Response to “Nonoperative Management of Isolated Thoracolumbar Flexion Distraction Injuries”

We appreciate the letter to the editor from Drs Aly and Joaquim in response to our study, in particular highlighting the distinct differences in pathophysiology and management of B1 vs B2 injuries. The authors point out that it is increasingly accepted that B1, pure osseous monosegmental injuries, can be successfully managed nonoperatively. However, there is a lack of substantial comparison of operative vs nonoperative management of these injuries in the current spine literature. Therefore, the purpose of our study was to provide a single-center retrospective cohort analysis to add to the body of literature and help support surgical decision-making as well as patient consultation regarding these injuries.

We believed that it was important to analyze and share our outcomes to ensure that we as spine surgeons are practicing in an evidence-based manner. In particular, we wanted to pay attention to the progression of kyphosis, as this was the most objective parameter available. While we did not directly address the topic of pseudoarthrosis in our study, failure of radiographic progression of kyphosis as well as resolution of back pain can be used as proxies for this evaluation, and it is a parameter that should be included in future studies.

In terms of B2 injuries being misclassified as B1 injuries, we believe this makes a strong argument for advanced imaging, including computed tomography and possibly magnetic resonance imaging, if there is uncertainty as to whether an injury is purely transosseous or has a ligamentous component.

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