Spinal injury, recognized as one of the most devastating traumas an individual can endure, has a storied history stretching back to ancient civilizations1. The Edwin Smith Papyrus, an ancient Egyptian medical text from around 3000 BC, serves as one of the earliest recorded documents to document traumatic paraplegia, reflecting the ancient understanding of spinal injuries as often untreatable afflictions2. Throughout the centuries, medical luminaries like Celsus and Sir Ludwig Guttman have left indelible marks on the field of spinal care. Celsus, a Roman encyclopedist and medical writer, made significant contributions by differentiating between cervical and thoracolumbar injuries, while also expanding on Hippocrates' concept of manual extension for spinal deformities3. Sir Ludwig Guttman, a pioneer in the field of spinal cord injury treatment, emphasized closed reduction techniques in the early 20th century, laying the groundwork for modern practices4. In more recent history, Harrington's posterior spinal instrumentation devices, introduced in the 1960s, marked a turning point in spinal care and rehabilitation. These devices revolutionized the treatment of dorso-lumbar spine injuries, providing a means for stabilization and support that was previously unavailable5. However, despite these advancements, treating dorso-lumbar spine injuries remains challenging, with outcomes contingent on various factors such as the severity and stability of the fracture, as well as secondary damage to the spinal cord from multiple transfers. It is during the second to fourth decades of life that individuals are most susceptible to these injuries, with civil construction workers and victims of high-velocity road traffic accidents being particularly at risk. Spine injuries evoke profound fear not only in the patients who endure them but also in the healthcare providers tasked with their care. The potential for permanent neurologic deficits, compromised function, and diminished quality of life underscores the urgency of prompt and effective intervention6. Additionally, the litigious nature of modern healthcare environments further intensifies the pressure on emergency physicians and surgeons tasked with evaluating and treating trauma patients. Despite the challenges, ongoing research offers hope for improved outcomes. Advances in stem cell research, though in their infancy, hold promise for advancements into clinical practice remains a formidable task, highlighting the ongoing challenges faced by both medical professionals and patients alike.

In light of these complexities, this study deals with the comparison of conservative and operative treatments, underscoring the critical importance of early intervention through comprehensive medical, surgical, and physiotherapeutic approaches. By addressing these multifaceted challenges head-on, we aim to enhance the care and outcomes for individuals grappling with spinal injuries, ultimately improving their quality of life and long-term prognosis.

The present study was conducted in the Department of Orthopaedics, with minor help from The period of study extended from May 2011 to May 2014. The study included 80 patients as cases aged from 16 years to 70 years with spinal cord injury at different levels, of which two groups were selected from perspective as well as retrospectively, The first group included patients treated conservatively; 24 were males and 16 were females, age range 16 to 70, mean age 38 years. The cases were followed up for a minimum of 12 months. All the cases have complained of motor weakness, numbness, and sensory loss with or without bladder and bowel involvement initially after injury. The mode of accident includes fall from height-39 patients, road traffic accidents-32, railway accidents-9 attending to Sir Sundarlal Hospital, Banaras Hindu University. The operative group; comprises 24 males and 26 females, age range 16 to 70, mean age of 32 years. Informed and written consent were taken from all the cases. Inclusion criteria All cases with spinal cord injury in the thoracolumbar region with neurological deficit and involving D6 to L3 vertebrae after SCI. They were followed accordingly whether they are operated on or treated non-operatively. Clinical profile and investigations The clinical history, examination and relevant investigations as per the need to establish diagnosis and injury status were done and recorded in a standard proforma: • History • Physical examination • Neurological examination • X-ray report • MRI report Evaluation of neurological severity and recovery To assess neurological severity, we utilized both the American Spinal Injury Association Motor Score (ASIA MS) and the Frankel classification system, which categorizes neurological involvement as A, B, C, D, and E. These assessments were conducted at the initial reporting and at the final follow-up. For the purpose of analysis, Frankel grades A and B were grouped together, while grades C and D were categorized in a separate group (see Table 1). The ASIA MS evaluates the function of ten key muscles related to critical neurological levels, with a total muscle power score of 5 for each muscle, yielding a maximum score of 50. Neurological recovery was evaluated for all 80 cases using the Frankel classification system at the final follow-up, which occurred 12 months after the spinal cord injury (SCI). The recovery outcomes were compared to the acute phase of spinal cord injury. Table 1: Frankel classification grading System Grade A Complete neurological injury—no motor or sensory function is clinically detected below the level of the injury. Grade B Preserved sensation only—no motor function is clinically detected below the level of the injury; sensory function persists below the level of the injury, but may be only partial (sacral sparing is considered preserved sensation). Grade C Preserved motor function but non-functional—some motor function is observed below the level of the injury, but it is not functionally useful to the patient. Grade D reserved motor function—useful motor function exists below the level of the injury; the patient can move the lower limbs and walk with or without assistance, though the gait or strength in all motor groups may not be normal. Grade E Normal motor function—no clinically detected abnormalities in motor or sensory function with normal sphincter control; abnormal reflexes and subjective sensory abnormalities may be present. Data analysis Frankel grading was assessed at 3 months, 6 months and 1 year follow-up. Frankel grading from A to C was considered as not useful, and D and E as useful so that improvement in neurological condition can be shown from not useful to useful power and the number of patients can be calculated in percentage and then compared to draw out the conclusion.

