You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-L5.
Abstract 1:
STUDY DESIGN A retrospective review of 42 patients treated at three major medical centers for burst fractures of L3 , L4 , and L5 . This is the largest low lumbar ( L3-L5 ) burst fracture study in the literature to date . The study was design ed to assess both radiographic and clinical outcomes in a cohort of patients treated during a 16-year period . OBJECTIVES The objective of this study was to determine whether conservatively treated patients with low lumbar burst fractures had satisfactory outcomes compared with those in a surgically treated cohort of patients . The study included patients with and without neurologic deficits . SUMMARY OF BACKGROUND DATA Burst fractures of the low lumbar spine ( L3-L5 ) represent a small percentage of all spine fractures . The iliolumbar ligaments and location below the pelvic brim are two stabilizing factors that are unique to these fractures when compared with burst fractures at the thoracolumbar junction . METHODS Forty-two ( n = 42 ) patients with low lumbar burst fractures were identified from 1980 through 1996 . Medical records , radiographs , and follow-up Dallas Pain Question naires were obtained . Loss of anterior vertebral height , kyphotic angulation , and amount of retropulsion were recorded at several phases of treatment . Mean follow-up time was 45.2 months ( range , 5 - 132 months ) . Twenty patients were treated without surgery ( 18 were neurologically intact , and 2 had isolated nerve root injury ) , and 22 underwent surgery ( 14 had neurologic injury , 8 were intact ) . RESULTS No patient showed neurologic deterioration , regardless of treatment . Fracture of the third lumbar segment showed the greatest tendency toward kyphotic collapse and loss of height in the nonoperative group , although this was not reflected in the final functional outcome of both groups . The ability to return to work and achieve a good-to-excellent long-term result was not significantly different among fracture levels or between surgical and nonsurgical treatments . CONCLUSIONS The results of nonoperative treatment of low lumbar burst fractures were comparable with those of operative treatment . The rate of repeat surgery ( 41 % ) and absence of a clearly definable long-term functional or radiographic benefit in patients without neurologic compromise may make surgery less appealing


Title 2:
Some Complications of Common Treatment Schemes of Thoracolumbar Spine Fractures Can Be Predicted With Magnetic Resonance Imaging: Prospective Study of 53 Patients With 71 Fractures
Abstract 2:
Study Design . Prospect i ve cohort study . Objectives . To study the predictive value of magnetic resonance imaging ( MRI ) findings of thoracolumbar spine fractures concerning the radiologic and clinical outcome . Summary of Background Data . Disagreement about the proper treatment of thoracolumbar spine fractures is caused by insufficiency of conventional imaging techniques . Previous studies have shown that MRI is capable of distinguishing injury to all structures of the fractured spine and thus may help develop schemes with higher predictive power . Methods . A total of 53 patients with 71 fractures were studied with MRI in a prospect i ve fashion . A total of 24 patients with 39 fractures were treated conservatively and 29 patients with 32 fractures were treated operatively after a protocol concerning the treatment options . MRI scans were obtained within 1 week of injury and at the 2-year follow-up . Pain scores were obtained at the 2-year follow-up . Previously described MRI schemes concerning the trauma and post-trauma conditions were used . Results and Conclusions . An unfavorable outcome in the conservative group was related to the progression of kyphosis , which in most cases was predictable with the use of trauma MRI findings concerning the endplate comminution and vertebral body involvement . In the operatively treated group , recurrence of the kyphotic deformity was predictable by the lesion of the posterior longitudinal ligamentary complex together with endplate comminution and vertebral body involvement as seen on trauma MRI . The authors recommend the use of MRI to develop reliable prognostic criteria for these injuries


Title 3:
Management options in thoracolumbar burst fractures.
Abstract 3:
BACKGROUND Both surgery and recumbency have been adopted in the treatment of spinal fractures . Herein we present the indications for each , and our experience with thoracolumbar junction ( T12 , L1 and L2 ) burst fractures . METHODS Sixty-eight patients with thoracolumbar burst fractures were treated operatively in 36 cases , and nonoperatively in 32 with recumbency  for 1 - 6 weeks . Treatment was based on clinical and radiological criteria . Eighty-one percent of the recumbency patients , but only 14 % of the surgical patients were intact on admission . Patients were followed for a mean+/-SD of 9+/-10 months in the recumbency group , and 21+/-21 months in the surgical group . RESULTS Neurological improvement and progressive angular deformity occurred in both groups . The cost of recumbency in our patients was nearly half that of those who required surgery , though the length of hospitalization between the two groups was similar at 1 month + /-2 weeks . CONCLUSION The above study emphasizes that the selection of operative versus nonoperative treatment in burst fractures should not be r and om but based on clinical as well as radiological criteria . Recumbency is favored in patients who are intact , with angular deformity less than 20 degrees , a residual spinal canal greater than 50 % of normal , and an anterior body height exceeding 50 % of the posterior height . Surgical intervention is generally indicated in patients with partial neurological deficit , and those with severe instability


