Patient-reported outcomes following operative and nonoperative management of A3 versus A4 thoracolumbar burst fractures

J Neurosurg Spine. 2026 May 29:1-13. doi: 10.3171/2026.1.SPINE251316. Online ahead of print.

ABSTRACT

OBJECTIVE: The aim of this study was to compare patient-report outcome measures in patients with thoracolumbar burst fractures managed either operatively or nonoperatively.

METHODS: A prospective multicenter observational study was conducted of neurologically intact patients who sustained traumatic thoracolumbar burst fractures managed operatively or nonoperatively. Outcome measures included scores on the EQ-5D index, EQ-5D visual analog scale (VAS), pain numerical rating scale (NRS), and AO Spine Patient Reported Outcome Spine Trauma (PROST) tool and patient satisfaction with follow-up up to 2 years. The Wilcoxon rank-sum test and Cochran-Armitage test were used to evaluate differences between continuous and ordinal variables, respectively. Mixed models for repeated measures (MMRM) were used for continuous outcomes using unstructured covariance. A generalized estimating equations (GEE) model was employed for the ordinal outcomes of anxiety and depression.

RESULTS: In total, 198 patients were identified. The EQ-5D index scores were similar for A3 and A4 fractures at long-term 2-year follow-up with respect to operative (p = 0.48) and nonoperative (p = 0.51) management. This was paralleled by EQ-5D VAS scores for surgical (p = 0.33) and nonsurgical (p = 0.21) treatment. The adjusted mixed-effects model for EQ-5D index and EQ-5D VAS scores showed significant improvements for both operatively and nonoperatively treated A3 and A4 fractures at all follow-up evaluations (p < 0.05), except for EQ-VAS at 6 weeks in the nonsurgical group (p = 0.812). The GEE model confirmed that there was a higher proportion of patients who were less anxious or depressed among operatively managed patients with A4 fractures compared to those with A3 fractures at 2-year follow-up (OR 7.7, 95% CI 1.5-40.5, p = 0.02). MMRM for pain NRS and AO Spine PROST suggested that there was a significant improvement in outcome compared to discharge for both surgically and nonsurgically treated patients (p < 0.05) but no significant difference between the surgical subgroups. Patient satisfaction was similar between those with A3 and A4 fractures for nonoperatively (p = 0.62) and operatively (p = 0.50) treated patients at final follow-up.

CONCLUSIONS: The contemporary management of thoracolumbar burst fractures in neurologically intact patients has evolved to the extent that there is improvement in function, pain, and disability for both A3 and A4 fractures regardless of whether surgical or nonsurgical management is pursued. Patients who sustained the more severe A4 morphology experienced improved mental health outcomes at the final 2-year follow-up if operatively managed. Ultimately, patient satisfaction was similar when compared with the EQ-5D index and EQ-5D VAS.

PMID:42214102 | DOI:10.3171/2026.1.SPINE251316