This study revealed significant insights from the analysis of conservative and operative groups. In conservative group out of 40, 16 were females and 24 were males with mean age of 37.40±16.896. In operative group the results are similar with mean age of 32.70 ± 15.686 (Table 2). Most common involved vertebra are D11, D12.

Neurological results

Frankel et al.⁸ developed a classification system that allows for the assessment of neurological status both upon admission and at discharge. We chose to employ this system to evaluate any notable differences between patients who received conservative treatment and those who underwent surgical intervention. The neurological states were categorized according to Frankel's system as follows: A—complete lesion; B—sensory sparing only; C—motor function ineffective; D—motor function useful; and E—recovery (normal). Most of the patients at the time of admission were having complete neurological deficit with bladder and bowel involvement. In conservative 27 patients (67.5%) and in operative 34 (85%) were with frankle grading A, while C were 12 (30%) in group 1, and 4 (10%) in group 2 (Table 1). Total number of patients improving from useless power i.e. A+C to useful power i.e. D+E showed 42.50%in conservative group and 42.10% in operative group which is not much to be statistically significant. Of the patients treated conservatively, only one out of twenty eight with a complete neurological lesion on admission showed significant recovery, against ten of twelve patients with initially incomplete lesions. Thus eleven of the patients treated conservatively (27 per cent) made a significant neurological recovery, mostly from initially incomplete lesions.

Among the patients who underwent surgical treatment, two out of thirty-four with initially complete lesions experienced significant neurological recovery, while five out of six with incomplete lesions showed improvement. In total, seven patients (17%) demonstrated substantial neurological enhancement. The recovery rate was notably higher for those with incomplete lesions compared to those with complete lesions. In comparison, 27% of patients who received conservative treatment exhibited significant neurological recovery, whereas 17% of those who had surgical intervention showed similar improvements. However, the difference between these recovery rates was not statistically significant.

Complications

It was also observed that there was a higher rate of complications in the operative group compared with the conservative group. In the operated group, overall 20% patients developed various complications as compared to 15% patients in conservative group and this difference was statistically insignificant (p = 0.588; Table 2).

Hospital stay

The hospital stay decreased significantly in conservative group as compared to operative group. The hospital stay was 5.27 and 20.28 days in conservative and operative group respectively and this difference was found to be statistically significant (p<0.001; Table 2).

