fracture treated with spinal fixation? A systematic review and meta-analysis

J Neurosurg Spine. 2017 Nov;27(5):584-592

Contributing Authors: RV Botelho JM Diniz

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Synopsis

Five randomized and quasi-randomized controlled trials were included in this meta-analysis comparing surgical and postoperative outcomes in internal fixation of thoracolumbar burst fractures with and without additional fusion. For surgical outcomes, fusion groups demonstrated significantly longer operative time and intraoperative blood loss. For postoperative outcomes, there were no significant differences observed between fusion and no fusion groups for functional scores, radiographic outcomes, or the incidence of fixation failure.

Publication Funding Details +
Funding:
Not Reported
Conflicts:
None disclosed

Risk of Bias

9.5/10

Reporting Criteria

19/20

Fragility Index

N/A

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?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

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.

4/4

Introduction

4/4

Accessing Data

3/4

Analysing Data

4/4

Results

4/4

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?

Thoracolumbar burst fractures are common spinal fractures. While traditionally managed nonoperatively, there has been increasing use of fixation for these fractures over the past few decades. Arthrodesis - or fusion - can also be used alongside fixation, though the role of fusion, from an evidence-based standpoint, is still debated.

What was the principal research question?

Is there any significant difference in outcome after thoracolumbar burst fracture between internal fixation with and without additional fusion?

Study Characteristics -
Data Source:
Medline and the Cochrane Register of Controlled Trials were searched for relevant article published up to February 28 2016. Reference lists of identified articles were also searched for any additional studies.
Index Terms:
Search strategy included keyword terms: ("fusion" or "arthrodesis") and ("burst fracture" or "thoracolumbar fracture" or "spinal fracture").
Study Selection:
Eligibility criteria included: a randomized or quasi-randomized controlled trial design; enrolled at least 20 patients, over the age of 18 years and with a single-level thoracolumbar burst fracture; allocated patients to internal fixation with or without arthrodesis; and performed follow-up for a minimum of 12 months after surgery. Screening and selection were performed independently by two reviewers, with disagreement resolved through discussion and consensus. A total of 5 studies were selected for final inclusion.
Data Extraction:
Data extraction was performed independently by two reviewers, with disagreement resolved through discussion and consensus.
Data Synthesis:
Statistical analyses were performed using Comprehensive Meta-analysis software. Continuous outcomes were expressed using mean differences, and dichotomous outcomes were expressed using odds ratios, both with 95% confidence intervals.

What were the important findings?

  • Differences in clinical outcome scores between the fusion and no fusion groups were not significant, including a VAS function score (2 studies; MD 0.1 [95%CI -0.31, 0.51]; p=0.63) and the Low Back Outcome Score (4 studies; MD 4.03 [95%CI -4.97, 13.05; p=0.38)
  • Differences significantly favoured no fusion over fusion for operative time (4 studies; MD -54.9min [95%CI -77.27, -32.65]; p<0.05) and in intraoperative blood loss (4 studies; MD -164.45mL [95%CI -236.64, -92.26]; p<0.05). The difference between groups was not significant for length of hospital stay (3 studies; MD 0.88 days [95%CO -0.42, 2.17]; p=0.18).
  • Incidence of fixation failure did not significantly differ between the fusion (4.6%) and no fusion group (7.2%) (3 studies; OR 0.687 [95%CI 0.211-2.238]; p=0.53).
  • No significant differences in segment mobility, correction of kyphosis, loss of correction of kyphosis, final kyphotic angle, or correction of vertebral height were observed between fusion and no fusion groups.

What should I remember most?

In surgical management of thoracolumbar burst fractures, the addition of fusion to fixation did not result in any significantly different effect on clinical outcome, radiological outcome, or fixation failure rate when compared to fixation alone. Adjunct fusion was also associated with significantly longer operative time and greater intraoperative blood loss.

How will this affect the care of my patients?

The results of this meta-analysis suggest that routine fusion in addition to fixation may not be necessary in treatment of thoracolumbar burst fractures.

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