Abstract
Introduction: Reported standardized functional outcome assessment of flexion distraction injuries of the thoracolumbar spinal column seems to be lacking in the literature. The primary focus of this study was the long term functional outcome in this patient population in view of the management employed in a tertiary spine referral center. In an attempt to overcome the lack of pre-injury Health Related Quality of Life (HRQOL) data, patient recall of the pre-injury state was used.
Secondary outcomes included the long-term disease-specific HRQOL in these patients, the correlation between radiographic alignment and functional outcome, comparison of HRQOL between operative and non-operative care, and identifying potential prognostic factors influencing functional HRQOL.
Method: A database generated retrospective cohort study with a cross-sectional outcome analysis was carried out for patients with a thoracolumbar (T11-L2) flexion-distraction injury treated at a tertiary care referral center between 1995 and 2000.
Inclusion criteria were age over sixteen, and referral to our center for a traumatic thoracolumbar flexion-distraction injury within two weeks of the injury. Exclusion criteria were an associated spinal cord injury, a previous spine injury or a multi-level spine injury, a significant associated other system injury with an ISS > 50, or patient refusal or inability to complete the outcome questionnaires. Patients were followed for a minimum of two years. Injury classification, healing, and alignment were determined by radiographic analysis. Standing lateral x-rays at final follow-up were used to determine the amount of residual kyphosis by two independent observers.
Results: A total of 87 patients were identified by the research database, of which 83 met inclusion and exclusion criteria. Twenty-eight patients were lost to follow-up, leaving 55 eligible patients. Eight refused to participate. Of the 47 remaining patients, 40 completed questionnaires representing a response rate of 85%.
There were 26 males and 14 females with a mean age of 27.4 years (range 16–48). Average follow-up was 3.3 years (range 2.5–7). Twenty-five patients (64.9%) were treated operatively and fifteen patients (35.1%) underwent non-operative management. Complications in the surgical group included one non-union, three cases of painful instrumentation, and one infection. In the non-surgical group, two patients developed non-unions requiring surgical intervention.
Comparing the follow-up mean SF-36 PCS and MCS scores to the recalled baseline SF-36 pre-injury scores, demonstrated the patients did not return to baseline physical component and mental component scores (p < 0.001).
The mental component (MCS) and NASS pain scores showed significant statistical difference between the two groups with a trend of non-surgical patients scoring higher.
There was no statistically significant difference in the SF-36 PCS between the two groups.
Linear and multiple regression models identified “associated other system injuries” as the only useful predictor of outcome influencing the SF-36 PCS. Patients with associated injuries are likely to have a poorer prognosis with lower scores.
Radiographically, there was no association between degree of kyphosis at last follow-up and outcome.
Discussion: Long term functional outcome assessment in this patient population and comparison between the surgical and non-surgical groups, revealed a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. There were also a higher number of complications associated with the surgical group, as well as potential residual back pain related to instrumentation.
Limitations of the study were the retrospective nature of the study, as well as the inherent absence of real time pre-injury quality of life assessment. The study is, however, strengthened by a homogeneous cohort and the use of validated outcome measures. It also involves a cross-sectional analysis and so has a prospective component
Conclusion: The health related quality of life in patients treated for flexion-distraction injuries without spinal cord injury is favorable overall, but does not return to normal after an average of two years following injury, with a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. Radiographically, no association was found between degrees of focal kyphosis at last follow-up and functional outcome.
The abstracts were prepared by Orah Naor, IOA Co-ordinator and Secretary. Correspondence should be addressed to Israel Orthopaedic Association, PO Box 7845, Haifa 31074, Israel.
