Long-term Differences In Physical Functioning And Quality Of Life Between Conservatively And Surgically Treated Traumatic Thoracolumbar A3/A4 Fractures

Long-term Differences In Physical Functioning And Quality Of Life Between Conservatively And Surgically Treated Traumatic Thoracolumbar A3/A4 Fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-term Differences In Physical Functioning And Quality Of Life Between Conservatively And Surgically Treated Traumatic Thoracolumbar A3/A4 Fractures Anna Silke Sienema, Inge HF Reininga, Joost Hoekstra This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7990888/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose To compare recovery rates of patient-reported outcome measures (PROMs) in terms of physical functioning and health-related quality of life (QoL) between surgically treated and conservatively treated patients with an A3/A4 thoracolumbar vertebral fracture, and compared to the general population. Methods A cross-sectional study including patients with thoracolumbar A3/A4 vertebral fractures in a level 1 trauma center between 2010 and 2020. SMFA-NL was used to evaluate physical functioning, and EQ-5D was used to assess QoL. Outcomes were compared with normative data from the Dutch population. Patient-reported outcomes and complication rates were reported for each treatment type. Recovery was defined as reaching the lower limit of the 95% confidence interval of the normative data in all outcome measures. Results PROMs were available for 98 (37%) of the eligible patients with a median follow-up of 4.5 (IQR = 5.6) years. No significant differences in physical functioning or QoL were found between conservatively and surgically treated patients. The following non-recovery rates were found in the conservatively treated patients: physical functioning = 56–74%, QoL = 48% and in the surgically treated patients: physical functioning = 77–80%, QoL = 45%. Surgically treated patients showed significantly higher complication rates than conservatively treated patients. Conclusion No significant differences were found between conservatively and surgically treated patients with a thoracolumbar A3/A4 fracture in outcome regarding physical functioning or QoL. However, both surgically and conservatively treated patients showed significantly low recovery rates, up to 80% of no recovery, in comparison with their peers from the general population. Thoracolumbar A3/A4 fractures patient-reported outcome vertebral fractures physical functioning quality of life Figures Figure 1 Figure 2 Introduction Vertebral fractures are common and can have significant consequences [ 1 ]. Not only do they lead to more disability than other musculoskeletal injuries, but they also come with higher healthcare costs [ 2 ]. In younger patients, the vertebral fracture is often caused by a high-energy trauma (HET). Older patients also acquire vertebral fractures through low-energy trauma (LET) [ 3 ]. Approximately 90% of all spinal fractures occur in the thoracolumbar junction [ 4 ]. The incidence of thoracolumbar vertebral fractures is rising. In 2010, 21.5 per 100,000 inhabitants acquired a thoracolumbar vertebral fracture, which increased to 24 per 100,000 inhabitants in 2017 [ 5 ], representing approximately a 12% increase over 7 years. This increase can be attributed to the rising incidence of osteoporosis with age [ 6 ]. Vertebral fractures can lead to severe complications like neurologic deterioration, chronic back pain, and a deterioration in physical functioning. All these complications may, in turn, result in disability and loss of quality of life [ 1 , 7 ]. Vertebral fractures are usually classified according to the AO Spine Classification System. Based on the AOSpine classification, a specific treatment will be started. This treatment could involve surgical stabilization of the affected vertebra or conservative treatment, including pain management, physical therapy, and, if necessary, an orthosis [ 8 ]. For some types of vertebral fractures, the treatment plan is obvious. For example, an A0 fracture, where only the processus spinosus has been affected, is almost always treated conservatively. Of the thoracolumbar fractures, 14–17% are classified as A3 or A4 fractures according to the AO Spine Classification System [ 9 ]. However, despite being a prevalent type of fracture, the treatment of A3 and A4 thoracolumbar fractures remains a grey area, as the optimal treatment has not yet been established [ 10 ]. A3 and A4 fractures are treated surgically as well as conservatively; however, neither therapy has proven itself superior to the other [ 9 – 10 ]. The meta-analysis by Chou et al. [ 11 ] showed no significant differences in outcomes between surgical and conservative treatment for thoracolumbar A3/A4 vertebral fractures. They examined outcomes at least 6 months following fracture regarding pain, as measured by analgesic use or the VAS pain score and physical functioning using the Oswald Disability Index and Roland Morris Questionnaire on Disability (RMQD) [ 11 ]. A systematic review and meta-analysis on measurement properties of the ODI and RMDQ showed that both PROMs lack a sufficient level of reliability and validity [ 12 ]. Moreover, no standard population norms for the RMDQ and ODI are available. Overall, evidence regarding long-term QoL following A3/A4 thoracolumbar fractures is also lacking. Hence, aim of this study was to compare the self-reported outcomes of patients on long-term physical functioning and QoL between surgically and conservatively treated patients with an A3 or A4 thoracolumbar vertebral fracture. Valid and reliable PROMs (SMFA and EQ-5D-5L) were used. For these PROMs, general population norms are available.. Hence, this study also aimed to assess whether these patients showed lower levels of recovery of physical functioning and QoL, compared to normative data of the Dutch population. Methods Patients The study design was a retrospective cohort study. All adult patients (≥ 18 years of age) who were treated for an A3 or A4 vertebral fracture at the trauma surgery department of the UMCG between 01-01-2010 and 01-05-2020 and had a minimum follow-up of one year following the injury were included. The data from 01-01-2010 until 31-12-2019 had already been collected for previous research. This database consists of 284 patients. This database was complemented with data on patients treated for an A3/A4 fracture between 01-01-2020 and 31-12-2021, totaling an additional 37 patients. The local medical ethics review board reviewed the methods and waived the need for further approval (METc 2019/606). Data collection Data on patient characteristics, treatment type, and possible complications were gathered from the hospital’s electronic patient records. Patients' comorbidities were classified according to the Charlson Comorbidity Index, which assigns points to each comorbidity; a higher score indicates more comorbidities [ 13 ]. Complications were classified according to the Clavien-Dindo (CD) grading system, ranging from grade 0 to 5 [ 14 ]. A score of 0 indicates no complications, whereas a score of 5 indicates complications resulting in the patient's death. An experienced trauma surgeon reassessed all radiographic images of the included patients to validate the type of fracture. Data was collected and stored using REDCap software. REDCap is a secure, web-based software platform to facilitate data acquisition and storage for research purposes [ 15 ]. Patient-reported outcome measures Patients without cognitive disorders who were still alive at follow-up received a letter with a link to an online questionnaire to assess their long-term physical functioning and quality of life. The functional status of the patients has been evaluated using the Dutch version of the Short Musculoskeletal Function Assessment (SMFA-NL). The SMFA is a patient-reported questionnaire comprising 46 questions and is used to detect differences in functional status among patients with a broad range of musculoskeletal injuries [ 16 ]. The SMFA-NL consists of four subscales: lower extremity, upper extremity, mental and emotional problems and ADL (general activities of daily living) The score ranges from 0 to 100, with higher scores indicating better functional status. To assess patients' quality of life (QoL), the Dutch EuroQol 5L (EQ-5D) questionnaire has been used [ 17 ]. The EQ-5D consists of five items and is built on five domains that assess patients' QoL. These domains are: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The EQ-5D yields a utility score ranging from 0 to 1, with 0 indicating the worst imaginable health and 1 the best. Normative data of the SMFA-NL [ 18 ] and the EQ-5D [ 17 ] were used to determine whether the patient recovered to the expected level of their age group in the general Dutch population. SMFA-NL normative data were further specified by gender. If the patient’s score reached the lower limit of the 95% confidence interval of the normative data, the patient was considered recovered. Statistical analysis Multiple imputation and data analysis were performed using IBM SPSS software version 30.0.0.0 with a significance