What is the treatment for a burst stable fracture?

Treatment of Burst Stable Fractures

For neurologically intact patients with stable thoracolumbar burst fractures, nonoperative management with early mobilization—either with or without external bracing—is the evidence-based treatment of choice, as both approaches produce equivalent outcomes in pain, disability, and radiographic parameters. 1

Defining a Stable Burst Fracture

A stable burst fracture is characterized by:

• Neurologically intact status (no motor or sensory deficits) 1, 2
• Absence of significant vertebral collapse, angulation, or canal compromise 1, 2
• No evidence of shear, rotation, or translational injury components 2
• Intact posterior column (the key determinant of stability, not the middle column) 3

Treatment Algorithm

Step 1: Confirm Stability Criteria

Verify the patient meets ALL of the following:

• Neurologically intact examination 1, 2
• No significant posterior ligamentous complex disruption 2
• TLICS score ≤4 (if using this classification system) 2
• Reasonable spinal alignment maintained 3

Step 2: Choose Between Bracing vs. No Bracing

The Congress of Neurological Surgeons provides a Grade B recommendation that management with or without external bracing produces equivalent outcomes—the decision is at the treating physician's discretion. 1, 2

Evidence supporting equivalence:

• Level I randomized controlled trial data demonstrates no difference in Roland Morris Disability Questionnaire scores, visual analog pain scales, or SF-36 quality of life measures at 6 months between braced and non-braced patients 1, 2
• Radiographic outcomes (vertebral height maintenance, kyphotic angulation) are equivalent between groups 1
• Bracing is not associated with increased adverse events compared to no brace 1

Practical considerations for bracing decision:

• Consider TLSO bracing for patients with borderline stability, higher anxiety about injury, or those requiring additional pain control during early mobilization 2
• Consider no bracing for patients who prefer early unrestricted mobilization, have skin integrity concerns, or body habitus making brace fitting difficult 2
• Both approaches allow early mobilization and weight-bearing as tolerated 1, 2

Step 3: Outpatient Follow-Up Protocol

• Schedule follow-up within 1-2 weeks of initial diagnosis 4, 5
• Obtain serial imaging (standing radiographs or CT) at 2 weeks, 6 weeks, and 12 weeks to monitor for progressive deformity 4, 5
• Monitor for development of neurological symptoms at each visit 1

Absolute Contraindications to Nonoperative Management

Surgical consultation is mandatory if ANY of the following are present:

• Any neurological deficit (motor weakness, sensory loss, bowel/bladder dysfunction) 1, 2, 4
• Significant vertebral collapse, angulation, or canal compromise 1, 2
• TLICS score >4 suggesting instability 2
• Evidence of shear, rotation, or translational injury (indicating posterior ligamentous complex disruption) 2
• Progressive deformity on serial imaging during nonoperative management 4

Common Pitfalls to Avoid

• Do not assume bracing is mandatory—high-quality Level I evidence supports early mobilization without orthosis as equally effective 1, 2
• Do not order TLSO for patients with neurological deficits—these require immediate surgical evaluation, not bracing 2, 4
• Do not rely on canal compromise percentage alone to determine stability in neurologically intact patients—canal stenosis ranging from 20-90% has been successfully managed nonoperatively in intact patients 6
• Do not confuse middle column compromise with instability—the posterior column integrity, not the middle column, is the critical determinant of burst fracture stability 3
• Do not delay spine surgery consultation for fractures with >40% vertebral height loss or significant retropulsion, even if neurologically intact 5

Expected Outcomes with Nonoperative Management

• Pain improvement occurs progressively over 6 months in both braced and non-braced cohorts 1
• Neurologic deterioration is unlikely in properly selected stable fractures 7, 3
• Progressive deformity is uncommon when posterior column remains intact 7, 3
• Return to function is equivalent between bracing and no-bracing approaches 1