The management of thoracolumbar burst fractures: a prospective study between conservative management, traditional open spinal surgery and minimally interventional spinal surgery

Abstract

The objective of this study was to assess which patient group had better outcomes for management of single level thoracolumbar spinal fractures. We prospectively collected data on the outcomes of patients having either conservatively managed, traditional open surgery, or minimally interventional surgery (MIS) for treatment of a single level thoracolumbar fracture. All patients had previously asymptomatic spines prior to their fractures and had a single level thoracolumbar burst fracture of more than 20° kyphosis. Fractures treated operatively, either via open surgery or MIS techniques, were corrected to less than 10° of residual kyphosis using a monoaxial pedicle screw construct 2 levels above & 2 levels below the fracture posteriorly only. The metalwork was removed between 6 months and 1 year post operatively to remobilise the spinal segments. All patients were then evaluated at least 6 months after metal work removal and at 18 months post fracture using radiographs and the Oswestry Disability Index (ODI).
Those patients treated with MIS techniques demonstrated superior outcomes compared to traditional open techniques and conservative methods of treatment, with significantly reduced hospital stay, better return to work & leisure, and the best chance of restoring their spine to near its pre-injury status. We would recommend MIS techniques as the best way of treating single level thoracolumbar spinal fractures. There is a significant improvement in ODI when treated by MIS over open surgical methods.

Full text

RES E AR C H Open Access
The management of thoracolumbar burst fractures:
aprospectivestudybetweenconservative
management, traditional open spinal surgery and
minimally interventional spinal surgery
Amit Kumar
1*
, Randeep Aujla
1
and Christopher Lee
2
Abstract
The objective of this study was to assess which patient group had better outcomes for management of single
level thoracolumbar spinal fractures. We prospectively collected data on the outcomes of patients having either
conservatively managed, traditional open surgery, or minimally interventional surgery (MIS) for treatment of a single
level thoracolumbar fracture. All patients had previously asymptomatic spines prior to their fractures and had a
single level thoracolumbar burst fracture of more than 20° kyphosis. Fractures treated operatively, either via open
surgery or MIS techniques, were corrected to less than 10° of residual kyphosis using a monoaxial pedicle screw
construct 2 levels above & 2 levels below the fracture posteriorly only. The metalwork was removed between
6 months and 1 year post operatively to remobilise the spinal segments. All patients were then evaluated at least
6 months after metal work removal and at 18 months post fracture using radiographs and the Oswestry Disability
Index (ODI).
Those patients treated with MIS techniques demonstrated superior outcomes compared to traditional open techniques
and conservative methods of treatment, with significantly reduced hospital stay, better return to work & leisure, and the
best chance of restoring their spine to near its pre-injury status. We would recommend MIS techniques as the best way
of treating single level thoracolumbar spinal fractures. There is a significant improvement in ODI when treated by MIS
over open surgical methods.
Keywords: Thoracolumbar fracture; Minimally invasive surgery; Open surgery; Oswestry disability index; Single level
Introduction
The treatment of thoracolumbar burst fractures of the
spine still excites debate and disagreement. In patients
without neurological deficit, there are those who advo-
cate conservative treatment whatever the instability or
deformity (Chow et al. 1996; Shen et al. 2001; Cantor
et al. 1993). However, some patients are left with signifi-
cant disability when fractures have healed with a signifi-
cant deformity, particularly kyphosis (Xiang-Wang et al.
2008; Shen and Shen 1999). Many would advise fixation
and correction of fractures with kyphosis more than 30°,
and a significant number with deformity less than that
(Xiang-Wang et al. 2008; Shen and Shen 1999; Kim
et al. 2011; Logroscino et al. 2009; Tezeren et al. 2009).
The risk of late collapse in conservatively managed pa-
tients is a risk. Spinal braces are poor at preventing this
and fixation usually avoids this problem (McAfee et al.
1982). There are many that claim that operative fixation
carries a morbidity risk, with significant risk to soft tis-
sues, particularly paraspinal muscles (Kim et al. 2009;
MacNab et al. 1977). Fixation also carries the risk of fail-
ure of correction and loss of position, particularly with
older types of implants and short segment fixation
(Xiang-Wang et al. 2008; Alanay et al. 2001; Tezeren
and Kuru 2005).
Minimally interventional surgery (MIS) seeks to avoid
the soft tissue damage that comes with traditional open
techniques, and allows the benefits of longer constructs
* Correspondence: mrakumar78@gmail.com
1
Specialist Orthopaedic Registrar, University Hospitals Leicester, Infirmary
Square, Leicester LE1 5WW, UK
Full list of author information is available at the end of the article
a SpringerOpen Journal
© 2015 Kumar et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.
Kumar et al. SpringerPlus (2015) 4:204
DOI 10.1186/s40064-015-0960-4