level of p < 0.05. Descriptive statistics have been used to present the clinical outcomes and PROMs. For normally distributed data, the mean and standard deviation (SD) have been used; for non-normally distributed data, the median and interquartile range (IQR) have been used, and numbers are represented as frequencies and percentages (%). To account for uncertainty associated with missing data, we used multiple imputation to impute missing values for the SMFA subscale scores and the EQ-5D utility score when the respective PROMs were partially completed. In the dataset, 6 patients (6%) had missing items on the SMFA Lower extremity subscale, 2 (2%) on the SMFA Upper extremity subscale, 2 (2%) on the SMFA Emotional status subscale and 7 (7%) on the SMFA ADL subscale One patient (1%) had one missing item for the EQ-5D utility score. Imputation was used under the assumption that the missing data were missing at random. The following variables were included in the imputation model to impute missing data for the SMFA subscale scores or EQ-5D utility score: gender, Charlson Comorbidity Index (CCI), and available individual item scores of the respective SMFA subscale or EQ-5D. A total of 5 complete datasets were generated, using 10 iterations. To assess differences in functional status and QOL between the surgical and conservative treatment groups, an independent-samples t-test was performed on the SMFA and EQ-5D outcomes. Next, to assess whether there wass a difference in recovery rate, the recovery rate of the surgical group was compared with that of the conservatively treated group using a Chi-square test. To evaluate differences in SMFA and EQ-5D scores between patients and the general population, independent-samples t-tests were conducted. Additionally, comparisons were made between conservatively and surgically treated patients relative to normative data from the general population using independent-samples t-tests. In addition, to assess whether there was a difference in complication rate, a chi-square test has been used based on the Clavien-Dindo index. Grades 1 and 2 were defined as minor complications, grade 3 and higher as severe. In case of a positive chi-square, a subgroup analysis was performed. To determine whether the presence of complications was associated with reaching the lower limit of the 95% CI of the norm data of the PROMs outcomes, a chi-square test was performed. Results Study population A total of 284 patients with thoracolumbar A3/A4 fractures were identified. The patient characteristics are shown in Table 1 . Table 1 patient characteristics Total (n = 284) Conservative treatment (n = 166) Surgical treatment (n = 118) Age, median (IQR) 55 (27) 59 (28) 52.5 (26.5) Male (%) 160 (56) 85 (51) 75 (64) multiple spinal fractures (%) 23 (8) 13 (8) 10 (8) Trauma mechanism (%) Traffic car 27 (10) 18 (11) 9 (8) Traffic motorcycle 8 (3) 4 (2) 4 (3) Traffic bike 27 (10) 17 (10) 10 (8) Traffic pedestrian 1 (0.3) 0 (0) 1 (1) Fall 3 meter 37 (13) 22 (13) 15 (13) Other 43 (15) 18 (11) 25 (21) Neurologic injury (%) N0 247 (87) 156 (94) 91 (77) N1 5 (2) 4 (2) 1 (1) N2 12 (4) 4 (2) 8 (7) N3 13 (5) 0 (0) 13 (11) N4 1 (0.3) 0 (0) 1 (1) Nx 1 (0.3) 1 (1) 1 (1) Type of fracture (%) A3 136 (48) 104 (63) 32 (27) A4 148 (52) 62 (37) 86 (73) Comorbidities (%) CCI 0–1 136 (48) 73 (44) 63 (53) CCI 2–5 123 (43) 75 (45) 48 (41) CCI > 5 25 (9) 18 (11) 7 (6) Charlson Comorbidity Index score (CCI) Availability of patient-reported outcome measures A flowchart illustrating patient inclusion and the availability of PROMs is shown in Fig. 1 . Of the 284 patients with a thoracolumbar A3/A4 vertebral fracture, 260 (92%) were deemed eligible to participate by filling out PROMs. Among those eligible, 97 (37%) completed PROMs with a median follow-up duration of 4.5 years (IQR = 5.6). Complication rate The analysis of complication rates showed that surgically treated patients had significantly higher complication rates than conservatively treated patients (Table 2 ). Table 2 Complication rates of conservatively versus surgically treated patients Total Conservative treatment Surgical treatment P-value No complications, n (%) 244 (87) 154 (93) 90 (80) 0.002 Minor complications, n (%) 27 (10) 11 (7) 16 (14) Major complications, n (%) 8 (3) 1 (1) 7 (6) Table 3 shows the pooled means of the SMFA subscales and EQ-5D scores for all patients, compared with those of the norm population. Notably, patients treated for a thoracolumbar A3/A4 fracture scored significantly lower on all subscales, except the SMFA upper extremity subscale. Table 3 Mean SMFA subscale scores and EQ-5D utility score compared to normative data of the Dutch population Patient Norm P-value SMFA score Lower extremity 83.4 87.7 0.030 Upper extremity 95.3 94.3 0.417 Mental and Emotional problems 74.0 79.0 0.004 ADL 75.6 85.8 < 0.001 EQ-5D 0.798 0.860 0.004 Imputed data are presented To assess differences in means and significance between surgically treated and conservatively treated patients, a subgroup analysis was conducted. Table 4 shows the pooled means of the SMFA and EQ-5D scores per treatmen type, compared with the normative data for the Dutch population Table 4 Mean SMFA subscale scores and EQ-5D utility score per treatment, compared to normative data of the Dutch population Conservative treatment Surgical treatment Patient Norm P-value Patient Norm P-value SMFA-score Lower extremity 83.9 87.4 0.120 82.7 88.2 0.135 Upper extremity 95.8 94.0 0.205 94.5 94.8 0.888 Mental and Emotional problems 74.8 78.6 0.085 72.7 79.7 0.018 ADL 76.3 85.3 < 0.001 74.7 86.5 0.004 EQ-5D 0.815 0.86 0.060 0.77 0.86 0.027 Imputed data are presented These results show that patients in both treatment groups scored significantly lower on the SMFA ADL subscale and EQ-5D than the norm population. The score on the mental and emotional problems subscale of the SMFA, however, was significantly lower in the surgically treated group but not in the conservatively treated group. The number of patients recovered in each subscale, i.e., reaching the lower limit of the 95% CI for the respective norm data, is shown in Table 5 and Fig. 2 , along with the comparison of these recovery rates between the conservative and surgical treatment groups. Table 5 Number (%) of patients that did not recover on the SMFA subscales and EQ-5D Total Conservative treatment Surgical treatment P-value* SMFA-score Lower extremity, n (%) 71 (76) 43 (74) 28 (80) 0.286 Upper extremity, n (%) 61 (63) 33 (56) 28 (80) 0.073 Mental and Emotional problems, n (%) 69 (71) 40 (67) 29 (78) 0.190 ADL, n (%) 68 (74) 41 (72) 27 (77) 0.448 EQ-5D, n (%) 46 (47) 29 (48) 17 (45) 0.667 Imputed data are presented * P-value of comparison between surgical and conservative treated patients It was observed that many patients did not recover from a thoracolumbar A3/A4 fracture. Comparing recovery rates between surgically and conservatively treated patients did not show significant differences between the two treatment groups. Discussion This study presents patient-reported outcomes on physical functioning and health-related quality of life (QoL) in individuals treated for thoracolumbar A3/A4 fractures, either conservatively or surgically, at a median follow-up of 4.5 (IQR = 5.6) years. No statistically significant differences were observed between the conservative and surgical treatment groups in levels of physical functioning or health-related quality of life. These findings suggest that, despite differences in treatment approach, long-term patient-reported outcomes are comparable across both groups. Compared with normative data from the Dutch population, patients in both treatment groups reported significantly lower levels of physical functioning and QoL. Specifically, impairments were noted in daily activities, lower extremity function, mental and emotional well-being, and overall QoL. Notably, a substantial proportion of patients did not achieve recovery to the level of physical functioning and QoL of their healthy peers. On the EQ-5D, 47% of patients failed to reach the normative threshold. In comparison, non-recovery rates on the SMFA subscales were even higher: 76% for lower extremity, 63% for upper extremity, 71% for mental and emotional problems and 74% for ADL. No differences in non-recovery rates were observed between the two treatment groups, although patients who underwent surgical treatment showed slightly higher non-recovery rates across most domains. A significant difference in complication rates was observed between the treatment groups: patients treated conservatively experienced notably fewer minor and major complications than those who underwent surgical treatment. This finding aligns with expectations, as surgical treatment is inherently more invasive, which may increase the risk of complications. However, it is essential to note that conservative treatment is not suitable for all patients, particularly those with neurological deficits or unstable fracture patterns, where surgical management remains necessary. Patient-reported physical functioning Several studies have compared surgical and conservative treatment approaches for A3/A4 thoracolumbar fractures using patient-reported