Prognosis

Conservative versus surgical management

Thoracolumbar fractures with neurologic deficit:

There is conflicting evidence as to whether there is any difference between operative and non-operative treatment with regard to neurologic improvement or length of stay.[158][159][160] Other evidence has suggested that 29% of patients receiving conservative management for complete motor and sensory paralysis below the level of the injury (postural techniques and bed rest) improve by at least 1 grade during the course of their hospital stay.[161] When neurologic involvement is significant, operative management is generally advised, but there is no clear evidence to support one approach over the other.[162]

Thoracolumbar fractures without neurologic deficit:

Surgery for people with thoracolumbar burst fracture without neurologic deficit is likely to be associated with greater cost and an increased risk of complications compared with nonsurgical intervention, but there is insufficient evidence to determine which treatment modality yields superior pain and functional outcomes for these patients.[163][164][165]​ The most common reason for post-traumatic kyphosis is untreated, unstable burst fractures.[56]​ Operative management may improve residual kyphosis compared with nonoperative management.[164]

One study using ACS Trauma Quality Improvement Program (TQIP) data, suggested that for patients without spinal cord injury, the optimal timing for spine stabilization surgery (with the lowest rate of major complications) was at 21 hours post-injury, reflecting the time necessary to stabilize patients.[11][166]

Further studies are required, as there is inconsistent evidence regarding the effect of therapeutic exercise on osteoporotic vertebral fractures.[167]

Decompression surgery

There is mixed evidence evaluating the specific timing of surgical decompression in neurologic recovery.[10][46][115]​​[168][169]​​​​​​​​ However, most studies conclude that, when operative treatment is indicated, it is more beneficial to carry this out earlier rather than later.[10][115]​​​​ One randomized control trial showed that surgical decompression within 24 hours of acute traumatic thoracic and thoracolumbar spinal cord injury is safe and associated with improved neurologic outcomes.[10][113]​​ In a meta-analysis, patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury, as measured by an improvement in total motor scores, light touch scores, and pinprick scores.[114]​ Patients who had early decompression also had superior improvement in lower limb motor scores at one year after surgery, compared with patients who had late surgery.[114]​ One systematic review demonstrated that early stabilization of thoracic fractures reduced the mean number of days on a ventilator, the number of days in intensive care and in the hospital, and respiratory morbidity compared with late stabilization.[170] The benefits with stabilization of lumbar fractures were less marked; only a reduction in the length of hospital stay was observed. There is not enough evidence to determine the effect of the timing of stabilization on mortality in thoracolumbar fractures.[171]

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