Large-scale multicentre RCT needed to fully establish optimal surgical intervention for thoracolumbar burst fractures


A large, high-quality, multicentre randomised controlled trial (RCT) is needed to determine the optimal surgical intervention for thoracolumbar burst fractures, according to new research.

The systematic review and meta-analysis, published by Hannah Hughes (Mater Misericordiae University Hospital, Dublin, Ireland) et al in the journal Spine, concludes that an RCT with standardised reporting of outcomes and a particular focus on outcomes relating to patient function and severe complications causing long-term morbidity is needed.

The meta-analysis sought to compare the clinical, functional, and radiological outcomes of posterior-only versus combined anterior-posterior instrumentation in order to determine the optimal surgical intervention for thoracolumbar burst fractures.

The authors note that “unstable thoracolumbar burst fractures warrant surgical intervention to prevent neurological deterioration and progressive kyphosis, which can lead to significant pain and functional morbidity. The available literature remains largely inconclusive in determining the optimal instrumentation strategy.”

Electronic searches of MEDLINE, EMBASE, the Cochrane Library, and other databases were conducted.

Outcomes of interest were divided into three categories: radiological (degree of postoperative kyphosis correction; loss of kyphosis correction at final follow-up), functional (visual analogue scale [VAS] pain score; Oswestry Disability Index [ODI] score), and clinical (intraoperative blood loss; length of stay [LOS]; operative time; the number and type of postoperative complications).

Four RCTs were retrieved which together included 145 randomised participants. A total of 73 patients underwent posterior-only instrumentation and 72 underwent combined instrumentation.

No significant difference was found in the degree of postoperative kyphosis correction (p=0.39), VAS (centimetres) at final follow-up (p=0.67), ODI at final follow-up (p=0.89) or the number of postoperative complications between the two approaches (p=0.49).

However, posterior-only instrumentation was associated with lower blood loss (p<0.001), operative time (p<0.001), and LOS (p=0.01). Combined instrumentation had a lower degree of kyphosis loss at final follow-up (p=0.001). There was also heterogeneity in the duration of follow-up between the included studies (mean follow-up range 24–121 months).


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