(Logroscino et al. 2009; Tezeren and Kuru 2005; Choll
2010; Ringel et al. 2006; Hatta et al. 2009; Smith et al.
2010). MIS techniques, however, have to deliver correc-
tion and stabilisation that is as good as with conven-
tional open techniques, without compromise to implant
placement or increased risk of complications, and allow
easy implant insertion and removal. Such techniques
involve placing pedicle screws through small paraspinal
incisions, preserving the overlying muscles and soft
tissues, then sliding a rod bent to the appropriate shape
under the muscles from one incision to the other before
locking it down into the screws with the appropriate
end-caps, reducing and stabilising the fracture.
To date there have been no prospective trials that
demonstrate the benefits of MIS techniques over others
when correcting or stabilising spinal fractures and none
that directly compares open and MIS techniques using
exactly the same implants for both. Our study looks at
prospectively collected data of the past nine years, which
addresses this.
Results
In total 78 patients met the inclusion criteria for the
study. 30 patients were treate d conservatively, 23 pa-
tients were treated via open operative techniques, and
25 patients were treated via MIS techniques. The total
cohort confirmed a pre-injury ODI score of 0, and had a
single level spinal fracture at T12, L1 or L2, with a local
kyphosis greater than 20°. There were 29 fractures (37%)
involving T12, 41 fractures (53%) involving L1, and 8
fractures (10%) involved L2. The youngest was 18 years
and oldest was 53 years of age at the time of injury.
There was no variance in patient demographics or char-
acteristics between conservative, open conventional sur-
gery or MIS groups (Table 1). The mechanism of injury
and fracture characteristi cs are shown in Table 2 and 3
respectively.
Analysis of data showed there was no difference in
degree of post-traumatic kyphosis between the groups
(p = 0.79). The re is a significant difference in the t ime
spent in hospital between conser vative treatme nt
(mean 36 days) and any surgical interve ntion (mean
2–4 days, p < 0.005). There is also a significant difference
in time spent in hospital between the two surgical groups,
with favourable results for MIS (mean 4 days for open
surgery versus mean 2 days for MIS; p < 0.001, Table 4).
In the conservatively managed cohort 8 patients (27%)
did not return to their original occupa tions. 5 (17%) of
these eventually returned to a less demanding occupa -
tion, and 3 (10%) became unemployed. In the conven-
tional surgery group, 4 (17%) patients did not return to
original occupa tion and eventually returned to a less
demanding occupation. For the MIS cohort all patients
returned to their original occupations.
With regard to the ODI, our results showed that there
is a significant difference between MIS (ODI = 4) and
conventional open treatment (ODI = 14) at all ODI time
scales (p < 0.0001). There is an even greater difference
between MIS (ODI = 4) and conservatively treated pa-
tients (ODI = 32) (p < 0.0001) for both 18 and 30 months.
At 30 months follow up the ODI scores failed to im-
prove and were unchanged in all groups (Table 4). The
MCID for t he ODI at 30 months for conser vative,
conventional surgery and MIS are 4.5, 2.8 and 1.7
respectively.
The degree of corre ction achieved using the two surgi-
cal techniques showed no significant difference (p = 0.8).
Patients whom underwent conventional open surgery
had a mean kyphosis of 3.5° after correction. This was
an 87% improvement on their initial post traumatic
Table 1 Demographics and patient characteristics for the
three treatments groups for single level spinal fractures
Demographics Conservative (%) Open surgery (%) MIS (%)
Number of patients 30 23 25
Mean age (range) 31 (21–52) 29 (19–49) 31 (18–53)
Gender M:F 19:11 15:8 14:11
Manual occupation 12 (40) 10 (44) 11 (44)
Non-manual
occupation
16 (53) 11 (47) 12 (48)
Sports person 2 (7) 2 (9) 2 (8)
Table 2 Incidences of different mechanism/place of
injuries for the spinal fractures treated conservatively or
by different surgical methods
Mechanism of injury Conservative (%) Open surgery (%) MIS (%)
Road traffic accident 12 (40) 10 (44) 11 (44)
Sporting injury 8 (27) 5 (22) 6 (24)
Industrial injury 4 (13) 4 (17) 4 (16)
Domestic injury 6 (20) 4 (17) 4 (16)
Table 3 Fracture characteristics for the spinal fracture
groups treated conservatively or by different surgical
methods
Fracture
characteristics
Conservative (%) Open surgery (%) MIS (%)
T12 12 (40) 9 (39) 8 (32)
L1 15 (50) 12 (52) 14 (56)
L2 3 (10) 2 (9) 3 (12)
Magerl Type A 19 (63) 9 (39) 11 (44)
Magerl Type B 11 (37) 14 (61) 14 (56)
Mean Post-Traumatic
Kyphosis (degrees)
24 (20–27) 26 (20–33) 26 (21–34)
Kumar et al. SpringerPlus (2015) 4:204 Page 2 of 10

