{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T20:00:06Z","timestamp":1772827206360,"version":"3.50.1"},"reference-count":90,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","license":[{"start":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T00:00:00Z","timestamp":1765497600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,12,12]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>The objective was to compare incomplete (A3) versus complete (A4) thoracolumbar burst fractures managed nonoperatively or operatively with respect to reaching minimal clinically important difference (MCID) in Oswestry Disability Index (ODI) score.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>A prospective observational international multicenter cohort study was conducted. After stratification using the AO Spine Thoracolumbar Injury Classification System, A3 and A4 outcomes were analyzed separately within nonoperative and operative management groups. Outcomes included absolute and relative improvement in ODI scores between discharge and 12-month follow-up. Kaplan-Meier curves were generated and compared with the log-rank test. Multivariable Cox regression models were constructed. The Cox regression models were adjusted using the key covariates of age, sex, thoracolumbar injury classification and severity (TLICS) score, and the interaction between fracture type and treatment type. Additional adjustment was performed for discharge ODI scores to compare relative improvement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>In total, 198 neurologically intact patients were identified, with incomplete fractures (58.6%) being more common than complete burst fractures (41.4%). The rate of nonoperative management was significantly higher among A3 than A4 fractures (48.3% vs 24.4%, p &lt; 0.01). A4 fractures demonstrated a higher mean TLICS score than A3 fractures (2.8 vs 2.4, p = 0.04). There were no significant functional differences in MCID in ODI scores, defined as an improvement in 12.8 points within 1 year after treatment (HR 1.21, 95% CI 0.86\u20131.70, p = 0.28). Examination of only the surgically treated cohort of patients also revealed no significant difference in achieving relative ODI score improvement within 1 year after treatment between those with A4 and those with A3 fractures (HR 1.19, 95% CI 0.78\u20131.82, p = 0.43). A similar finding was demonstrated for the nonoperative cohort, with no difference between the incomplete or complete burst fracture morphologies (HR 1.24, 95% CI 0.68\u20132.27, p = 0.48). Odds of achieving an absolute ODI score of 20 or less were also similar between patients with A4 and A3 fractures, regardless of whether operative (HR 0.81, 95% CI 0.52\u20131.25, p = 0.34) or nonoperative (HR 0.72, 95% CI 0.38\u20131.35, p = 0.30) management was pursued.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>Patients with A3 and A4 fractures had similar odds to reach MCID in ODI score at 1 year. Even when exclusively considering the nonoperative cohort of patients who sustained A4 fractures with perceived increased biomechanical stability, there was no difference in functional improvement compared to patients with A3 fractures. Further large prospective multicenter studies are required to specifically assess radiographic outcomes and compare surgical approaches in the management of A3 and A4 fractures.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2025.7.spine25285","type":"journal-article","created":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T17:12:27Z","timestamp":1770829947000},"page":"469-482","source":"Crossref","is-referenced-by-count":0,"title":["Incomplete (A3) versus complete (A4) thoracolumbar burst fractures: results from a prospective international multicenter cohort study"],"prefix":"10.3171","volume":"44","author":[{"given":"Jin W.","family":"Tee","sequence":"first","affiliation":[{"name":"Spine and Neurotrauma, National Trauma Research Institute, Melbourne;"},{"name":"Central Clinical School of Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne;"},{"name":"Central Clinical School of Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Barry T. S.","family":"Kweh","sequence":"additional","affiliation":[{"name":"Spine and Neurotrauma, National Trauma Research Institute, Melbourne;"},{"name":"Department of Neurosurgery, The Alfred Hospital, Melbourne;"},{"name":"Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Victoria, Australia;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander R.","family":"Vaccaro","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Klaus J.","family":"Schnake","sequence":"additional","affiliation":[{"name":"Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien Erlangen;"},{"name":"Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Germany;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammad","family":"El-Sharkawi","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University, Asyut, Egypt;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eugen C.","family":"Popescu","sequence":"additional","affiliation":[{"name":"Emergency Hospital, Iasi, Romania;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shanmuganathan","family":"Rajasekaran","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lorin M.","family":"Benneker","sequence":"additional","affiliation":[{"name":"Spine Unit, Sonnenhof Spital, University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sebastian F.","family":"Bigdon","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital, University of Bern, Switzerland;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John","family":"France","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, West Virginia University, Morgantown, West Virginia;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jerome","family":"Paquet","sequence":"additional","affiliation":[{"name":"Neurosurgery Unit, Department of Surgery, CHU