Treated Non-Surgically?
Clinical Outcome of Type A Thoracic and Lumbar Fractures 
Is There an Association With Spino-Pelvic Relationships and

D. SCHROEDER, ALEXANDER R. VACCARO and ALPESH A. PATEL
GREGORYSILVA, OTÁVIO TUROLO DA SILVA, ENRICO GHIZONI, HELDER TEDESCHI, 

ANDREI FERNANDES JOAQUIM, SÉRGIO AUGUSTO RODRIGUES, FELIPE SOARES DA

http://ijssurgery.com/content/12/3/371
https://doi.org/10.14444/5043doi: 

2018, 12 (3) 371-376Int J Spine Surg 

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International Journal of Spine Surgery, Vol. 12, No. 3, 2018, pp. 371–376
https://doi.org/10.14444/5043
�International Society for the Advancement of Spine Surgery

Is There an Association With Spino-Pelvic Relationships

and Clinical Outcome of Type A Thoracic and Lumbar

Fractures Treated Non-Surgically?

ANDREI FERNANDES JOAQUIM, MD, PHD,1 SÉRGIO AUGUSTO RODRIGUES, PHD,2 FELIPE SOARES
DA SILVA,1 OTÁVIO TUROLO DA SILVA, MD,1 ENRICO GHIZONI, MD, PHD,1 HELDER TEDESCHI, MD,
PHD,1 GREGORY D. SCHROEDER, MD,3 ALEXANDER R. VACCARO, MD, PHD, MBA,3 ALPESH A.

PATEL, MD, FACS4

1Department of Neurology, Neurosurgical Division, State University of Campinas–UNICAMP, Campinas-SP, Brazil, 2Department of Bioprocess and
Biotechnology, State University of São Paulo–UNESP, Botucatu-SP, Brazil, 3Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson

University, Philadelphia, Pennsylvania, 4Department of Orthopedics, Northwest University, Chicago, Illinois

ABSTRACT

Background: The objective was to evaluate if there is an association of the spino-pelvic relationships and the
global spinal alignment with the outcome of AO type A injuries treated nonsurgically.

Methods: This is a retrospective case series. Patients treated nonsurgically for AOSpine type A fractures (T1-L5)
with at least 1 year follow-up identified. A standing antero-posterior and lateral 36-inch radiographs and measures of
spino-pelvic relationships and sagittal alignment were obtained, as well as clinical assessment using the visual analog

scale, the Short-Form 36 (SF-36) questionnaire, the Oswestry Disability Index (ODI), and labor status.
Results: Twenty-two patients with 33 fractures were included (L1 was the most injured level with 18.2%). There

were 17 men (77.2%) and the mean age was 47.1 years. Follow-up ranged from 12 to 60 months (mean of 27.8 months).

There were 22 type A1 (66.7%), 3 type A2 (9%), 6 type A3 (18%), and 2 type A4 (6%) fractures. The ODI ranged from
4% to 58%, with a mean of 24.4%. The SF-36 physical health score ranged from 23 to 82.25 (mean 49.59), and the
mental health score ranged from 14.75 to 94.25 (mean 63.28). No association was identified between the spino-pelvic

measurements, global alignment, and patient-reported outcomes.
Conclusions: Type A fractures had a clinically relevant amount of long-term disability even when surgical

treatment is not required. Spino-pelvic relationships and final global spinal alignment did not associate with outcome
measurements.