Title 4:
Nonoperative Treatment Versus Posterior Fixation for Thoracolumbar Junction Burst Fractures Without Neurologic Deficit
Abstract 4:
Study Design . A prospect i ve clinical trial was conducted . Objective . To compare the results of nonoperative treatment versus short-segment posterior fixation using pedicle screws . Summary of Background Data . A previous study showed that nonoperative treatment with early mobilization produced good results , even when the posterior column was involved . Methods . This study involved 80 patients . Inclusion criteria required the following : neurologically intact patient , single-level closed burst fracture involving T11–L2 , no fracture dislocations or pedicle fractures , age of 18 to 65 years ( nonpathologic adult ) , and no other major organ system or musculoskeletal injuries . Patients in the nonoperative group ( n = 47 ) were allowed activity to the point of pain tolerance beginning on the day of injury using a hyperextension brace . Patients in the operative group ( n = 33 ) underwent three-level , ( one above , one at fracture level , and one below ) fixation using VSP or TSRH instrumentation . The follow-up period was 2 years . Results . The surgical group had less pain up to 3 months and a better Greenough Low Back Outcome Score up to 6 months , but the outcome was similar afterward . No neurologic deficit in any patient . In the nonoperative group , the kyphosis angle worsened by 4 ° , and the retropulsion decreased from 34 % to 15 % . In the operative group , there was one case of superficial infection and two cases of broken screws . The kyphosis angle was improved initially by 17 ° , but this was gradually lost . Hospital charges were four times higher in the operative group . Conclusions . Short-segment posterior fixation provides partial kyphosis correction and earlier pain relief , but the functional outcome at 2 years is similar . Early activity to the point of pain tolerance can be safely allowed


Title 5:
Scoliosis Research Society. Multicenter spine fracture study.
Abstract 5:
This study consisted of 1,019 spinal fracture patients followed prospect ively for 2 years . Sixty-four physicians from 12 countries participated . The purpose of the study was to determine : 1 ) the relationship between neurologic deficit and fracture type , level , and spinal canal compromise ; 2 ) the neurologic outcome comparing surgical versus nonsurgical treatment and anterior versus posterior surgery ; and 3 ) the relationship of pain to both kyphotic deformity and to surgical and nonsurgical treatment . The main findings of this study are as follows : 1 ) seat belts reduced the incidence of severe neurologic injury ; 2 ) there was a higher incidence of neurologic deficit with fracture-dislocations and a higher incidence of neurologically intact patients with compression and flexion-distraction injuries ; 3 ) there was a greater incidence of complete neurologic deficits caused by fractures at the spinal cord level , and a diminished incidence at the cauda equina level ; 4 ) for burst fractures there was a weakly positive relationship between canal compromise and neurologic deficit , including bladder function ; 5 ) surgical intervention led to a greater percentage of improved neurologic function than nonoperative treatment , but the rate of improvement was not statistically different ; 6 ) anterior surgery was not more effective than posterior surgery in improving the neurologic function when function was assessed using the Frankel or Motor Index scales , but it was statistically significant when compared to the Manabe scale ; 7 ) in patients who deteriorated before surgery and underwent surgery , there was a greater improvement neurologically , particularly for anterior surgery , compared to those patients treated nonoperatively or to the overall surgically treated group ; 8) There was a statistically significant relationship between bladder function and fracture type , with an increased incidence of absent function seen with fracture-dislocations , of impaired function with burst fractures , and of intact bladder function with compression and flexion-distraction injuries ; 9 ) anterior surgery was more beneficial in improving complete bladder impairment to partial impairment compared to posterior surgery ; 10 ) a kyphotic deformity of greater than 30 degrees at 2-year follow-up was associated with an increased incidence of significant back pain ; 11 ) patients who had surgery complained less of severe pain than those who were treated without surgery
The current literature does not provide a reliable answer to whether operative or conservative treatment  is more effective for unstable traumatic thoracolumbar fractures .