Table 2: Comparison of conservative (nonoperative) and operative treatments for spinal injury reveals differences in patient age, improvement percentages, complication rates, affected vertebrae, hospital stays, and cost implications

Traumatic spinal cord injury (TSCI) represents one of the most severe forms of injury, leading to varying degrees of paralysis, sensory deficits, and disturbances in bladder and bowel function. The impact of TSCI extends beyond personal health, imposing significant financial strain on both families and society. Given the absence of a cure for TSCI, preventive measures are of utmost importance. Despite preventive measures, thoracolumbar injuries remain a significant concern within the spectrum of TSCI. The thoracolumbar region, comprising the thoracic and lumbar spine, is particularly vulnerable to trauma due to its anatomical location and biomechanical characteristics. Injuries to this region often result from high-energy mechanisms such as falls from heights, motor vehicle accidents, and sports-related incidents. Operative and nonoperative treatments for thoracolumbar injuries offer distinct approaches that aim to address the specific needs and circumstances of patients, considering factors such as the severity of the injury, neurological status, and overall health. Table 3: Comparison of the effectiveness of operative versus nonoperative treatment in various regions across the world Ca se Study design Fracture type Type of treatment Neurol ogical deficit Follow-up (month s) Outcome Conclusions Reference 42 Retrospective D10-L5 Non-operative 22% 240 Deterioration : none return to work :88% kyphotic angle 26.4° in flexion and 16.8° in extension average back pain score 3.5 (0–10) Non-operative treatment of thoracolumbar burst fractures without neurological deficit can lead to acceptable long-term results Weinstein et al.9 41 Retrospective Single level thoracolu mbar burst fractures T11–L5: type I: 5% type II: 78% type III: 5% type V: 12% Non-operative: bedrest mean: 31.3 (range, 7–68days) bracing mean 11.9 (range, 2–24 weeks None 24 functional results: excellent 49% good 17% fair 22% poor 12% one patient developed neurological deterioration that required surgery Non-operative management yields acceptable results bony deformity progressesmarginal ly relative to the rate of canal area remodeling radiographic severity of injury or residual deformity does not Mumfordt et al.10 (Denis classifica tion) correlate with longterm symptoms 24 Retrospective Unstable burst fractures (T11–L2) Non-operative: casting or bracing and early ambulatio n None 34 No correlation between post-traumatic kyphosis and outcome little/no pain 79% return to work 75% no restrictions at work 75% Hyperextension casting or bracing is a safe and effective method for treatment of thoracolumbar burst fractures Chow et al.11 15 0 Retrospective Frankel grades A (24%) B (58%) C (6%) D (7%) E (4%) Operative: single stage anterior spinal decompres sion, strut grafting, and anterior instrument ation 100% 96(60- 156) Neurology improved at least one grade in 95% of patients. 72% of patients with bladder dysfunction recovered completely. 96% returned to work, 86% to their previous job without restrictions Anterior decompression and stabilization in patients with burst fractures and neurological deficit yielded good functional results Kaneda et al.12 Prospective, Multicenter Thoracol umbar fractures (T12–L2) type: Operative: Posterior (59%) combined anterior-posterior 20% 27(4- 61) - All treatment methods resulted in comparable clinical and functional Knop et al.13 A (69%) B (17%) C (14%) (35%) anterior (6%) stabilizatio n outcome. 37 1 Retrospective N/A 35% standalone anterior thoracosco pic stabilizatio n 65%additi onal posterior pedicle screw instrument ation 15% 24(4- 72) Low rate of severe complications (1.3%). Anterior thoracoscopic assisted reconstruction of thoracolumbar fractures can be safely accomplished, reducing pain and morbidity associated with open approaches Khoo et al.14 18 Retrospective type B and C fractures (AO classifica tion),(D1 0-L4) operative: posterior monosegm ental fixation and arthrodesis 38.9% 78(24- 144) Low residual pain rates and high level patient satisfaction with final result. 