Table 4.
Study Characteristics—Baseline.
| Author (Year) Study Design LoE | Inclusion and Exclusion Criteria | Treatment | Demographic Characteristics | Injury Characteristics (Grade, Level) |
|---|---|---|---|---|
| Wood (2003) RCT II | Inclusion criteria: Isolated burst fracture within the thoracolumbar region (T10 to L2) demonstrated on anteroposterior and lateral radiographs Computed tomography scan revealing a burst-type fracture with retropulsion of vertebral body bone posteriorly into the spinal canal No new neurological abnormality of the lower extremities or abnormality of bowel or bladder function Presentation less than 3 wk after the time of the injury An age between 18 and 66 years No medical illnesses that would preclude an operative intervention No ongoing cancer, infection, bleeding disorder, or skin disease An understanding of the English language. Concomitant stable compression fractures elsewhere in the spine were permitted if they did not require specific treatment. Exclusion criteria: Closed-head injury (a score of <14 points on the Glasgow coma scale on admission) Open vertebral fracture Neurological deficit related to the fracture Loss of structural Integrity within the posterior osteoligamentous complex (such as facet fracture, dislocation or flexion-distraction ligament disruption) Senile, osteopenic, or insufficiency fracture. A laminar fracture was neither an exclusionary criterion nor a contraindication for nonoperative treatment No absolute degree of kyphosis, canal encroachment by bone, or anterior loss of height was a criterion for exclusion | Operative: Short-segment (2- to 5-level) posterolateral spinal arthrodesis with pedicle screw-hook instrumentation and ICBG or Anterior 2-level fibular and rib-strut construct arthrodesis with local autogenous bone-grafting and instrumentation. | Operative: Mean age: 43.3 y Male: 16 (66.7%) Female: 8 (33.3%) | Operative: T11: 1 (4.2%) T12: 4 (16.7%) L1: 13 (54.2%) L2: 6 (25.0%) |
| Nonoperative: Body cast with manual kyphosis reduction through anterior force, worn for 8-12 wk, followed by thoracolumbosacral orthosis for 8 wk or Thoracolumbosacral orthosis with the spine in hyperextension to reduce the kyphosis and subsequent molded plaster cast that was then converted to an encompassing plastic jacket, worn for 24 h/d except for showering for 12-16 wk | Nonoperative: Mean age: 39.4 y Male: 16 (69.6%) Female: 7 (30.4%) | Nonoperative: T12: 4 (17.4%) L1: 15 (65.2%) L2: 4 (17.4%) | ||
| Landi (2014) Retrospective cohort III | Inclusion criteria: Magerl type A.3, involving only one level McCormack score 6 or less Spinal canal invasion 25% or less acc. to Hashimoto Disco-ligamentous integrity confirmed on MRI Neurologically intact (ASIA E) | Operative: Percutaneous short stabilization: One level above and one below | ND | A3.1:10 (40%) A3.2: 5 (20%) A3.3: 10 (40%) |
| Nonoperative: Rigid brace for 2 mo followed by semirigid brace for another 2 mo | ND | A3.1:12 (48%) A3.2: 7 (28%) A3.3: 6 (24%) | ||
| Post (2009) Retrospective cohort III | Inclusion criteria: Age 18-60 years at the time of injury A3 thoracolumbar (T7-L5) spinal fracture according to the Comprehensive Classification as diagnosed on radiographs and CT scans Without neurological deficit Treated at the University Medical Centre Groningen Exclusion criteria: Previous spinal disorders in the medical history Psychiatric illnesses Pathological fractures Insufficient command of the Dutch language. | Operative: Short fixation (for A3 fractures: called MSPI by other authors) involving 1 or two segments (depending on fx type, ie, with 2 damaged endplates: 2 segmental fixation; with 1 damaged endplate: 1-segmental fixation) | Operative: Mean age: 37.2 ± 11.8 y (18-56 y) Male: 26 (68%) Female: 12 (32%) | Operative: A3.1 15 (40%) A3.2 18 (47%) A3.3 5 (13%) Levels: T9-L5 Of these: T12/L1: 74% Multiple fractures: 5 patients* |