kyphosis (see Table 5 and Figure 1). The MIS cohort had
a mean corrected kyphosis of 3.7°, giving an 86% im-
provement. The residual kyphosis after removal of
metalwork remained the same as after fixation.
There was no significant difference in improvement in
kyphosis of patients with Magerl Type A (p = 0.6) or
Type B (p = 0.4) fractures between the Open surgery
group and MIS group. There was no significant change
in kyphosis in those patients managed conservatively
from post-traumatic to final degree of kyphosis (P > 0.5).
The mean operative time for both surgical groups
(conventional open and MIS) was 120 minutes. The
mean blood loss was 80mls for the MIS group and
550mls for the conventio nal open group. No patients
required blood transfusion post operatively in either
surgical group.
Complications
In the conservative group, 6 patients had a kyphosis that
deteriorated further (mean 5°, 3-8°) during the follow-up
period with 5 patients requiring subs equent procedures
to correct post-traumatic kyphosis. These patients
underwent anterior reconstructive techniques to restore
stability and kyphosis. The other complication that did
exist in 4 patients was a transient bowel ileus. All cases
resolved spontaneously without treatment and its occur-
rence likely to be related to bed rest. Only one patient
had loss of correction (3°) in conventional open opera-
tive group and one patient had a post-operative wound
infection that settled with antibiotics. There were no
complications in the MIS group.
There were no cases of venous-thromboembolism
(DVT or PE). All patients received mechanical prophy-
laxis and when deemed safe commenced on low molecu-
lar weight heparin after 5 days while recumbent.
Patients had mechanical prophylaxis also during surgery
and were mobilised post-operatively as soon as safely
possible. This was a universal departmental policy.
Patients treated with bed rest had regular pressure
areas checks and log-rolls to avoid decubitus ulcers.
There were no incidences of other medical complica-
tions such as chest infection or res piratory problems.
We feel our incidence of VTE was low as the cohort
consisted of young fit patient s with little other medical
co-morbidities and the spine injury as their only injury.
Discussion
Non-operative management of stable thoracolumbar
spinal fractures has been advocated even in the pres ence
of kyphotic collapse (C how et al. 1996; Shen et al. 2001;
Cantor et al. 1993). Our results show that correction of
these fractures offers significant benefit to patients in
terms of ODI scores, return to work, time spent in hos-
pital and secondary complications. If the spine is left
with a deformity after fracture, then this has significant
effects on spinal balance and the vertebral levels above
and below (Xiang-Wang et al. 2008; Shen and Shen
1999). The older the patient, the less able the spine will
be to compensate, and even in younger patients one
would expect the spine to decompensate in later years
with consequent disa bility. We believe that fractured
spines should be treated like any other bony injury – i.e.
to reduce, hold and rehabilitate, and that an unreduced
deformed fracture is likely to cause disability.
Traditional open operations on the spine do lead to a
legacy of soft tissue damage, particularly from stripping
the posterior paraspinal muscles away from the spine
(MacNab et al. 1977). A fusion adds an additional mech-
anical insult by creating a permanent stiff segment with
stress transfer to other levels. If no fusion is carried out,
then damage to those paraspinal muscles results in func-
tional loss as those muscle groups are required to sup-
port and move those segments (MacNab et al. 1977;
Choll 2010). Many surgeons try to limit the soft tissue
damage caused by restricting the number of segments
spanned by any construct to one level above and below
the fractured vertebra. Short segment fixations such as
these from the posterior aspect alone have a significant
Table 4 Time spent in hospital in days, time taken to
return to work in months, and ODI at all time scales
Conservative
(Range)
Open surgery
(Range)
MIS (Range)
Time in hospital (days) 36 (10–104) 4 (2–7) 2 (1–4)
Time to return to work
(months)
9 (3–24) 4 (0.5-9) 2 (0.1-6)
ODI prior to metalwork
removal
n/a 14 (4–26) 4 (0–10)
ODI at 18 months 32 (12–46) 14 (4–26) 4 (0–10)
ODI at 30 months 32 (12–46) 14 (4–26) 4 (0–10)
Table 5 Showing the degree of kyphosis pre and post
treatment
Fracture kyphosis Conservative Open surgery MIS
Mean in degrees
(Range)
Initial post- traumatic 24 (20–27) 26 (20–33) 26 (21–34)
Post treatment 25 (20–32) 4 (0–8) 4 (0–7)
Initial post- traumatic
Magerl Type A
23 22 23
Post treatment Magerl
Type A
23 2 3
Initial post- traumatic
Magerl Type B
25 28 28
Post treatment Magerl
Type B
25 4 4
Kumar et al. SpringerPlus (2015) 4:204 Page 3 of 10

