Evidence-Based Recommendations for Spine Surgery

Alexander R. Vaccaro, MD, PhD, MBA; Charles G. Fisher, MD; Srinivas K. Prasad, MD; Alpesh A. Patel, MD, FACS; John Chi, MD, MPH; Kishore Mulpuri, MBBS, MHSc; Kenneth C. Thomas, MD, MHSc; Peter G. Whang, MD, FACS


Spine. 2020;45(21):E1441-E1448. 

In This Article

Recommendation Regarding Impact on Clinical Practice

In general, the methodological design of this study is appropriate for answering the clinical question of interest and for the most part the results are presented clearly. The follow-up rate is relatively high at all time points and for all measures. While the authors did identify a significant difference in the primary outcome (i.e., fusion rates), the diagnostic criteria used to define fracture healing based may be too broad and likely increase the incidence of false-positive results. One important concern is that it is uncertain as to how the sample size was determined and it is unclear whether there was sufficient power; this information is required to determine if the lack of any differences in the secondary clinical and radiological outcomes between the groups serves to confirm the equivalence of these fixation constructs or is simply due to lack of power. Given these myriad issues, the choice of surgical technique for stabilizing fractures involving the thoracolumbar junction should still be left to the discretion of the treating surgeons and we do not recommend any changes to clinical practice.

Mohamedi A, Goodanian A, Ahmadi A, et al. Comparison of surgical or nonsurgical treatment outcomes in patients with thoracolumbar fracture with score 4 of TLICS: a randomized, single-blind, and single-central clinical trial. Medicine 2018; 97:e9842.

Thoracolumbar fractures are among the most common spinal injuries, and the manner in which they are managed can vary depending upon a number of different factors. The Thoracolumbar Injury Classification and Severity (TLICS) scale was developed to not only elucidate the most critical components of these injuries but also to provide guidance regarding their treatment. This paradigm is based on three parameters: fracture morphology, integrity of the posterior ligamentous complex, and the neurological status of the patient. Each of these categories is graded and the values summed to yield the TLICS score. Surgery is generally indicated for injuries with a score greater than 4, whereas nonoperative modalities (e.g., bracing) are typically implemented for those with a score of less than 4. However, the optimal therapeutic protocol for injuries assigned a score of 4 (which are most commonly burst fractures) remains a matter of some controversy because the safety and efficacy of surgery relative to conservative management have not been definitively established in the literature. Unfortunately, there is still a paucity of high-quality studies directly comparing one treatment to the other in this patient population (i.e., thoracolumbar fractures with a TLICS value of 4). In their investigation, Mohamadi et al[18] compare the clinical and radiographic outcomes associated with surgical intervention and nonoperative care for injuries with a TLICS score of 4.