| Nonoperative: Bed rest (or rest on a Stryker frame) for 6 wk, followed by a reclination brace and mobilization. Weightbearing exercises after 3 months. Brace worn for 9 mo (24 h/d in first 6 months, only during the day in last 3 months). | Nonoperative: Mean age: 37.4 ± 12.2 y (19-58 y) Male: 15 (60%) Female: 10 (40%)” | Non-operative: A3.1 22 (88%) A3.2 3 (12%) A3.3 0 Levels: T7-L5 of these: T12/L1: 60% multiple fractures: 4 patients* | ||
| Difference in fx distribution (A3.2 and A3.3 vs A 3.1) ss: P < .01 | *Most severe registered, further fx not taken into account | |||
| Shen (2001) Prospective cohort III | Inclusion criteria: Neurologically intact with normal anal tone and no motor deficits, radiculopathy, or lower extremity spasms Single-level closed burst fracture involving T11, T12, L1, or L2 No dislocations, with pedicles and facet joints appearing intact, although the pedicles may have fractured from the vertebral body Nonosteopenic, nonpathologic adult 18 to 65 y of age No other major organ system or musculoskeletal injuries. Other radiographic parameters such as posterior column involvement, kyphosis angle, and degree of canal compromise were not used as inclusion or exclusion criteria. | Operative: Three-level fixation: Pedicle screws in the level above, in the fractured vertebrae, and in the level below the fractured vertebrae (3 levels, 6 screws). | Operative: Mean age: 42 y (20-64 y) Male: 18 (54.5%) Female: 15 (45.5%) | Operative: T11: 0 (0%) T12: 10 (30.5%) L1: 14 (42%) L2: 9 (27.5%) |
| Nonoperative: Bed rest with activity allowed (including ambulation) as tolerated by pain with hyperextension brace fitted in slight hyperextension with the patient standing. Brace worn 24 h/d (except when bathing) for 3 months (according to instructions, but no monitoring of compliance undertaken) | Nonoperative: Mean age: 44 y (19-64 y) Male: 23 (49%) Female: 24 (51%) | Nonoperative: T11: 1 (2%) T12: 11 (23%) L1: 23 (49%) L2: 12 (26%) | ||
| Wei (2010) RCT Ib | Inclusion criteria: Single-level closed burst fractures AO-ASIF type A3.1 and A3.2 involving T11–L2 No neurologic impairment Age 20-60 y Nonpathologic adult. Both pedicles intact without any cortical wall defect At least one of the endplate is intact or close to intact. Sagittal index (SI) > 15° or loss of anterior body height >50% Exclusion criteria: Other associated injuries, such as skull and brain injury, cervical whiplash injury, and fracture of the calcaneous, forearm, costal arches, and so on Poor bone mineral density (≤2.5 SD) Unfavorable body mass index (≥35 kg/m2) Multilevel involvement (>2 segments) | MSPI (mono-segmental pedicle instrumentation): Screws inserted into the vertebrae adjacent to the injured endplate (if the broken endplate was the superior and the adjacent vertebra was the upper, or if the broken endplate was the inferior and the adjacent vertebra was the lower). | MSPI Mean age: 39.3 ±14 y Male: 30 (71.5%) Female: 12 (28.5%) | MSPI: A3.1: 25 A3.2: 22 pts Levels: T11: 5 (10.7%) T12: 8 (17.0%) L1: 18 (38.30%) L2: 16 (34.0%) |
| SSPI (short-segment pedicle instrumentation): Pedicle screws in one level above and one level below the injured vertebra. | SSPI Mean age: 42.0±13 y Male: 33 (76.8%) Female: 10 (23.2%) | SSPI: A3.1: 21 pts A3.2: 17 pts Levels: T11: 6 (12.5%) T12: 7 (14.5%) L1: 21 (44.0%) L2: 14 (29.0%) | ||
| In total: Mean age: 40.5 ±11.7 y (Range, 20-60 y) Male 63 (74%) Female 22 (26%) | In total: T11 + T12: 16 (19%) L1: 39 (46%) L2: 30 (35%) | |||