incidence of loss of correction and metalwork failure
(Xiang-Wang et al. 2008; Alanay et al. 2001; Tezeren
and Kuru 2005). Anterior procedures provide greater
structural supp ort to short segment posterior constructs
such as these, but carry a significant complication risk
and morbidity (Kim et al. 2009). Anterior procedures for
thoracolumbar fractures also means taking down the
diaphragm and violating the chest, which is best avoided
if possible, particularly if patients have concomitant
chest trauma. Stabilising the spine in these patients how-
ever has marked benefits for the recovery from associ-
ated trauma to other organs (Bellabarba et al. 2010).
MIS offers the benefit s of longer segment posterior
correction and fixation without the damage to soft tis-
sues and paraspinal muscles that traditional open sur-
gery involv es (Choll 2010; Hatta et al. 2009; Smith et al.
2010). The fractured segment is stable once healed
(Lindsey et al. 1993; Wang et al. 2006) and allows sec-
ondary removal of metalwork to remobilise those seg-
ments spanned (Kim et al. 2011). MIS techniques allow
this withou t further soft tissue trauma. MIS techniques
must satisfy certain criteria if they are to show benefit.
There must be no compromise when using these tech-
niques , and the surgeon must be able to achieve every-
thing that would be attained with open surgery.
Implants must be able to be placed as reliably and accur-
ately as with open techniques. Fractures and deformity
must be able to be reduced as well and reliably as with
open techniques. The desired outcome should be
achieved as well as with open techniques. Our study
demonstrates that our techniques achieve this, and that
our techniques are safe, reliable and reproducible.
Another issue is equipment and its availability. There
are now a number of different systems available on the
market for MIS techniques, but virtually all rely on tubes
attached to the pedicle scr ews to guide and seat the rods
allowing reduction into the pedicle screw. These systems
all have a disadvantage, because they can only be used
with polyaxial screws to allow for pedicle screw angle
variation. This is because a tube attached to the screw
head magnifies this variation, and polyaxiality is there-
fore required to align the screws/tubes to allow passage
of the rod. This means that with these systems, the ped-
icle screw itself cannot be used as a vehicle to reduce a
fracture or deformity. Our techniques do not have this
disadvantage, because we have adapted a system de-
signed for open surgery directly for MIS techniques. The
reduction is carried out directly into the screw head on
the surface of the bone, which means that we can use
monoaxial or solid screws. When the reduction clamps
are applied, this allows the unit to behave like a Schanz
pin/screw, thereby permit ting strong reliable active cor-
rection of the fracture and deformity with the pedicle
screw.
Our conservative methods of treatment were standard
and part of an agreed departmental protocol. Patients
were assessed for brace tolerance, pressure areas and
compliance (although all patients assured us they were
complying), psychological factors (espe cially with bed
rest) and problems with immobility (DVT/PE, pressure
areas, bowel & bladder habit, chest problems). We have
an aggressive physiotherapy protocol with regular roll-
ing, in bed exercises & chest protocols. These protocols
are comprehensive and regularly reviewed to ensure best
practice.
There was a clear difference in return to work between
open and conservative groups in our paper in contrast
to the paper by Wood et al. In their paper, they found
no difference in return to work between surgical and
conservative methods (Wood et al. 2003). All of our pa-
tients who underwent MIS returned to work. This may
be related to our young patient cohor t. The mean ages
Figure 1 Chart showing mean kyphosis (degrees) post treatment.
Kumar et al. SpringerPlus (2015) 4:204 Page 4 of 10