outcome measures (PROMs), consistently showing that long-term outcomes are broadly comparable between the two strategies. The systematic review by Chou et al. [ 11 ] reported no significant differences in physical functioning between surgical and conservative treatments after 6 months of follow-up, based on scores from the patient-reported Roland-Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) [ 11 ]. Although these results are in line with our findings, they included all thoracolumbar burst fractures and not only the A3/A4 fractures. The extensive international AO Spine cohort study by Dvorak et al. [ 19 ] further confirmed that both treatment modalities for thoracolumbar A3/A4 fractures result in comparable long-term disability, as assessed using standardized instruments such as the Oswestry Disability Index (ODI). However their sample size was relatively small. Moreover, both the RMDQ and ODI lack adequate reliability and validity [ 12 ]. In contrast, our study utilized the SMFA, offering a broader and more detailed assessment of physical functioning. The SMFA demonstrates sufficient measurement properties. It captures a wider range of musculoskeletal limitations and daily activity impairments than the ODI or RMDQ, providing a more comprehensive view of long-term recovery in this patient population. Collectively, these studies underscore that thoracolumbar A3/A4 fractures have a lasting impact on patients’ physical and emotional functioning, reinforcing the notion that full functional recovery to pre-injury levels is uncommon, irrespective of treatment modality. Health-related quality of life To date, limited research has explored the impact of thoracolumbar A3/A4 fractures on quality of life, particularly when comparing outcomes between surgical and conservative treatment approaches. Vialle et al. [ 20 ] reported similar outcomes comparing conservative treatment to surgical treatment in patients with thoracolumbar A3/A4 fractures as in our study. However this study reports a low sample size of 16 patients with a 2.5-year follow-up. They also presented raw EQ-5D scores rather than utility index conversions in their primary analysis. Failing to convert EQ-5D scores to utility indices results in less standardized comparisons across patient groups or interventions. In comparison, our study included a relatively larger sample size and utilized EQ-5D utility scores, thereby enhancing the standardization and clinical relevance of the findings. Comparison with normative data of the general Dutch population The present study is, to our knowledge, the first to assess recovery following A3/A4 thoracolumbar fractures using normative data from a general population as a reference point. This approach provides a more objective benchmark for evaluating outcomes and highlights the extent to which patients fall short of population norms, regardless of treatment strategy. Our findings further demonstrate that most patients fail to reach even the lower limit of the 95% confidence interval of the normative data of their peers. This highlights the need for continued research to optimize treatment strategies and better understand why patients fail to reach this point, enabling the development of more effective treatments. Complication rate This study showed significantly higher complication rates after surgical treatment of thoracolumbar A3/A4 fractures, compared to conservative treatment. These findings correspond with recent evidence reporting a higher incidence of procedure-related morbidity following operative stabilization of thoracolumbar burst fractures. A retrospective multicenter analysis by Wang et al. [ 21 ] demonstrated that postoperative complications occurred in 10–14% of surgically treated patients, most commonly wound infections, hardware loosening, and pulmonary complications, while conservatively managed patients experienced fewer adverse events overall. Similarly, a population-based registry study by Aono et al. [ 22 ] found that although surgery provided superior radiological correction, it was associated with a twofold higher risk of perioperative complications and prolonged hospital stay. More recently, Chen et al. [ 23 ] reported comparable findings in a prospective cohort, noting that 12% of surgical patients developed procedure-related complications compared to only 5% in the nonoperative group. Overall, these findings confirm that while modern surgical techniques have improved safety, complication rates remain higher compared to conservative treatment. This reinforces the need for careful consideration when opting for surgery, balancing potential risks with the comparable long-term outcomes of conservative management. In conclusion, patients who sustained a thoracolumbar A3/A4 fracture and were treated conservatively or surgically have similar outcomes in terms of physical functioning and quality of life. Most patients do not recover to the level of their peers from the general population and the choice for surgical treatment should be made carefully because of the higher incidence of complications. Strengths and Limitations A key strength of this study is the use of valid and reliable patient-reported outcome measures, including both the SMFA and the EQ-5D, to capture not only the functional consequences of thoracolumbar A3/A4 fractures in daily living but also health-related quality of life. To our knowledge, this is the first study to compare quality of life between conservatively and surgically treated patients with thoracolumbar A3/A4 fractures using the EQ-5D utility scores. Furthermore, it is the first to evaluate patient-reported outcome measures (PROMs) in this population against normative data from the general Dutch population, providing a robust reference point for interpreting recovery and residual disability. To our knowledge, this is the first study to compare the quality of life between conservatively and surgically treated patients with thoracolumbar A3/A4 fractures using the EQ-5D utility scores. Furthermore, it is the first to evaluate patient-reported outcome measures (PROMs) in this population against normative data from the general Dutch population, providing a robust reference point for interpreting recovery and residual disability. Nevertheless, several limitations must be acknowledged. The cross-sectional study design may introduce selection bias, as treatment decisions are often influenced by neurological status and fracture characteristics. The sample size, while sufficient to reveal meaningful differences in physical functioning and QoL, may be underpowered to detect more subtle differences between treatment groups. Furthermore, the cross-sectional nature of the analysis prevents a complete understanding of recovery trajectories over time. Another weakness of this study design is that data collection was depended on the completeness of data recorded in the electronic patient files. As a result, relevant data may have been missed. Finally, unmeasured confounding factors such as pre-injury health status socioeconomic determinants, and adherence to rehabilitation may have influenced patient-reported outcomes. Implications for Clinical Practice The findings highlight that despite advances in both conservative and surgical management, many patients with thoracolumbar A3/A4 fractures do not achieve the physical functioning and quality-of-life levels of their peers from the general population. Importantly, no significant differences were observed between surgical and conservative treatments, suggesting that surgical intervention does not guarantee superior long-term recovery. However, surgical treatment remains necessary in certain cases, particularly with neurological involvement or unstable fracture patterns. These results underscore the importance of patient education and shared decision-making in treatment planning, with realistic communication about expected outcomes and the likelihood of residual limitations. Clinicians should also consider early integration of comprehensive rehabilitation and psychosocial support, as functional impairment and emotional challenges persist in a substantial proportion of patients. Directions for Future Research Future studies should adopt prospective, multicenter designs with larger cohorts to better delineate which patient subgroups may benefit most from surgical versus conservative management. Longitudinal studies are needed to track recovery trajectories and identify predictors of incomplete recovery, both functional and psychosocial. Further research should also focus on understanding why many patients fail to reach the level of their peers, whether due to persistent pain, biomechanical limitations, psychosocial burden, or insufficient rehabilitation strategies. Conclusion Patients with thoracolumbar A3/A4 fractures showed significant long-term limitations in physical functioning and health-related quality of life compared to the general population, regardless of whether they were treated surgically or conservatively. While complication rates were higher in surgically managed patients, no significant differences in physical functioning and health-related quality of life were observed between treatment strategies, indicating that surgery does not ensure superior recovery. Importantly, a substantial proportion of patients fail to reach the levels of their peers, underlining the need for further research to better understand the rehabilitation process, fracture morphology, and the specific factors contributing to persistent problems. Future prospective studies are essential to identify these determinants and develop targeted interventions to improve long-term outcomes. Declarations Author Contribution This study represents a great deal of effort, resources, and dedication of the authors. All the authors have contributed materially to the elements below: Conceptualization: JH, IR, AS. Methodology: AS, IR. Formal analysis and investigation: AS, IR. Writing—original draft preparation: AS. Writing—review and editing: AS, IR, JH. Funding acquisition: not applicable. Resources: AS, IR, JH. Supervision: JH, IR. Data Availability Data sets generated during the current study are available from the corresponding author on reasonable request. Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. 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Cite Share Download PDF Status: Published Journal Publication published 12 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 15 Dec, 2025 Reviews received at journal 12 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviewers agreed at journal 17 Nov, 2025 Reviewers agreed at journal 17 Nov, 2025 Reviewers invited by journal 10 Nov, 2025 Editor assigned by journal 09 Nov, 2025 Submission checks completed at journal 04 Nov, 2025 First submitted to journal 30 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7990888","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":546531592,"identity":"d2104d37-ee5b-402b-94ee-e147b102a5b2","order_by":0,"name":"Anna Silke Sienema","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYNACAzDJ+ADCY24gWgszhGJgJEYLBLBJEKWFv4H9AeOPAps8frHDz6p5c+zsGqQb8WuROMBjwMxjkFYsOTvN7DbvtuTkBpmDBBx2gIeBmcHgcOKG2wkgLQeSGSQS8WuRPwBymMH/xP23078VE6XF4AAwuHgMDiRukM4xYwZqsSOoxfAwjwEQJSfOuJ1TLDl3W3ICGyEtcsfbHz788ccusX92+sYPb7fZ2fNLJB/AqwXodwYUFYlt+NVjAfYk6xgFo2AUjIJhDwDndEMu/LK69AAAAABJRU5ErkJggg==","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":true,"prefix":"","firstName":"Anna","middleName":"Silke","lastName":"Sienema","suffix":""},{"id":546531593,"identity":"5e08679e-ab22-4686-9532-3c4783f8c9a7","order_by":1,"name":"Inge HF Reininga","email":"","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":false,"prefix":"","firstName":"Inge","middleName":"HF","lastName":"Reininga","suffix":""},{"id":546531594,"identity":"11de9028-1cd8-4544-8628-c0c729245a56","order_by":2,"name":"Joost Hoekstra","email":"","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":false,"prefix":"","firstName":"Joost","middleName":"","lastName":"Hoekstra","suffix":""}],"badges":[],"createdAt":"2025-10-30 15:23:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7990888/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7990888/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-026-03135-2","type":"published","date":"2026-03-12T15:58:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":96302614,"identity":"47d0ae7d-980f-4acc-99c6-25b242535265","added_by":"auto","created_at":"2025-11-19 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14:42:32","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97529,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7990888/v1/5a11be7340b124d3aa8bdb2c.html"},{"id":96302618,"identity":"1639f858-ab62-4123-82e7-b1109135928b","added_by":"auto","created_at":"2025-11-19 14:42:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85975,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFlowchart depicting the availability of PROMs\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7990888/v1/734ad44ac7de31f46e746eb2.png"},{"id":96365002,"identity":"881c252a-8439-4ca5-9e0f-80c33eb04779","added_by":"auto","created_at":"2025-11-20 10:09:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":247728,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePercentage of patients deemed not recovered per treatment group\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7990888/v1/cf9d882ebe653cb80c4ebf10.png"},{"id":104739371,"identity":"7402594f-25da-4157-9eb6-bb0b8ea42635","added_by":"auto","created_at":"2026-03-16 16:04:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1077222,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7990888/v1/7031d17f-f4ad-48c8-9cc5-83b376fdaf4f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-term Differences In Physical Functioning And Quality Of Life Between Conservatively And Surgically Treated Traumatic Thoracolumbar A3/A4 Fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVertebral fractures are common and can have significant consequences [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Not only do they lead to more disability than other musculoskeletal injuries, but they also come with higher healthcare costs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In younger patients, the vertebral fracture is often caused by a high-energy trauma (HET). Older patients also acquire vertebral fractures through low-energy trauma (LET) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Approximately 90% of all spinal fractures occur in the thoracolumbar junction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The incidence of thoracolumbar vertebral fractures is rising. In 2010, 21.5 per 100,000 inhabitants acquired a thoracolumbar vertebral fracture, which increased to 24 per 100,000 inhabitants in 2017 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], representing approximately a 12% increase over 7 years. This increase can be attributed to the rising incidence of osteoporosis with age [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eVertebral fractures can lead to severe complications like neurologic deterioration, chronic back pain, and a deterioration in physical functioning. All these complications may, in turn, result in disability and loss of quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Vertebral fractures are usually classified according to the AO Spine Classification System. Based on the AOSpine classification, a specific treatment will be started. This treatment could involve surgical stabilization of the affected vertebra or conservative treatment, including pain management, physical therapy, and, if necessary, an orthosis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor some types of vertebral fractures, the treatment plan is obvious. For example, an A0 fracture, where only the processus spinosus has been affected, is almost always treated conservatively. Of the thoracolumbar fractures, 14\u0026ndash;17% are classified as A3 or A4 fractures according to the AO Spine Classification System [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, despite being a prevalent type of fracture, the treatment of A3 and A4 thoracolumbar fractures remains a grey area, as the optimal treatment has not yet been established [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A3 and A4 fractures are treated surgically as well as conservatively; however, neither therapy has proven itself superior to the other [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe meta-analysis by Chou et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] showed no significant differences in outcomes between surgical and conservative treatment for thoracolumbar A3/A4 vertebral fractures. They examined outcomes at least 6 months following fracture regarding pain, as measured by analgesic use or the VAS pain score and physical functioning using the Oswald Disability Index and Roland Morris Questionnaire on Disability (RMQD) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A systematic review and meta-analysis on measurement properties of the ODI and RMDQ showed that both PROMs lack a sufficient level of reliability and validity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, no standard population norms for the RMDQ and ODI are available. Overall, evidence regarding long-term QoL following A3/A4 thoracolumbar fractures is also lacking. Hence, aim of this study was to compare the self-reported outcomes of patients on long-term physical functioning and QoL between surgically and conservatively treated patients with an A3 or A4 thoracolumbar vertebral fracture. Valid and reliable PROMs (SMFA and EQ-5D-5L) were used. For these PROMs, general population norms are available.. Hence, this study also aimed to assess whether these patients showed lower levels of recovery of physical functioning and QoL, compared to normative data of the Dutch population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u003c/h2\u003e\u003cp\u003eThe study design was a retrospective cohort study. All adult patients (\u0026ge;\u0026thinsp;18 years of age) who were treated for an A3 or A4 vertebral fracture at the trauma surgery department of the UMCG between 01-01-2010 and 01-05-2020 and had a minimum follow-up of one year following the injury were included. The data from 01-01-2010 until 31-12-2019 had already been collected for previous research. This database consists of 284 patients. This database was complemented with data on patients treated for an A3/A4 fracture between 01-01-2020 and 31-12-2021, totaling an additional 37 patients.