| Li (2012) Retrospective cohort III | Inclusion criteria: Thoracolumbar burst fracture examined through 3-dimensional CT to investigate pedicle and vertebral displacement. Intact pedicles Only in MSPI group: unilateral end-plate injury] Exclusion criteria: Oversized bone in the spinal canal Neurological deficit | MSPI (monosegmental pedicle instrumentation): Screws inserted into the vertebrae adjacent to the injured endplate (if the broken endplate was the superior and the adjacent vertebra was the upper, or if the broken endplate was the inferior and the adjacent vertebra was the lower). | MSPI: Mean age: 41.3 y (29-54 y) Male: 18 (60%) Female: 12 (40%) | MSPI: A3.1: 28 (93.5%) A3.2: 2 (6.5%) Levels: T11: 4 (13%) T12: 6 (20%) L1: 13 (43%) L2: 6 (20%) L3: 1 (3.3%) |
| SSPI (short-segment pedicle instrumentation) Pedicle screws in one level above and one level below the injured vertebra | SSPI: Mean age: 40.2 y (30-53 y) Male: 18 (60%) Female: 12 (40%) | SSPI: A3.1: 28 (93.5%) A3.2: 2 (6.5%) Levels: T11: 6 (20%) T12: 9 (30%) L1: 9 (30%) L2: 5 (16.7%) L3: 1 (3.3%) | ||
| Bailey (2014) RCT Ib | Inclusion criteria: Isolated AO-A3 burst fracture (vertebral body compression with retropulsion of the posterior vertebral body into the canal and excludes posterior element injury) between T10 and L3 Kyphotic deformity lower than 35° Neurologically intact 16 to 60 y of age Recruited within 3 days of injury Exclusion criteria: Patients who could not wear a brace (ie, pregnancy/body mass index >40 kg/m2) Mobilized with or without a brace before recruitment Suffered a pathologic or open fracture Alcohol or drug abusers Previous injury or surgery to the thoracolumbar region Unable to complete the outcome questionnaires | No orthosis (NO): Immediate mobilization as tolerated with restrictions to limit bending and rotating through the trunk. Return to normal activities encouraged after 8 weeks. | NO: Mean age: 39.8±15.3 y Male: 69.4% Female: 30.6% | NO: AO: A3 Levels: T11: 2 (4.1%) T12: 9 (18.4%) L1: 29 (59.2%) L2: 3 (6.1%) L3: 6 (12.2%) |
| Early mobilization with “off-the-shelf” adjustable thoracolumbosacral orthosis (TLSO): Strict bed rest until fitted with a TLSO and mobilization in the brace. The TLSO worn at all times except when lying flat in bed for a total of 10 wk with start of weaning from the brace at 8 weeks | TLSO: Mean age: 40.5±14.8 y Male: 70.2% Female: 29.8% | TLSO: AO: A3 Levels: T11: 2 (4.3%) T12: 9 (19.1%) L1: 21 (44.7%) L2: 12 (25.5%) L3: 3 (6.4%) | ||
| Proietti (2014) Retrospective cohort III | Inclusion criteria: Single-level A3 fracture between T11 and L5 Age 18-65 y No neurological involvement Exclusion criteria: Pathological or osteoporotic fracture Multilevel fracture Previous surgery at site of fracture | All patients (groups A + B): Short stabilization: One level above and one below | Total (groups A + B): Mean age: 51.2 y (20–65 y) Male: 38 (63.5%) Female: 22 (36.5%) | Total (groups A + B): Magerl classification A 3.1= 28 (47%) A 3.2= 8 (13%) A 3.3= 24 (40%) Levels: T11: 5 (8.3%) T12:17 (28.3%) L1: 17 (28.3%) L2: 8 (13.5%) L3: 9 (15%) L4: 3 (5%) L5: 1 (1.6%) |
| Group A, n = 39: SI value >10° ≤15° | ||||
| Group B, n = 21 SI > 15° | ||||
| Schmid (2011) Prospective cohort III | Inclusion criteria: Burst fractures (type A3 according to Magerl) of the thoracolumbar junction (T12-L2) No neurological deficits (Frankel/ASIA E) Age <60 y Exclusion criteria: Fractures above T12 or below L2 Fractures with intact posterior wall (A1 and A2 acc. to Magerl) Neurological deficits (Frankel/ASIA A–D) Pathological or osteoporotic fractures Incomplete radiological or clinical follow-up Nonresident patients | Short segmental posterior fixation with angular stable pedicle screw systems Plus posterolateral fusion Plus unilateral TLIF with monocortical strut grafts and cancellous bone (ICBG) Implant removal at a mean of 15.1 ± 3.7 months The analysis was performed separately for 2 patient groups, but only group B (“TLIF group”) was large enough to be eligible for this review, group A is not considered here | Mean age: 32.7±11.3 y Male: 16 (76%) Female: 5 (24%) | Magerl A3 T12: 7 (33.5%) L1: 11 (52.5%) L2: 3 (14.0%) |