of our patients has been stated whereas solely an age
range of 18–66 years was mentioned in the paper of
Wood et al.
Additionally, the paper by Wood et al. does not have
the degree of kyphosis that our patients did. In their
paper, the average degree of kyphosis pre-op was 10° and
5° post- surgery (Wood et al. 2003). Most surgeons
would accept a pre-op kyphosis post injury of 10° but
this is patient dependent. This also may indicate less vio-
lence in their patients, more stable fractures, and that
the degree of kyphosis plays more of a part than their
paper might perhaps gives credit to.
One would expect that for their cohort of patients
with such a low degree of deformity that operative treat-
ment would not be expected to confer an advantage.
The patients in our study, by contrast, represent an en-
tirely different group. In relation to this, the ODI scores
in their paper was 20.75 at final follow up in the opera-
tive group, and 10.7 for the conservative group (Wood
et al. 2003). Our ODI scores are much lower for our
MIS group at 4 point s, and higher for our conservative
group at 32 points, which may reflect the greater degree
of viole nce involved and the effects of a greater degree
of post-traumatic kyphos is. Our MCID scores were
smaller than previous studies for the ODI due to narrow
standard deviations (Copay et al. 2008; Ostelo et al.
2008; Hagg et al. 2003).
We accept that the limitations of our study include
the lack of variability in patients within the cohort. We
have adopted strict inclusion criteria to try and make pa-
tient groups a s comparable as possible. Patients were
not random ised to treatment but were given the option
after full discussion of the risks and benefits with the
senior author of treatment options of surgery and con-
servative treatment. Additionally this is a study of short
term follow up and longer term outcome data is re-
quired to assess the long term sequelae of such injuries.
Conclusions
To date there has been no study to directly compare
MIS techniques with open techniques using the exactly
the same equipment for each. Our non-randomised,
comparative study conclusively addresses this, and
shows the benefits of MIS techniques. The advantages of
correcting spinal fractures with a significant deformity
over conservative methods where that deformity is left is
evident. We would, therefore, advocate tha t these frac-
tures are corrected via MIS techniques, as described
above.
Patients and methods
We have been prospectively collecting data on all single
level thoracolumbar burst fractures since January 2003
to 2012.
All fractures in the study were single level and in-
volved a degree of local kyphosis of 20° or greater. All
fractures were at either T12, L1 or L2 vertebrae and
were of Magerl classification type A or type B grade
(Magerl et al. 1994) without any evidence of neurological
compromise (Figure 2a & b).
Additional inclusion criteria were patients of working
age and in employment or full time education. All pa-
tients had no history of any back or spinal complaint
and had no prior spinal surgery. Of the several groups ,
30% of patients smoked and 5 % had diabetes. None had
osteoporosis or any other medical condition that would
affect their outcome. They were all asked to fill out an
Oswestry Disability Index (ODI) form regarding their
pre-accident spinal history upon admission to confirm
this. All patients underwent an MRI scan at time of ad-
mission to en sure there was no significant spinal path-
ology elsewhere. All patients were neurologically normal
clinically and radiologically. All patients had their spinal
injury as their only injury. This was to ensure that when
assessing patients there would be no confounding
Figure 2 Radiograph showing a single level L1 fracture at time of injury a. Lateral b. Antero-posterior.
Kumar et al. SpringerPlus (2015) 4:204 Page 5 of 10

Figure 4 Clinical photo showing pedicle screw finder insertion through minimally invasive techniques.
Figure 3 Clinical photo showing pedicle screw insertion through minimal skin incision.
Kumar et al. SpringerPlus (2015) 4:204 Page 6 of 10