de Quebec, Universit\u00e9 Laval, Quebec City, Montreal, Canada;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"R. Todd","family":"Allen","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of California, La Jolla, San Diego, California;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"William F.","family":"Lavelle","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, SUNY Upstate Medical University, Syracuse, New York;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Miguel","family":"Hirschfeld","sequence":"additional","affiliation":[{"name":"Orthopedic Surgery and Traumatology, Hospital Costa del Sol, Marbella, Spain;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Spyridon","family":"Pneumaticos","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, KAT Hospital, Kifisia, Greece;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard J.","family":"Bransford","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, Washington;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrei F.","family":"Joaquim","sequence":"additional","affiliation":[{"name":"Neurosurgery Division, Department of Neurology, State University of Campinas, Campinas-S\u00e3o Paulo, Brazil;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Harvinder S.","family":"Chhabra","sequence":"additional","affiliation":[{"name":"Spine and Rehabilitation Services, Sri Balaji Action Medical Institute, New Delhi, India;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ulrich","family":"Spiegl","sequence":"additional","affiliation":[{"name":"Clinics of Trauma Surgery, Orthopaedics, and Reconstructive Surgery, M\u00fcnchen Klinik Harlaching, Sanatoriumplatz, Munich, Germany;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hauri","family":"Dimitri","sequence":"additional","affiliation":[{"name":"AO Spine Knowledge Forum Trauma and Infection, AO Foundation, D\u00fcbendorf, Switzerland;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"F. Cumhur","family":"Oner","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University Medical Centers, Utrecht, The Netherlands; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marcel","family":"Dvorak","sequence":"additional","affiliation":[{"name":"Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gregory D.","family":"Schroeder","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Charlotte","family":"Dandurand","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of California, La Jolla, San Diego, California;"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"4","key":"b1","series-title":"Eur J Trauma Emerg Surg","first-page":"1261","article-title":"ESTES recommendation on thoracolumbar spine fractures: January","volume":"50","author":"Wendt K","year":"2024","unstructured":"Wendt K, Nau C, Jug M,  ESTES recommendation on thoracolumbar spine fractures: January. 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Injury. 2021;52(12):3685\u20133690."},{"issue":"1","key":"b4","series-title":"J Neurosurg Spine","first-page":"101","article-title":"Expectations of recovery and functional outcomes following thoracolumbar trauma: an evidence-based medicine process to determine what surgeons should be telling their patients","volume":"22","author":"Schouten R","year":"2015","unstructured":"Schouten R, Lewkonia P, Noonan VK, Dvorak MF, Fisher CG. Expectations of recovery and functional outcomes following thoracolumbar trauma: an evidence-based medicine process to determine what surgeons should be telling their patients. 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Spine (Phila Pa 1976).2001;26(9):1038\u20131045."},{"issue":"1_suppl","key":"b10","series-title":"Global Spine J","first-page":"32S","article-title":"The AO spine thoracolumbar injury classification system and treatment algorithm in decision making for thoracolumbar burst fractures without neurologic deficit","volume":"14","author":"Kweh BTS","year":"2024","unstructured":"Kweh BTS, Tee JW, Dandurand C,  The AO spine thoracolumbar injury classification system and treatment algorithm in decision making for thoracolumbar burst fractures without neurologic deficit. 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The clinical efficacy and outcome of nonoperative management. Spine (Phila Pa 1976). 1993;18(8):955\u2013970."},{"issue":"6","key":"b13","series-title":"Global Spine J","first-page":"975","article-title":"The role of spinal orthoses in osteoporotic vertebral fractures of the elderly population (age 60 years or older): systematic review","volume":"11","author":"Kweh BTS","year":"2021","unstructured":"Kweh BTS, Lee HQ, Tan T,  The role of spinal orthoses in osteoporotic vertebral fractures of the elderly population (age 60 years or older): systematic review. Global Spine J. 2021;11(6):975\u2013987."},{"issue":"4","key":"b14","series-title":"J Spine Surg","first-page":"506","article-title":"In defence of the efficacy and safety of braces in osteoporotic vertebral fractures","volume":"9","author":"Kweh BTS","year":"2023","unstructured":"Kweh BTS, Gonzalvo A, Khoo B, Tee JW. In defence of the efficacy and safety of braces in osteoporotic vertebral fractures. J Spine Surg. 2023;9(4):506\u2013508."},{"issue":"3","key":"b15","series-title":"J Spine Surg","first-page":"224","article-title":"Spinal orthoses in osteoporotic vertebral fractures of the elderly","volume":"9","author":"Khoo B","year":"2023","unstructured":"Khoo B, Gonzalvo A, Kweh BTS. Spinal orthoses in osteoporotic vertebral fractures of the elderly. J Spine Surg. 2023;9(3):224\u2013228."},{"issue":"20","key":"b16","series-title":"Spine (Phila Pa 1976)","first-page":"2154","article-title":"Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-L5","volume":"24","author":"Seybold EA","year":"1999","unstructured":"Seybold EA, Sweeney CA, Fredrickson BE, Warhold LG, Bernini PM. Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-L5. 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