| Jeong (2013) retrospective cohort III | Inclusion criteria: Thoracic and lumbar burst fractures A fractured posterior vertebral surface dislocated into the spinal canal No neurological deficit A minimum of 1-year follow-up Indirect decompression using the ligamentotaxis technique Short-segment implants (1 level above and 1 level below the fracture) Exclusion criteria: Complete tear of the PLL as seen on MRI Any neurolgical deficit. | Pedicle screws 1 level above and 1 level below the fracture level The analysis was performed separately for 2 patient groups, but only one group (“high grade fracture group”) was large enough to be eligible for this review, so the other group is not considered here | Mean age: 38.8 y (16-61 y) Male: 15 (65%) Female: 8 (35%) | McCormack ≥7 27 levels in 23 pts |
| Koller (2008) Retrospective case series IV | Inclusion criteria: Single-level thoracolumbar (T11–L2) or lumbar (L3–5) compression or burst fracture Absence of neurological injury (Frankel A-D) Age 18-60 y at injury Understanding of the author’s language ≤10 days between injury and index treatment Full set of injury lateral and anteroposterior radiographs; CTscans were not necessary for inclusion Exclusion criteria: Medical illness that precluded operative treatment Prior thoracic, lumbar, abdominal or genitourinary surgery Major organ system or musculoskeletal injuries Spinal disorders in the patient’s medical history requiring a specific medical treatment Chronic drug and alcohol abuse Concomitant serious head, thoracic, or abdominal injuries Proven evidence of osteoporosis Serious mental disorders leading to medical intervention Pregnancy End-stage medical diseases Lower extremity injuries affecting gait or limb length Failure to comply in wearing the brace Worker’s compensation claims Preexisting spinal deformity | Manual kyphosis reduction through anterior force, then 3 mo of brace (24 h/d) | Mean age: 49.1 ± 15.7 y Male: 15 (71.5%) Female: 6 (28.5%) | A3.1: 52.4% (n = 11) - A3.1.1: 9 - A3.1.2: 2 A3.2: 38.1% (n = 8) - A3.2.1: 7 - A3.2.2: 1 A3.3: 9.5% (n = 2) - A3.3.1: 1 - A3.3.3: 1 Levels: T12: 5 (23.8%) L1: 9 (42.9%) L2: 2 (9.5%) L3: 2 (9.5%) L4: 3 (14.3%) |
| Andress (2002) Retrospective case series IV | Inclusion criteria: Burst-compression fracture at the thoraco-lumbar spine (T11–L2) which involved the middle column but left the posterior column intact (type A 3 according to Magerl) No neurological deficit No pathologic fracture Exclusive dorsal stabilization with the AO internal fixator (Synthes Cooperation, Bochum, Germany) in combination with or without transpedicular bone grafting Single level injury Complete documentation of the case including a pre-operative spinal CT Conventional biplanar X-rays of the thoracolumbar spine pre- and postoperatively, at the time of implant removal and at follow-up Minimal time period between surgery and follow-up examination: 36 mo Implant removal 9-15 mo after surgery. Exclusion criteria: Neurological deficit Injuries at the dorsal column Rotation injuries | Internal fixator either with or without transpedicular spongiosa grafting with fixed-angle pedicle screw instrumentation and pedicle screws above and below the fractured vertebral body In cases where the kyphotic angle was large or where the fractured vertebral body was completely destroyed: transpedicular inter- and intracorporal autologous bone grafting after transpedicular discectomy Transpedicular spongiosa grafting: 29 pts (58%) No grafting: 21 pts (42%) | Mean age: 46.2 y (22-77 y) Male: 27 (54%) Female: 21 (46%) | Magerl A3: A3.1: 19 (38%) A3.2: 17 (34%) A3.3: 14 (28%) Levels: L1: 27 (54%) L2: 12 (24%) Th12: 11 (22%) |
Abbreviations: LoE, level of evidence; CT, computed tomography; RCT, randomized controlled trial; ICBG, iliac crest bone graft; SI, sagittal index; pts, patients.