\u003c/p\u003e\u003cp\u003eThe local medical ethics review board reviewed the methods and waived the need for further approval (METc 2019/606).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData on patient characteristics, treatment type, and possible complications were gathered from the hospital\u0026rsquo;s electronic patient records. Patients' comorbidities were classified according to the Charlson Comorbidity Index, which assigns points to each comorbidity; a higher score indicates more comorbidities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Complications were classified according to the Clavien-Dindo (CD) grading system, ranging from grade 0 to 5 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A score of 0 indicates no complications, whereas a score of 5 indicates complications resulting in the patient's death. An experienced trauma surgeon reassessed all radiographic images of the included patients to validate the type of fracture. Data was collected and stored using REDCap software. REDCap is a secure, web-based software platform to facilitate data acquisition and storage for research purposes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePatient-reported outcome measures\u003c/h3\u003e\n\u003cp\u003ePatients without cognitive disorders who were still alive at follow-up received a letter with a link to an online questionnaire to assess their long-term physical functioning and quality of life. The functional status of the patients has been evaluated using the Dutch version of the Short Musculoskeletal Function Assessment (SMFA-NL). The SMFA is a patient-reported questionnaire comprising 46 questions and is used to detect differences in functional status among patients with a broad range of musculoskeletal injuries [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The SMFA-NL consists of four subscales: lower extremity, upper extremity, mental and emotional problems and ADL (general activities of daily living) The score ranges from 0 to 100, with higher scores indicating better functional status.\u003c/p\u003e\u003cp\u003eTo assess patients' quality of life (QoL), the Dutch EuroQol 5L (EQ-5D) questionnaire has been used [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The EQ-5D consists of five items and is built on five domains that assess patients' QoL. These domains are: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The EQ-5D yields a utility score ranging from 0 to 1, with 0 indicating the worst imaginable health and 1 the best.\u003c/p\u003e\u003cp\u003eNormative data of the SMFA-NL [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and the EQ-5D [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] were used to determine whether the patient recovered to the expected level of their age group in the general Dutch population. SMFA-NL normative data were further specified by gender. If the patient\u0026rsquo;s score reached the lower limit of the 95% confidence interval of the normative data, the patient was considered recovered.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eMultiple imputation and data analysis were performed using IBM SPSS software version 30.0.0.0 with a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Descriptive statistics have been used to present the clinical outcomes and PROMs. For normally distributed data, the mean and standard deviation (SD) have been used; for non-normally distributed data, the median and interquartile range (IQR) have been used, and numbers are represented as frequencies and percentages (%).\u003c/p\u003e\u003cp\u003eTo account for uncertainty associated with missing data, we used multiple imputation to impute missing values for the SMFA subscale scores and the EQ-5D utility score when the respective PROMs were partially completed. In the dataset, 6 patients (6%) had missing items on the SMFA Lower extremity subscale, 2 (2%) on the SMFA Upper extremity subscale, 2 (2%) on the SMFA Emotional status subscale and 7 (7%) on the SMFA ADL subscale One patient (1%) had one missing item for the EQ-5D utility score. Imputation was used under the assumption that the missing data were missing at random. The following variables were included in the imputation model to impute missing data for the SMFA subscale scores or EQ-5D utility score: gender, Charlson Comorbidity Index (CCI), and available individual item scores of the respective SMFA subscale or EQ-5D. A total of 5 complete datasets were generated, using 10 iterations.\u003c/p\u003e\u003cp\u003eTo assess differences in functional status and QOL between the surgical and conservative treatment groups, an independent-samples t-test was performed on the SMFA and EQ-5D outcomes. Next, to assess whether there wass a difference in recovery rate, the recovery rate of the surgical group was compared with that of the conservatively treated group using a Chi-square test.\u003c/p\u003e\u003cp\u003eTo evaluate differences in SMFA and EQ-5D scores between patients and the general population, independent-samples t-tests were conducted. Additionally, comparisons were made between conservatively and surgically treated patients relative to normative data from the general population using independent-samples t-tests.\u003c/p\u003e\u003cp\u003eIn addition, to assess whether there was a difference in complication rate, a chi-square test has been used based on the Clavien-Dindo index. Grades 1 and 2 were defined as minor complications, grade 3 and higher as severe. In case of a positive chi-square, a subgroup analysis was performed. To determine whether the presence of complications was associated with reaching the lower limit of the 95% CI of the norm data of the PROMs outcomes, a chi-square test was performed.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStudy population\u003c/h2\u003e\u003cp\u003eA total of 284 patients with thoracolumbar A3/A4 fractures were identified. The patient characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003epatient characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal \u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;284)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConservative treatment \u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;166)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSurgical treatment\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55 (27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52.5 (26.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85 (51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75 (64)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emultiple spinal fractures (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrauma mechanism (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTraffic car\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTraffic motorcycle\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTraffic bike\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTraffic pedestrian\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFall\u0026thinsp;\u0026lt;\u0026thinsp;3 meter\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e140 (49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87 (52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53 (45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFall\u0026thinsp;\u0026gt;\u0026thinsp;3 meter\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43 (15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (21)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurologic injury (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eN0\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e247 (87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e156 (94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e91 (77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eN1\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eN2\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eN3\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eN4\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNx\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of fracture (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eA3\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e136 (48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104 (63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 (27)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eA4\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e148 (52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62 (37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86 (73)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidities (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCCI 0\u0026ndash;1\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e136 (48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73 (44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63 (53)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCCI 2\u0026ndash;5\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e123 (43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75 (45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48 (41)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCCI\u0026thinsp;\u0026gt;\u0026thinsp;5\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eCharlson Comorbidity Index score (CCI)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAvailability of patient-reported outcome measures\u003c/h3\u003e\n\u003cp\u003eA flowchart illustrating patient inclusion and the availability of PROMs is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the 284 patients with a thoracolumbar A3/A4 vertebral fracture, 260 (92%) were deemed eligible to participate by filling out PROMs. Among those eligible, 97 (37%) completed PROMs with a median follow-up duration of 4.5 years (IQR\u0026thinsp;=\u0026thinsp;5.6).