Lumbar Spine

Keywords: thoracolumbar, compression, burst, fractures, conservative treatment, outcome, sagittal balance, spino-
pelvic relationships, VAS, ODI, SF-36, TLICS

INTRODUCTION

Thoracic and lumbar fractures are the most
common site of spinal fractures. These mainly
involve the thoracolumbar junction (T11 to L2), as
it is a transitional area between the rigid thoracic
and the mobile lumbar spine.1,2 Vaccaro et al3 and
the AOSpine Trauma Knowledge Forum recently
proposed a new classification with 3 major types:
type A–compression injuries (including burst frac-
tures), type B–lesions with anterior and/or posterior
tension band injury, and type C–translation inju-
ries.3 While there is no universally accepted treat-
ment algorithm for A3 (burst fractures involving the
posterior vertebral wall and a single endplate) and
A4 fractures (burst fractures involving the posterior

vertebral wall and both endplates), most commonly

type A injuries without neurological deficits may be

managed without surgery, with a low ris\k of late

neurological deterioration.2,4,5

While the short-term results of nonsurgical

fracture management are known, the long-term

outcomes of such treatment remain uncertain.1

Nonsurgical treatment may yield residual deformity

which, in turn, may lead to sagittal imbalance, pain,

or functional disability. Furthermore, the effects of

spino-pelvic relationships on these outcomes remain

uncertain. The objective of this study is to determine

the functional outcomes of patients with type A

fractures treated nonsurgically and their association

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with global spinal alignment and spino-pelvic
relationships.

METHODS

After institutional review board approval, 46
patients with type A fractures treated nonsurgically
at a single, tertiary institution were retrospectively
identified through a prospectively collected data-
base. All patients were contacted by telephone.
Twelve patients were not found: 2 had died of
nonrelated causes, 2 refused to participate, and 8
could not be found by any means. Thirty-four
patients agreed to participate in the study: 27
completed questionnaires and 22 underwent a new
radiological evaluation and were included in the
study. Patients without radiographic follow-up,
those with pathological fractures, as well as patients
with symptomatic previous degenerative spine
diseases, patients with amputation in any limb,
poor mental status, or with traumatic brain injury
with cognitive or physical sequels were all excluded.

Of note, conservative treatment of the fractures
consisted in the following: an external orthosis
according to the involved level for about 3 months,
followed by prescription of pain medication with
ambulation permitted but all other physical activ-
ities restricted. Plain radiographs were generally
obtained after 2 weeks, 1 month, 3 months and,
then, every 6 months to assess bone healing or
progressive deformity/instability. Patients were all
treated and followed at the same institution (blinded
for review) by the same spine surgeon (blinded for
review).

Patient-reported outcome measures included 2
surveys performed at the last patient visiting: (1) the
Oswestry Disability Index (ODI) (Table 1), and (2)
the Short-Form 36 Health Survey Questionnaire
(SF-36) mental and health status, both with
validated versions in Portuguese.6–8 The ODI
interpretation used was as follows: (1) 0% to
20.99%—the patient can cope with most living

activities. Usually no treatment is indicated apart

from advice on lifting sitting and exercise; (2) 21%

to 40.99%—the patient experiences more pain and
difficulty with sitting, lifting, and standing. Travel

and social life are more difficult and they may be

disabled from work. Personal care, sexual activity,
and sleeping are not grossly affected, and the patient

can usually be managed by conservative means; (3)

41% to 60.99%—pain remains the main problem in
this group but activities of daily living are affected.

These patients require a detailed investigation; (4)

61% to 80.99%—back pain impinges on all aspects
of the patient’s life. Positive intervention is required;

(5) and 81% to 100%—these patients are either bed-

bound or exaggerating their symptoms.

The SF-36 had a scale ranging from 0 to 100,
when 0 is the worst and 100 is the best functional

score.

Additionally, we assessed the visual analog scale

(VAS) for back pain. We asked patients to evaluate
their mean degree of pain in the fracture region in

the last month, by giving it a score of 0 to 10 points

(being 0 no pain, and 10 the most severe pain). We
also questioned them about their working status at

the time we performed the interview.

