FUNCTIONAL OUTCOME OF THORACOLUMBAR BURST FRACTURES MANAGED WITH HYPEREXTENSION CASTING OR BRACING AND EARLY MOBILIZATION

Study Design. A retrospective study to review the results of unstable thoracolumbar burst fractures managed with casting or bracing and earl y ambulation in neurologically healthy patients. Objectives. To determ ine the clinical outcome of patients with unstable burst fractures of the thoracolumbar spine treated without surgery, and to identify any v ariables that may adversely influence the final outcome. Summary of Ba ckground Data. The management of unstable fractures of the thoracolumb ar spine as described by Bedbrook involves a period of recumbency for 6-8 weeks followed by gradual mobilization. Newer techniques of surgic al stabilization of the fracture and decompression of the neural eleme nts have become popular because immediate stability of the spine is cr eated and because the need for prolonged bedrest and hospitalization i s eliminated. There have been only three reports in the literature des cribing the nonoperative management of these fractures with early mobi lization; some authors believe that this is appropriate only if the po sterior column is intact. The results reported in the literature of no noperative management of thoracolumbar burst fractures have indicated that this is an effective method of management. Methods. A retrospecti ve review of 26 patients with unstable burst fractures in the thoracol umbar region (T11-L2) was performed; follow-up evaluation was obtained from 24 patients. Clinical follow-up examination was performed by the use of a questionnaire in which the patients were asked to rate their pain, ability to work, ability to perform in recreational activities, and their overall satisfaction with treatment. Results. Mean follow-u p time for the 24 patients was 34.3 months. Mean duration of hospitali zation was 8.2 days; those patients who did not have injuries other th an their spine fracture had a mean hospitalization time of 5.9 days. K yphotic deformity could be corrected with hyperextension casting but t ended to recur during the course of mobilization and healing. No corre lation was found between kyphosis and clinical outcome. At final follo w-up evaluation, 19 patients (79%) had little or no pain; 18 patients (75%) had returned to work; 18 (75%) stated that they had little or no restrictions in their ability to work, and 16 (67%) stated that they had little or no restrictions in their ability to participate in recre ational activities. Only one patient (4%) reported being dissatisfied with the initial nonoperative treatment of his spine fracture. Ten pat ients were found to have evidence of spinous process widening on plain films; there was no significant difference in the clinical or radiogr aphic outcome of these 10 patients when compared with the 14 others wh o did not have interspinous widening. Conclusions. Nonoperative manage ment of thoracolumbar burst fractures with hyperextension casting or b racing was proven to be a safe and effective method of treatment in se lected patients. Clinical results were favorable; no neurologic deteri oration was observed; hospitalization times were minimized, and patien t satisfaction was high. The authors do not believe that ligamentous i njury of the posterior column is a contraindication to nonoperative ma nagement of thoracolumbar burst fractures.