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eComplication rate\u003c/h3\u003e\n\u003cp\u003eThe analysis of complication rates showed that surgically treated patients had significantly higher complication rates than conservatively treated patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComplication rates of conservatively versus surgically treated patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConservative treatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSurgical treatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo complications, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e244 (87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e154 (93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinor complications, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMajor complications, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the pooled means of the SMFA subscales and EQ-5D scores for all patients, compared with those of the norm population. Notably, patients treated for a thoracolumbar A3/A4 fracture scored significantly lower on all subscales, except the SMFA upper extremity subscale.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean SMFA subscale scores and EQ-5D utility score compared to normative data of the Dutch population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNorm\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSMFA score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower extremity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper extremity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e94.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.417\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMental and Emotional problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eADL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEQ-5D\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.798\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.860\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eImputed data are presented\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo assess differences in means and significance between surgically treated and conservatively treated patients, a subgroup analysis was conducted. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the pooled means of the SMFA and EQ-5D scores per treatmen type, compared with the normative data for the Dutch population\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean SMFA subscale scores and EQ-5D utility score per treatment, compared to normative data of the Dutch population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eConservative treatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eSurgical treatment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNorm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNorm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSMFA-score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower extremity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e88.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.135\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper extremity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e94.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e94.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e94.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.888\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMental and Emotional problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.085\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e72.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e79.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eADL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e74.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e86.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEQ-5D\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.815\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.060\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eImputed data are presented\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese results show that patients in both treatment groups scored significantly lower on the SMFA ADL subscale and EQ-5D than the norm population. The score on the mental and emotional problems subscale of the SMFA, however, was significantly lower in the surgically treated group but not in the conservatively treated group.\u003c/p\u003e\u003cp\u003eThe number of patients recovered in each subscale, i.e., reaching the lower limit of the 95% CI for the respective norm data, is shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, along with the comparison of these recovery rates between the conservative and surgical treatment groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNumber (%) of patients that did not recover on the SMFA subscales and EQ-5D\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConservative treatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSurgical treatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSMFA-score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower extremity, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.286\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper extremity, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61 (63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.073\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMental and Emotional problems, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69 (71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eADL, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68 (74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.448\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEQ-5D, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.667\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eImputed data are presented\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e* P-value of comparison between surgical and conservative treated patients\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIt was observed that many patients did not recover from a thoracolumbar A3/A4 fracture. Comparing recovery rates between surgically and conservatively treated patients did not show significant differences between the two treatment groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study presents patient-reported outcomes on physical functioning and health-related quality of life (QoL) in individuals treated for thoracolumbar A3/A4 fractures, either conservatively or surgically, at a median follow-up of 4.5 (IQR\u0026thinsp;=\u0026thinsp;5.6) years. No statistically significant differences were observed between the conservative and surgical treatment groups in levels of physical functioning or health-related quality of life. These findings suggest that, despite differences in treatment approach, long-term patient-reported outcomes are comparable across both groups.\u003c/p\u003e\u003cp\u003eCompared with normative data from the Dutch population, patients in both treatment groups reported significantly lower levels of physical functioning and QoL. Specifically, impairments were noted in daily activities, lower extremity function, mental and emotional well-being, and overall QoL. Notably, a substantial proportion of patients did not achieve recovery to the level of physical functioning and QoL of their healthy peers. On the EQ-5D, 47% of patients failed to reach the normative threshold. In comparison, non-recovery rates on the SMFA subscales were even higher: 76% for lower extremity, 63% for upper extremity, 71% for mental and emotional problems and 74% for ADL. No differences in non-recovery rates were observed between the two treatment groups, although patients who underwent surgical treatment showed slightly higher non-recovery rates across most domains.\u003c/p\u003e\u003cp\u003eA significant difference in complication rates was observed between the treatment groups: patients treated conservatively experienced notably fewer minor and major complications than those who underwent surgical treatment. This finding aligns with expectations, as surgical treatment is inherently more invasive, which may increase the risk of complications. However, it is essential to note that conservative treatment is not suitable for all patients, particularly those with neurological deficits or unstable fracture patterns, where surgical management remains necessary.