Fractures were radiographically classified accord-

ing to the new AOSpine classification in type A1 to
A4 based on the computed tomography (CT) scan

obtained immediately after spine trauma.3 The

classification was performed by the one of the
authors (blinded for review), who had previous

experience in spinal trauma classification studies

and was blinded from the results of treatment.
Radiological measurements performed with a stand-

ing plain 36-inch x-ray in antero-posterior and

lateral views were as follows: (1) global sagittal
alignment (C7-SVA), (2) pelvic tilt (PT), (3) pelvic

incidence (PI), (4) lumbar lordosis (LL from L1 to

S1), thoracic kyphosis (TK from T5 to T12), (5)
kyphosis of the fracture(s) segment, measured

through the Cobb angle from the disc above from

the disc below the most severe fracture(s) level, and

kyphosis of the adjacent fracture segment, measured
as the Cobb angle from 1 level above and 1 level

below the most severe fracture(s) level, (6) canal

compression (for type A3 and A4 fractures), the
antero-posterior diameter of the most compressed

site was compared with the normal diameter of the

same vertebra estimated by the edges of both
pedicles using CT scan images.

Table 1. Functional outcome measurements performed in the 22 patients

included in our current study.

Range Median Mean

Standard

Deviation

Total ODI 4% to 58% 22% 24.4% 17.7%
SF-36 physical component 23 to 88 49.5 49.6 19.2
SF-36 mental component 14.8 to 94.2 58.4 63.3 21.9
Pain status (VAS) 0 to 9 4.00 4.68 2.57

Abbreviations: ODI, Oswestry Disability Index; SF-36, Short-Form 36; VAS,
visual analog scale.

Spino-Pelvic Relationships and Clinical Outcome of Thoracic and Lumbar Fractures

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The radiological measurements were also per-
formed by the senior surgeon (AFJ) using the PACS
Aurora database and DICOM images. PI – LL
mismatch was also calculated. The statistical anal-
ysis was performed using a Pearson correlation test
and the Kruskal-Wallis nonparametric test with a
significance defined as P , .05.

RESULTS

There were 17 men (77.2%) and 5 women
(22.8%) in our study, with ages ranging from 21
to 70 years old (mean of 47.1 years). The main
trauma mechanism was fall from the height in 50%
of the cases. The follow-up ranged from 12 to 60
months (mean of 27.8 months).

The mean VAS score obtained at the last follow-
up was 4.6 points, ranging from 0 to 9 points (Table
1). Six patients (27%) did not return to work after
trauma, one due to a fracture of the lower limb.
Excluding this patient, 22.7% (5 of 22 patients) did
not return to normal work after spinal trauma.
There were 9 patients with a VAS of 0 to 3 points
(40.9%), 5 patients had a VAS from 4 to 6 points
(22.7%), and 8 patients had a VAS of 7 or more
points (36.3%).

The ODI ranged from 4% to 58%, with a mean
of 24.4% (Table 1). There were 10 patients (45.5%)
with minimal disability (0% to 20%), 7 patients
(31.8%) with moderate disability (21% to 40%),
and 5 patients (22.7%) with severe disability (41%

to 60%). Interestingly, of the 5 patients with severe
disability, only 2 (40%) did not return to work.

The SF-36 (Table 1) for physical health ranged
from 23 to 82.25 (mean 49.59), and for mental
health it ranged from 14.75 to 94.25 (mean 63.28).

Eleven patients (50%) were performing routine
physical activities by the time of our clinical
assessment. Five patients reported pain when
performing any activity, such as mild walking
(22.7%), and the remained patients did not want
or did not explain the reason for being inactive.

Fractures Characteristics

There were 33 fractures in the 22 patients
included in our study. One patient (4.5%) had 4-
level fractures, 2 patients (9%) had 3-level fractures
(13.6%), and 4 patients (18%) had 2-level fractures.
Fifteen patients had only 1 fracture, with a total of
33 fractures. The most injured level was L1 (6 cases,
18.2%), followed by L2 (5 cases, 15.1%), T12 (4
cases, 12.1%), L3 and L4 (3 cases, 9%), T5, T11 and
L5 (2 cases, 6%), and T3, T4, T6, T7, T9, and T10
with 1 case each (3%). There were 22 type A1
(66.7%), 3 type A2 (9%), 6 type A3 (18%), and 2
type A4 (6%) fractures according to the new
AOSpine classification system. The thoracolumbar
injury classification system (TLICS) of the most
severe fracture of each patient ranged from 1 to 4
(mean 1.6 points). Only 2 patients had a TLICS of 4
points.

