Bed rest and TLSO bracing following neurologically stable burst fracture of the thoracolumbar spine
Date First Published:
June 18, 2007
Last Updated:
July 5, 2007
Report by:
Mark Gilhooly, Medical Student (MRI)
Three-Part Question:
In [adults diagnosed with burst fracture of the lumbar spine] does [bed rest and TLSO bracing/immobilisation] produce [satisfactory functional outcome]
Clinical Scenario:
A 45 year old male presents to the emergency department complaining of lower back pain following a 6 ft fall from a ladder. CT confirms your suspicion of a burst fracture at L1. Neurological examination is normal. You wonder if bed rest and TLSO bracing in these patients will produce a satisfactory functional outcome
Search Strategy:
Cochrane Database of Systematic Reviews 2nd Quarter 2007
Medline 1950 to June week 2 2007 using the Ovid interface
EMBASE 1996 to 2007 week 25.
Medline 1950 to June week 2 2007 using the Ovid interface
EMBASE 1996 to 2007 week 25.
Search Details:
({exp spinal fracture OR spinal fracture mp. OR burst fracture mp. OR thoracolumbar fracture mp. OR spinal trauma mp.} AND {thoracolumbar spinal orthosis mp. OR non-operative mp. OR recumbency mp. OR bed rest mp.} AND {exp treatment outcome OR functional outcome mp.}) LIMIT to english language. LIMIT to humans.
Outcome:
43 papers were found of which 5 were relavant to the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Functional outcome 5 years after non-operative treatment of a type A spinal fracture Post RB, et al 2006 The Netherlands | 33 patients with type A thoracolumbar fracture without neurological deficit treated non-operatively "unbraced group" n = 15 (mobilisation without brace) "braced group" n = 18 (2-6 weeks of bedrest followed by a three-point reclination brace) |
Case series | Restrictions in body function and structure using dynamic lifting tests and ergometry exercise test | 37 % were unable to perform the dynamic lifitng test within normal range (no difference was found between the braced and unbraced groups, P = 0.792). 40.9 % of the study group performed below the lowest normal value on the ergometry test (there was no significant difference netween the braced and unbraced groups, P = 0.300) | Study groups were small The RMDQ is not validated for spinal fracture, it is validated for low back pain |
| Restrictions in activities (RMDQ, VAS) | For the total study group the RMDQ score was 5.2, the mean VAS (Visual Analogue Scale) score was 79, no significant differences were found between the braced and unbraced groups, P = 0.442 and P = 0.190 respectively | ||||
| Restrictions in participation/quality of life (SF-36) | Braced and unbraced groups showed no significant differences with respect to SF-36 scores, 10 % patients had stopped working, 24 % had arranged changes in the intensity and duration of work and 3 patients had changed their job due to back complaints | ||||
| Thoracolumbar burst fractures: The clinical efficacy and outcome of non-operative management Mumford J, et al 1993 USA | 41 patients with single level, non-pathological burst fractures of the thoracolumbar spine (T11-L5) without neurological deficit | Case series | Clinical outcome and efficacy of closed management of thoracolumbar fractures | 49 % indicated excellent outcomes relative to pain and function, 17 % good, 22 % fair, and 12 % poor (6-point Likert scale, VAS, RMDQ) | The RMDQ (Roland Morris Disabiltiy Questionaire) is validated for low back paint not for fracture |
| Work status | 81 % of those who worked prior to injury returned to work, 53 % to the same job and 28 % at lower activity levels | ||||
| Nonoperative management of stable thoracolumbar burst frcatures with ealry ambulation and bracing Cantor JB, et al 1993 USA | 33 neurologically intact patients with burst fractures at the thoracolumbar junction treated with early ambulation in total orthosis 15 pateints were lost to follow-up |
Case series | Pain scale (Denis) | At follow-up of average of 19 months 9/18 patients reported no pain, 6 reported occasional/minimal pain, 2 moderate pain/occasional limitations, 1 moderate to severe pain, 0 reported constant severe pain | Small study group Only 18/33 patients were available for follow-up |
| Work scale (Denis) | 8/14 patients returned to previous employment heavy labour, 3 patients were able to return to sedentary work and 1 patient was unable to return to work due to disability | ||||
| Functional outcome of thoracolumbar fractures managed with hyperextension casting or bracing and early mobilization Chow GH, et al 1996 USA | 24 patients with unstable burst frcatures of the thoracolumbar region (T11-L2) | Retrospective case series | Recreational activity | 1 patient reported severe restrictions, 3 reported significant restrictions, 4 reported moderate restrictions, 5 reported minimal restriction and 11 reported no restrictions | Small sample size |
| Return to work | 6/24 patients were not working at the time of follow-up. The remaining 18 returned to work - 13/18 returned to a job of same physical demands as before injury, 3 worked in less physically demanding jobs. 2 patients were students | ||||
| Work restrictions | 1 patient reported severe restrictions, 2 patients reported significant restrictions, 3 reported moderate restrictions , 6 minimal restrictions and 12 reported no restrictions | ||||
| Non-operative treatment of burst-type thoracolumbar vertabra fractures: Clinical and radiological results of 29 patients Au H, Kayali C, Arslanta M 2005 Turkey | 29 neurologically intact patients with two or three column thoracolumbar burst fractures Group 1 - 16 patients with two-column injury (G1) Group 2 - 13 patients with three-column injury (G2) There were no significant differences with regard to fracture level (P = 0.679), gender (P = 0.702), age (P = 0.503) and follow-up periods (P = 0.170) between the two groups |
Case series | Work scale (Denis') and Pain scale (Denis') | Statistically significant differences between G1 and G2 were found when dispersion of percentages of both groups with respect to pain and work status (P = 0.003). Differences between G1 and G2 work and pain status was not significant if functional results were classified as satisfactory or unsatisfactory (P = 0.197) | Small sample size |
| Conservative treatment of fractures of the thoracolumbar spine Tezer M, et al 2005 Turkey | 48 pateints with thoracolumbar fracture (32 compression, 16 burst) 29 treated using TLSO 7 treated using body cast 6 treated using body cast and TLSO 6 treated using bed rest for 3 months |
Pain and function score (Denis') | Patients with burst fractures had a mean pain and functional score of 1.25 and 0.93 respectively |
Author Commentary:
Many studies highlight the distinct contreversy which exist regarding the treatment of spinal fractures. Outcome is dependant on fracture type.
Bottom Line:
Satisfactory outcome is achieved through bed rest and TLSO bracing/immobilisation. Satisfactory outcomes are achieved in terms of pain levels, work status and intensity and recreational activity.
References:
- Post RB, et al. Functional outcome 5 years after non-operative treatment of a type A spinal fracture
- Mumford J, et al. Thoracolumbar burst fractures: The clinical efficacy and outcome of non-operative management
- Cantor JB, et al. Nonoperative management of stable thoracolumbar burst frcatures with ealry ambulation and bracing
- Chow GH, et al. Functional outcome of thoracolumbar fractures managed with hyperextension casting or bracing and early mobilization
- Au H, Kayali C, Arslanta M. Non-operative treatment of burst-type thoracolumbar vertabra fractures: Clinical and radiological results of 29 patients
- Tezer M, et al. Conservative treatment of fractures of the thoracolumbar spine