95.5% returned to work and presented with a low disability index (Oswestry Disability Index =10.33%) posterior monosegmental fixation is an adequate and satisfactory procedure in specific types of thoracolumbar spine fractures Defino and Scarparo 15 38 Prospective, randomized Isolated burst fractures (T10–L2) Operative: 18 posterior fusion 20 anterior stabilizatio n None 43(24- 108) 17 minor complications in patients treated posteriorly, including implant removal, 3 minor complications with anterior stabilization similar functional outcomes. Anterior fusion and instrumentation may exhibit fewer complications and fewer additional surgeries Wood et al.16 Research from various regions has evaluated the effectiveness of surgical versus conservative treatments for thoracolumbar burst fractures, with findings summarized in Table 3. Although conservative management often yields favorable clinical results in patients with intact neurological function, it is associated with progressive kyphosis and vertebral body collapse over time. For example, Mumford et al.10 observed a 7-degree increase in kyphosis and a 6% further collapse in the anterior vertebral body at an average follow-up of two years. Similarly, Willen et al.17 reported a 6-degree average increase in kyphosis and a 7% increase in anterior body compression in a cohort of 54 patients six months post-fracture. However, these changes appeared to stabilize after one year. Krompinger et al.18 found that 36% of thoracolumbar burst fractures showed a progression of 10 degrees or more. Generally, surgical intervention is reserved for patients with neurological deficits, while the management of thoracolumbar burst fractures without such deficits remains debated. Denis et al.19 conducted a retrospective analysis of 104 cases of thoracolumbar burst fractures without neurological impairment. They found that all surgically treated patients avoided unrelated disabilities and could return to full-time employment. In contrast, 25% of patients who underwent nonoperative treatment were unable to return to work full time, and 17% developed neurological issues, indicating the substantial benefits of surgical treatment over conservative approaches for these fractures. Although surgery theoretically offers optimal outcomes through decompression, fracture reduction, and stabilization, most research shows that functional outcomes in the long term are comparable between surgical and non-surgical treatments for stable thoracolumbar burst fractures with normal neurological findings. While surgical intervention may offer partial kyphosis correction and earlier pain relief, a prospective, randomized study of 47 patients without neurological deficits revealed no significant differences in fracture kyphosis, return to work, or average pain scores between surgical and non-surgical groups. Similarly, Rechtine20 found no significant differences in the rates of decubitus ulcers, deep vein thrombosis, pulmonary emboli, or mortality between non-operatively and operatively treated patients. However, it is noteworthy that surgical treatment incurs higher hospitalization and treatment costs compared to nonoperative management. Our study, which analyzed neurological improvement according to Frankel's grading, complications, and duration of hospital stay for both treatment groups, revealed that conservative treatment led to a higher rate of significant neurological recovery, especially among patients with initially incomplete lesions. Despite this, statistical analysis indicated no significant difference in neurological improvement between the two treatment modalities. Complications were somewhat more frequent in the operative group, highlighting the need to carefully consider the risks and benefits of each treatment option. Notable complications in the surgical group included chest infections, deep vein thrombosis, pressure sores, and one fatality due to chest injuries in the conservative group. Additionally, seven patients in the operative group required intensive care unit support and experienced a higher incidence of bed sores compared to the conservative group. These findings emphasize the importance of evaluating both the effectiveness and the associated risks of different treatment strategies in clinical decision-making. Our study corroborates the view that nonoperative treatment remains a viable alternative for the majority of thoracolumbar fractures, consistent with earlier findings by Rechtine21. Furthermore, evidence from studies such as Vaccaro et al.22 indicates no significant difference in neurological recovery or long-term functional outcomes between operative and nonoperative treatments.

In conclusion, nonoperative treatment stands as a viable alternative to operative intervention in neurologically intact patients with thoracolumbar burst fractures. However, the need for randomized controlled trials with sufficient sample size is evident to definitively determine the comparative effectiveness of these treatment modalities. Such research endeavors are crucial for informing clinical decision-making and optimizing outcomes for individuals affected by thoracolumbar injuries.