DOI: 10.1097/01.BRS.0000092374.41594.E6

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Issn Print: 0362-2436

Publication Date: 2004/02/15


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Sigurd Berven

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Measuring outcomes in spinal surgery is important for the education of physicians and patients in promoting informed decision-making regarding future care. Outcomes assessments also provide a quantifiable measure of the value of care and a measure of accountability for the service that a spine surgeon provides. Measuring outcomes is a difficult challenge, especially in a cohort of patients who present with severe spinal column fractures. Ultimately, functional outcome as assessed by a record of return to work and activity is a useful endpoint to define for this patient population, because this endpoint is relevant to both economic and health status assessments of the outcome of care. This article offers an important contribution to our understanding of the efficacy of surgery in restoring function to adults with severe spinal column fractures.
The authors identify a lack of consensus regarding operative and nonoperative management of spinal fractures within the community of spine surgeons. The absence of consensus is a reflection of the absence of outcomes-based studies. The debate regarding operative and nonoperative care for spinal fractures persists in part because of an inadequate definition of indications for surgery. Stable fractures without neural deficit may benefit little from operative care compared with nonoperative management. 1,2 However, in this series the authors have identified a cohort of patients with unstable fractures, severe concurrent injuries, and clear indications for early surgical care. Fifty-six percent of patients had neural injury at the time of presentation and, ultimately, neural deficits were the most important determinant of functional recovery. This observation is important in the debate regarding the role of early surgery in incomplete spinal cord injury and in the development of new technologies to improve functional recovery after spinal cord injury.
The authors provide the longest follow-up of a large series of surgically treated patients with severe spinal fractures, and this outcomes article offers important insights into expectations regarding functional recovery for patients with these injuries. Future investigations in this area may focus on patient self-assessment measures of outcome or an objective functional measure of outcome including gait analysis and walking tolerance to avoid the effect of confounding factors, including vocational flexibility and employment. While a comparison with nonoperative care would not be appropriate for this population, consideration of randomization to combined anterior and posterior surgery and posterior-only surgery may be a useful multicenter investigation.

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