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePatient-reported physical functioning\u003c/h2\u003e\u003cp\u003eSeveral studies have compared surgical and conservative treatment approaches for A3/A4 thoracolumbar fractures using patient-reported outcome measures (PROMs), consistently showing that long-term outcomes are broadly comparable between the two strategies. The systematic review by Chou et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] reported no significant differences in physical functioning between surgical and conservative treatments after 6 months of follow-up, based on scores from the patient-reported Roland-Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although these results are in line with our findings, they included all thoracolumbar burst fractures and not only the A3/A4 fractures. The extensive international AO Spine cohort study by Dvorak et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] further confirmed that both treatment modalities for thoracolumbar A3/A4 fractures result in comparable long-term disability, as assessed using standardized instruments such as the Oswestry Disability Index (ODI). However their sample size was relatively small. Moreover, both the RMDQ and ODI lack adequate reliability and validity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn contrast, our study utilized the SMFA, offering a broader and more detailed assessment of physical functioning. The SMFA demonstrates sufficient measurement properties. It captures a wider range of musculoskeletal limitations and daily activity impairments than the ODI or RMDQ, providing a more comprehensive view of long-term recovery in this patient population. Collectively, these studies underscore that thoracolumbar A3/A4 fractures have a lasting impact on patients\u0026rsquo; physical and emotional functioning, reinforcing the notion that full functional recovery to pre-injury levels is uncommon, irrespective of treatment modality.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eHealth-related quality of life\u003c/h2\u003e\u003cp\u003eTo date, limited research has explored the impact of thoracolumbar A3/A4 fractures on quality of life, particularly when comparing outcomes between surgical and conservative treatment approaches. Vialle et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported similar outcomes comparing conservative treatment to surgical treatment in patients with thoracolumbar A3/A4 fractures as in our study. However this study reports a low sample size of 16 patients with a 2.5-year follow-up. They also presented raw EQ-5D scores rather than utility index conversions in their primary analysis. Failing to convert EQ-5D scores to utility indices results in less standardized comparisons across patient groups or interventions. In comparison, our study included a relatively larger sample size and utilized EQ-5D utility scores, thereby enhancing the standardization and clinical relevance of the findings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eComparison with normative data of the general Dutch population\u003c/h2\u003e\u003cp\u003eThe present study is, to our knowledge, the first to assess recovery following A3/A4 thoracolumbar fractures using normative data from a general population as a reference point. This approach provides a more objective benchmark for evaluating outcomes and highlights the extent to which patients fall short of population norms, regardless of treatment strategy. Our findings further demonstrate that most patients fail to reach even the lower limit of the 95% confidence interval of the normative data of their peers. This highlights the need for continued research to optimize treatment strategies and better understand why patients fail to reach this point, enabling the development of more effective treatments.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eComplication rate\u003c/h2\u003e\u003cp\u003eThis study showed significantly higher complication rates after surgical treatment of thoracolumbar A3/A4 fractures, compared to conservative treatment. These findings correspond with recent evidence reporting a higher incidence of procedure-related morbidity following operative stabilization of thoracolumbar burst fractures. A retrospective multicenter analysis by Wang et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] demonstrated that postoperative complications occurred in 10\u0026ndash;14% of surgically treated patients, most commonly wound infections, hardware loosening, and pulmonary complications, while conservatively managed patients experienced fewer adverse events overall. Similarly, a population-based registry study by Aono et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] found that although surgery provided superior radiological correction, it was associated with a twofold higher risk of perioperative complications and prolonged hospital stay. More recently, Chen et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported comparable findings in a prospective cohort, noting that 12% of surgical patients developed procedure-related complications compared to only 5% in the nonoperative group.\u003c/p\u003e\u003cp\u003eOverall, these findings confirm that while modern surgical techniques have improved safety, complication rates remain higher compared to conservative treatment. This reinforces the need for careful consideration when opting for surgery, balancing potential risks with the comparable long-term outcomes of conservative management. In conclusion, patients who sustained a thoracolumbar A3/A4 fracture and were treated conservatively or surgically have similar outcomes in terms of physical functioning and quality of life. Most patients do not recover to the level of their peers from the general population and the choice for surgical treatment should be made carefully because of the higher incidence of complications.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eA key strength of this study is the use of valid and reliable patient-reported outcome measures, including both the SMFA and the EQ-5D, to capture not only the functional consequences of thoracolumbar A3/A4 fractures in daily living but also health-related quality of life. To our knowledge, this is the first study to compare quality of life between conservatively and surgically treated patients with thoracolumbar A3/A4 fractures using the EQ-5D utility scores. Furthermore, it is the first to evaluate patient-reported outcome measures (PROMs) in this population against normative data from the general Dutch population, providing a robust reference point for interpreting recovery and residual disability. To our knowledge, this is the first study to compare the quality of life between conservatively and surgically treated patients with thoracolumbar A3/A4 fractures using the EQ-5D utility scores. Furthermore, it is the first to evaluate patient-reported outcome measures (PROMs) in this population against normative data from the general Dutch population, providing a robust reference point for interpreting recovery and residual disability.\u003c/p\u003e\u003cp\u003eNevertheless, several limitations must be acknowledged. The cross-sectional study design may introduce selection bias, as treatment decisions are often influenced by neurological status and fracture characteristics. The sample size, while sufficient to reveal meaningful differences in physical functioning and QoL, may be underpowered to detect more subtle differences between treatment groups. Furthermore, the cross-sectional nature of the analysis prevents a complete understanding of recovery trajectories over time. Another weakness of this study design is that data collection was depended on the completeness of data recorded in the electronic patient files. As a result, relevant data may have been missed. Finally, unmeasured confounding factors such as pre-injury health status socioeconomic determinants, and adherence to rehabilitation may have influenced patient-reported outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eImplications for Clinical Practice\u003c/h2\u003e\u003cp\u003eThe findings highlight that despite advances in both conservative and surgical management, many patients with thoracolumbar A3/A4 fractures do not achieve the physical functioning and quality-of-life levels of their peers from the general population. Importantly, no significant differences were observed between surgical and conservative treatments, suggesting that surgical intervention does not guarantee superior long-term recovery.