Operative Compared with Nonoperative Treatment of a Thoracolumbar Burst Fracture without Neurological Deficit

To The Editor: We read with great interest the article entitled “Operative Compared with Nonoperative Treatment of a Thoracolumbar Burst Fracture without Neurological Deficit. A Prospective, Randomized Study” (2003; 85:773-81), by Wood et al. The prospective, randomized design of this study sets it apart from the numerous retrospective case series that have been published in the last two decades and is generally regarded as the only way to obtain valid results1-3. Since the debate about the operative or nonoperative treatment of traumatic burst fractures has not been resolved because of weak scientific evidence from both sides, the study by Wood et al. could have provided us with some solid claims that could have guided us to an optimal treatment regimen. Therefore, we were a bit disappointed to find that the study had some serious flaws that, in our opinion, render the authors' conclusions unjustified. First, the inclusion and exclusion criteria were not described in sufficient detail. The study included patients with an isolated “burst fracture,” which, in our opinion, comprises a wide range of fracture types with varying severity. Since fracture classification schemes have been designed and validated to help one to choose the appropriate treatment and to predict clinical outcome, their use should be encouraged strongly4-6. Furthermore, since the authors used plain radiography and computed tomography but not magnetic resonance imaging to classify the fracture, the correct exclusion of patients with “a loss of structural integrity within the posterior osteoligamentous complex” can be in doubt7. Tables E3 and E4 in the appendix of the study list two patients (Case 8 from the operative treatment group and Case 8 from the nonoperative treatment group, both of whom had a fracture at L1) who had kyphosis angles of 32° and 30°, … Corresponding author: Kirkham B. Wood, MD Massachusetts General Hospital 15 Parkman Street Wang Ambulatory Center Suite 503 Boston, MA 02114 kbwood{at}partners.org