Figure 5 Clinical photo showing insertion of rod through small incisions.
Figure 6 Clinical photo showing extent of MIS exposure.
Kumar et al. SpringerPlus (2015) 4:204 Page 7 of 10

variables from other injuries that would skew or affect
the results. There were, therefore, no multiply injured
patients in the study.
On admission, patients were informed of the treat-
ment options along with risks by the senior author.
Patients who opted for conservative treatment were
either treated with bed rest for up to 3 months if their
spinal injury was deemed to be unstable, followed by
TLSO bracing for 3 months; or if their injury was
deemed to be stable, by TLSO bracing alone for
3 months. Stability was assessed by a MRI and CT scan
of the spine along with standing radiographs in the
brace. All patients underwent a functional rehabilitation
programme for at least 1 year after injury.
Patients who opted for surgery were treated by open
techniques until end of 2006, and via MIS techniques
from 2007 until the present day. All fractures were fixed
by a construct of pedicle screws inserted into the verte-
brae at the 2 levels above the fractured vertebra and the
2 levels below it (Figures 3, 4, 5 and 6) (Logroscino et al.
2009; Tezeren and Kuru 2005). Decompression was not
required and there was no instrumentation into the frac-
tured vertebra itself, with no transpedicular grafting
(Alanay et al. 2001). No fusion was attempted across any
part of the construct as treatment was aimed for fracture
correction and not fusion (Kim et al. 2011; Tezeren
et al. 2009; Jindal et al. 2012). Additionally fusion would
add to the operative time, blood loss and morbidity and
ultimately prevent remobilisation of the spinal segment.
All fractured vertebrae were corrected to less than 10° of
residual kyphosis and the instrumentation used was the
same for both open and MIS techniques. We used the
Camlok S-Rad 90 system (Stryker GmBh) for all cases,
with mono-axial (solid) screws throughout in both open
and MIS cases (Figures 7).
All surgically treated patients were mobilised immedi-
ately post-operatively without any secondary bracing,
and were monitored regularly po st-operatively. After the
Figure 7 Radiograph showing stabilisation and degree of kyphosis correction a. Lateral b. Anterio-posterior.
Figure 8 Radiograph of lower thoracic and lumbar vertebrae 12 months after stabilisation and correction a. Lateral b. Anterio-posterior.
Kumar et al. SpringerPlus (2015) 4:204 Page 8 of 10

removal of sutures at 2 weeks, patients were seen at 3
and 6 months post operatively with standing radiographs
prior to implant removal. As this was a corrective pro-
cedure for sagittal mal-alignment not involving fusion,
all implants were removed between 6 months and 1 year
after surgery to remobilise the stabilised segments once
the fractured vertebra had healed (Kim et al. 2011;
Tezeren et al. 2009; Jindal et al. 20 12) (Figure 8). Im-
plant removal was achieved via MIS methods. If the pa-
tient had undergone open surgery, then although the old
scar was opened, the implants were removed by muscle
splitting portholes, the rods being slid out from under-
neath the muscles from the top portholes, to spare the
muscles further violation from a midline approach. If
the patient had had MIS techniques, then the old inci-
sions were used and the implants were removed via the
same muscle sparing techniques as above. This ensured
that there was no mor bidity or further trauma caused to
the paraspinal muscles by implant removal.
Patients were subsequently assessed for length of stay
in hospital, and time to discharge post-surgery. All pa-
tients were assessed regarding return to work status, and
return to sporting or leisure pursuits. Complications,
loss of correction of deformity, and the need for second-
ary procedures were also recorded.
All patients were followed up 1–2 weeks post injury,
6 weeks and 3 months post discharge with standing
radiographs of the spine. All patients filled out an ODI
assessment at follow up 18 months post-injury (i.e. at
least 6 months after implant removal in those who had
had surgery) and another ODI a further year later
(30 months post-injury). Patients underwent standin g ra-
diographs finally at 6 months post hardware removal.
All post-treatment radiographs were analysed by the
senior author (CL). Statistica l analysis was performed
and analysed independently on SPSS V8.0 software for
windows (SPSS inc, Chicago, Illinois). Mann–Whitn ey U
and unpaired t-tests were used to assess differences
between the groups. Minimally clinically important dif-
ferences (MCID) were calculated using distribution
based methods involving half of the standard deviation.
Our study had local ethical approval in line with our
research and audit department and as set out by the
National Institution for Health Research (NIHR). Patients
followed an appropriate consent procedure for their inclu-
sion in the study.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AK lead the data collection and analysis, along with the study write up and
interpretation of results. RA analysed the data collected along with preparation
of results for the study. CL collected the data from the study and was behind
the study design and write up of the project. All authors read and approved the
final manuscript.
Author details
1
Specialist Orthopaedic Registrar, University Hospitals Leicester, Infirmary
Square, Leicester LE1 5WW, UK.
2
Consultant Orthopaedic & Spinal Surgeon,
Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY, UK.
Received: 21 January 2015 Accepted: 1 April 2015
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