\u003c/p\u003e\u003cp\u003eHowever, surgical treatment remains necessary in certain cases, particularly with neurological involvement or unstable fracture patterns. These results underscore the importance of patient education and shared decision-making in treatment planning, with realistic communication about expected outcomes and the likelihood of residual limitations. Clinicians should also consider early integration of comprehensive rehabilitation and psychosocial support, as functional impairment and emotional challenges persist in a substantial proportion of patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eDirections for Future Research\u003c/h2\u003e\u003cp\u003eFuture studies should adopt prospective, multicenter designs with larger cohorts to better delineate which patient subgroups may benefit most from surgical versus conservative management. Longitudinal studies are needed to track recovery trajectories and identify predictors of incomplete recovery, both functional and psychosocial. Further research should also focus on understanding \u003cem\u003ewhy\u003c/em\u003e many patients fail to reach the level of their peers, whether due to persistent pain, biomechanical limitations, psychosocial burden, or insufficient rehabilitation strategies.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePatients with thoracolumbar A3/A4 fractures showed significant long-term limitations in physical functioning and health-related quality of life compared to the general population, regardless of whether they were treated surgically or conservatively. While complication rates were higher in surgically managed patients, no significant differences in physical functioning and health-related quality of life were observed between treatment strategies, indicating that surgery does not ensure superior recovery. Importantly, a substantial proportion of patients fail to reach the levels of their peers, underlining the need for further research to better understand the rehabilitation process, fracture morphology, and the specific factors contributing to persistent problems. Future prospective studies are essential to identify these determinants and develop targeted interventions to improve long-term outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThis study represents a great deal of effort, resources, and dedication of the authors. All the authors have contributed materially to the elements below: Conceptualization: JH, IR, AS. Methodology: AS, IR. Formal analysis and investigation: AS, IR. Writing\u0026mdash;original draft preparation: AS. Writing\u0026mdash;review and editing: AS, IR, JH. Funding acquisition: not applicable. Resources: AS, IR, JH. Supervision: JH, IR.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData sets generated during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\u003cp\u003eEach author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the institutional review board.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis work was performed at the University Medical Center Groningen, Groningen, the Netherlands.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJohansson L, Sundh D, Nilsson M, Mellstrom D, Lorentzon M. 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Global Spine J. 2024;14(2):740\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChiarotto A, Maxwell LJ, Terwee CB, Wells GA, Tugwell P, Ostelo RW. Roland-Morris Disability Questionnaire and Oswestry Disability Index: which has better measurement properties for measuring physical functioning in non-specific low back pain? Systematic review and meta-analysis. Phys Ther. 2016;96(10):1620\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCharlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien P. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. 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Dutch tariff for the five-level version of EQ-5D. Value Health. 2016;19(4):343\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Graaf MW, Moumni E, Heineman M, Wendt E, Reininga IHF. Short Musculoskeletal Function Assessment: normative data of the Dutch population. Qual Life Res. 2015;24(8):2015\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDvorak MF, \u0026Ouml;ner CF, Dandurand C, Vaccaro AR, Rajasekaran S, Schnake KJ, et al. Surgical versus non-surgical treatment of thoracolumbar burst fractures in neurologically intact patients: a prospective international multicentre cohort study. Global Spine J. 2025;0(0):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVialle EN, Pimenta L, Almeida LP, Santos ERG, Fran\u0026ccedil;a M, Amaral R. Comparison between surgical and conservative treatment for AOSpine type A3 and A4 thoracolumbar fractures without neurological deficit: prospective observational study. Global Spine J. 2023;13(5):1135\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang H, Li C, Liu T, et al. Complications following surgical versus conservative treatment of thoracolumbar burst fractures: a multicenter retrospective study. Eur Spine J. 2022;31(8):2078\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAono H, Tobimatsu H, Ariga K, et al. Perioperative complications and long-term outcomes of surgical treatment for thoracolumbar burst fractures: analysis of a national spine registry. J Orthop Surg (Hong Kong). 2021;29(2):23094990211027764.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen Y, Zhao J, Lu Y, et al. Surgical and non-surgical management of thoracolumbar burst fractures: a prospective comparative cohort study. Spine J. 2023;23(7):1012\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Thoracolumbar A3/A4 fractures, patient-reported outcome, vertebral fractures, physical functioning, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-7990888/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7990888/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo compare recovery rates of patient-reported outcome measures (PROMs) in terms of physical functioning and health-related quality of life (QoL) between surgically treated and conservatively treated patients with an A3/A4 thoracolumbar vertebral fracture, and compared to the general population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study including patients with thoracolumbar A3/A4 vertebral fractures in a level 1 trauma center between 2010 and 2020. SMFA-NL was used to evaluate physical functioning, and EQ-5D was used to assess QoL. Outcomes were compared with normative data from the Dutch population. Patient-reported outcomes and complication rates were reported for each treatment type. Recovery was defined as reaching the lower limit of the 95% confidence interval of the normative data in all outcome measures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePROMs were available for 98 (37%) of the eligible patients with a median follow-up of 4.5 (IQR\u0026thinsp;=\u0026thinsp;5.6) years. No significant differences in physical functioning or QoL were found between conservatively and surgically treated patients. The following non-recovery rates were found in the conservatively treated patients: physical functioning\u0026thinsp;=\u0026thinsp;56\u0026ndash;74%, QoL\u0026thinsp;=\u0026thinsp;48% and in the surgically treated patients: physical functioning\u0026thinsp;=\u0026thinsp;77\u0026ndash;80%, QoL\u0026thinsp;=\u0026thinsp;45%. Surgically treated patients showed significantly higher complication rates than conservatively treated patients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eNo significant differences were found between conservatively and surgically treated patients with a thoracolumbar A3/A4 fracture in outcome regarding physical functioning or QoL. However, both surgically and conservatively treated patients showed significantly low recovery rates, up to 80% of no recovery, in comparison with their peers from the general population.\u003c/p\u003e","manuscriptTitle":"Long-term Differences In Physical Functioning And Quality Of Life Between Conservatively And Surgically Treated Traumatic Thoracolumbar A3/A4 Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 14:42:27","doi":"10.21203/rs.3.rs-7990888/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-15T07:37:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-12T22:18:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T09:59:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201358326086012444148281995147472452333","date":"2025-11-17T20:22:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88613558966680180924547668042549101965","date":"2025-11-17T10:58:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T13:10:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-09T11:01:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-04T12:44:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2025-10-30T15:12:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"aa342aa2-adce-4504-a6c7-c5589cff98a6","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:01:56+00:00","versionOfRecord":{"articleIdentity":"rs-7990888","link":"https://doi.org/10.1007/s00068-026-03135-2","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2026-03-12 15:58:13","publishedOnDateReadable":"March 12th, 2026"},"versionCreatedAt":"2025-11-19 14:42:27","video":"","vorDoi":"10.1007/s00068-026-03135-2","vorDoiUrl":"https://doi.org/10.1007/s00068-026-03135-2","workflowStages":[]},"version":"v1","identity":"rs-7990888","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7990888","identity":"rs-7990888","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}