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

To The Editor: We read with 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 authors speak about “stable” burst fractures of the thoracolumbar junction. The inclusion criteria included the absence of a posterior column lesion (except for a laminar fracture, which was neither an exclusionary criterion nor a contraindication for nonoperative treatment). The first definition categorizes the fractures as burst type-A3 fractures according to the AO classification system1, which is widely used. A laminar fracture, however, indicates a posterior column lesion, thereby categorizing the fracture as type B1 according to the AO classification1. According to the criteria described by Denis2 and Louis and Goutallier3, a type-A3 burst fracture, by definition, represents an unstable lesion as two of three columns are involved and a type-B1 fracture represents a highly unstable lesion as three columns are involved. Therefore, we think that it is incorrect to speak about a “stable” burst fracture. Furthermore, we fear that comparing operative treatment with nonoperative treatment on the basis of the follow-up data for forty-seven (89%) of fifty-three patients is misleading. We do not believe that it is advisable to test for significant differences between two small groups of patients because of the possibility of inducing … Corresponding author: Kirkham B. Wood, MD Massachusetts General Hospital 15 Parkman Street Wang Ambulatory Center Suite 503 Boston, MA 02114 kbwood{at}partners.org