Table 2. Radiological measurements performed in the 22 patients included in our current study.

Measurement Mean Median Range

Standard

Deviation 6

Pelvic tilt 15.358 17.508 0 to 27 7.84
Pelvic incidence 48.188 458 24 to 85 16.17
PI – LL 8.388 7.58 �32 to 67 20.82
C7-SVA 1.31 mm 3.68 mm �52 to 34 25
Thoracic kyphosis 35.118 338 6 to 55 13.6
Lumbar lordosis 39.868 41.58 18 to 63 14.51
Kyphosis of the most severe fracture(s) level 15.278 158 2 to 358 9.36
Kyphosis of the most severe segment fractured (1 level above and 1 level below) 14.468 128 1 to 348 9.7
Canal compression* 25.1% 0 0% to 83.3% 34.4

Abbreviations: PI, pelvic incidence; LL, lumbar lordosis; C7-SVA, global spinal alignment.
*Only 8 fractures had canal compression (6 A3 and 2 A4).

Table 3. Correlation of the outcome measurements (Oswestry Disability Index [ODI], Short-Form 36 [SF-36] physical component and SF-36 mental status) with the

radiological measurements performed in our study (P value using a Pearson correlation test).

Number

of Fractures PT C7-SVA TK PI LL PI – LL

Kyphosis

of the Vertebra

Kyphosis

of the Segment

Canal

Compression

Total ODI 0.432 0.914 0.478 0.879 0.471 0.725 0.835 0.938 0.198 0.915
SF physical 0.924 0.793 0.812 0.515 0.079 0.413 0.489 0.837 0.555 0.695
SF mental 0.823 0.584 0.721 0.230 0.113 0.153 0.887 0.631 0.609 0.002
Pain 0.599 0.681 0.758 0.994 0.140 0.722 0.360 0.915 0.206 0.562

Abbreviations: PT, pelvic tilt; C7-SVA, global spinal aligment; TK, thoracic kyphosis; PI, pelvic incidence; LL, lumbar lordosis.

Joaquim et al.

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In Table 2, we presented the radiological charac-

teristics measured in the 22 patients included in this

study. Using the Pearson correlation test, there was

minimal correlation between any of the radiograph-

ic measurements and the SF-36 physical component

score, the SF-36 mental component score, the ODI,

and the VAS back pain. The only correlation

obtained was with the SF mental score and the

Canal Compression rate (P ¼ .002); however, inter-

pretation of this is limited, as there were only 8/33

fractures that had retropulsion. Similarly, no

correlation between the ODI with the radiological

measurements performed in this study was identified

using a nonparametric test of Kruskal-Wallis. In

fact, there was not even a strong trend identified,

with the C7 Sagittal Vertical Axis coming the closest

to significance with a P value of .186. Any

radiological measurement correlated with the ODI

(Tables 3 and 4).

Finally, in Table 5, we presented the correlation

of the radiological measurements. The number of

fractures had association with TK (0.008) and LL

(0.007), and LL had association with TK (0.000)

and PI-LL (0.007). PI and LL correlates with PI-LL

(0.000 and 0.001, respectively).

Table 4. Correlation of the Oswestry Disability Index (ODI) with the radiological measurements performed in our study (P value using a nonparametric test of

Kruskal-Wallis).

Measurement

ODI

P Value1 (0% to 20.99%) 2 (21% to 40.99%) 3 (41% to 60.99%)

PT
Mean (SD) 15.7 (7.4) 14.4 (9.9) 16.0 (7.0)
Median (Q1–Q2) 17.4 (9.1 to 20.7) 17.0 (7.0 to 21.5) 18.0 (15.0 to 18.0) .995

C7-SVA
Mean (SD) 1.1 (24.2) �9.45 (31.2) 16.8 (12.7)
Median (Q1–Q2) 4.0 (�7.5 to 14.5) 0.0 (�29.3 to 3.7) 14.0 (13.0 to 23.0) .186

TK
Mean (SD) 37.7 (12.5) 30.7 (15.8) 36.2 (14.0)
Median (Q1–Q2) 36.0 (31.8 to 48.5) 31.0 (23.5 to 38.0) 31.0 (29.0 to 32.0) .621

PI
Mean (SD) 52.1 (18.8) 42.9 (17.8) 47.8 (3.3)
Median (Q1–Q2) 48.0 (38.8 to 60.8) 40.0 (30.5 to 50.5) 49.0 (45.0 to 49.0) .396

LL
Mean (SD) 42.4 (14.8) 36.0 (16.1) 40.2 (13.5)
Median (Q1–Q2) 46.5 (39.5 to 50.8) 29.0 (24.5 to 50.0) 34.0 (31.0 to 42.0) .736

PI7 � LL
Mean (SD) 8.7 (25.8) 8.3 (19.8) 7.6 (14.0)
Median (Q1–Q2) 4.0 (�3.0 to 14.0) 9.0 (�1.0 to 18.0) 10.0 (3.0 to 18.0) .946

Kyphosis of the most affected level
Mean (SD) 12.5 (10.1) 19.3 (9.4) 10.4 (7.8)
Median (Q1–Q2) 8.7 (6.0 to 13.5) 23.0 (11.5 to 27.5) 12.0 (4.0 to 15.0) .205

Kyphosis of the most affected segment
Mean (SD) 17.2 (11.1) 14.7 (9.5) 12.2 (5.4)
Median (Q1–Q2) 16.0 (6.8 to 26.5) 16.0 (7.0 to 23.0) 12.0 (11.0 to 16.0) .626

Canal compression
Mean (SD) 25.6 (33.3) 30.4 (38.3) 16.7 (37.3)
Median (Q1–Q2) 0.0 (0.0 to 59.8) 0.0 (0.0 to 66.5) 0.0 (0.0 to 0.0) .823

Abbreviations: PT, pelvic tilt; C7-SVA, global spinal aligment; TK, thoracic kyphosis; PI, pelvic incidence; LL, lumbar lordosis.

Table 5. Correlation test of radiological measurements performed in our study (P value after a Pearson).

Number

of Fractures PT C7-SVA TK PI LL PI � LL

Kyphosis

of the Vertebra

Kyphosis

of the Segment

Canal

Compression

Number of fractures 0.000 0.572 0.445 0.008 0.660 0.007 0.160 0.060 0.200 0.848
PT 0.000 0.925 0.069 0.451 0.049 0.050 0.995 0.428 0.381
C7-SVA 0.000 0.902 0.081 0.353 0.066 0.573 0.213 0.145
TK 0.000 0.927 0.000 0.007 0.564 0.735 0.978
PI 0.000 0.723 0.000 0.843 0.805 0.607
LL 0.000 0.001 0.773 0.919 0.821
PI � LL 0.000 0.904 0.702 0.974
Kyphosis of the vertebra 0.000 0.051 0.568
Kyphosis of the segment 0.000 0.612
Canal compression 0.000

Abbreviations: PT, pelvic tilt; C7-SVA, global spinal aligment; TK, thoracic kyphosis; PI, pelvic incidence; LL, lumbar lordosis.

Spino-Pelvic Relationships and Clinical Outcome of Thoracic and Lumbar Fractures

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DISCUSSION

In this study, we evaluated the outcome of
patients with type A fractures without neurological
deficits treated nonsurgically and the association of
functional status and pain with global spinal
alignment and spino-pelvic relationships. This is
the first study that associates the outcome of spinal
fractures with spino-pelvic relationships in the
literature. We found that a significant portion of
patients after a type A fracture have persistent
disability; however, this disability is not related to
spino-pelvic parameters. This finding is critical,
because it suggests that it may be the injury itself,
and not the change in alignment that leads to the
persistent disability. Some authors argue for aggres-
sive surgical treatment to better restore alignment,
but the current study finds that there is no
correlation between the final alignment and the
health-related quality of life outcomes.9

In general, the epidemiology of our patient
sample was similar to that of majority of trauma
series found in the literature, as most of our patients
were male adults with thoracolumbar junction
fractures.10–12 Additionally, none of our patients
had late neurological deficits, suggesting that
conservative treatment of type A fractures is safe
when considering neurological preservation, as
demonstrated in prior studies.13–15

However, while neurologically safe and effective,
the mean ODI of our series was 24.39%, suggesting
that type A fractures can lead to some degree of
long-term disability even when surgical treatment is
not required. Of note, 5 patients (22.7%) had severe
disability based on ODI. This fact enforces that even
mild fractures may have a tremendous impact in
social and economical life of patients. Among those
with severe disability, 3 patients (60%) were
working by the time we performed our clinical
assessment, suggesting that economical issues may
also play a role in the working status despite their
poor clinical condition. Five of the 22 patients did
not return to work. As expected, physical health
status in the SF-36 (mean 49.59) was more
compromised than mental health (mean 63.28) in
our patients. This is probably due to the fact that
spinal trauma generally compromises previously
health people and physical limitation may play a
major role for them.

The spino-pelvic relationships evaluated, the final
global spinal alignment, LL, and TK did not
associate with outcome measures (ODI and SF 36

physical status) (Table 3 and 4). Furthermore, while
the study is undoubtedly limited because of the
small size, the results of this study did not even find
a trend; therefore, it is likely that these results truly
represent no correlation and are not just the result
of an underpowered study. Distinct from degener-
ative spinal diseases and spinal deformities, clinical
outcomes of spinal trauma may not be associated
with these radiological measures as we hypothe-
sized.16–18 These will require further studies ad-
dressing the relationship between clinical outcome
and spinal fractures treated nonsurgically.

Considering association among the radiological
measurements, the total number of fractures had
correlation with TK and LL, probably because more
fractures may lead to more kyphosis and influencing
both TK and LL as compensatory changes (Table
5). A correlation of TK and LL was observed
potentially due to compensatory changes, since mild
TK had generally mild LL (Table 5).

Our study is limited by its retrospective nature
and small number of patients. However, we have
observed, for the first time, that the outcome of
patients with type A fractures treated nonsurgically
did not associate with any important spinal pelvic
relationship, nor global spinal alignment, nor the
number of fractures. Additionally, we could report
that even mild spinal trauma may lead to significant
levels of patient disability.

CONCLUSIONS

This paper demonstrates that conservative care of
stable thoracolumbar fractures yields safe neurolog-
ical outcomes yet may leave patients with clinically
significant disability. Patient-reported outcomes did
not associate with commonly reported radiographic
measures including kyphosis, global alignment, and
spino-pelvic parameters.

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Disclosures and COI: This paper was sup-
ported by FAPESP – Fundação de Amparo a
Pesquisa de São Paulo – process 2015/09848-8. No
benefits in any form have been or will be received
from a commercial party related directly or indi-
rectly to the subject of this manuscript. The authors
have no financial interest in the subject of this
article. The manuscript submitted does not contain
information about medical device(s).

Corresponding Author: Andrei F. Joaquim,
MD, PhD, Neurosurgery Division, Department of
Neurology, University of Campinas, Campinas-SP,
Brazil 13083-888. Phone: þ55 19 35217372; Email:
andjoaquim@yahoo.com.

Published 15 August 2018
This manuscript is generously published free of
charge by ISASS, the International Society for the
Advancement of Spine Surgery. Copyright � 2018
ISASS. To see more or order reprints or permis-
sions, see http://ijssurgery.com.

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