For an adult with an isolated lumbar burst fracture that is neurologically intact and mechanically stable (≤30 % canal compromise, minimal vertebral body height loss, intact posterior tension band), what is the recommended non‑operative management, including brace type and duration?

Lumbar Burst Fracture Bracing

For neurologically intact adults with stable lumbar burst fractures, bracing is optional—both braced and non-braced management produce equivalent outcomes in pain, disability, and radiographic results, and the decision should be based on physician discretion and patient comfort needs. 1

Evidence-Based Recommendation

The Congress of Neurological Surgeons provides a Grade B recommendation that management either with or without an external brace is acceptable for neurologically intact patients with thoracic and lumbar burst fractures. 1 This recommendation is based on Level I randomized controlled trial evidence demonstrating no significant difference in:

• Pain scores (VAS) at 6 months 1
• Disability measures (Roland Morris Disability Questionnaire) 1
• Quality of life outcomes (SF-36) 1
• Radiographic outcomes including kyphosis progression 1
• Patient satisfaction 1
• Length of hospital stay 1

Bracing is not associated with increased adverse events compared to no brace, making early mobilization without orthosis equally effective. 1, 2

When Bracing is Used: Type and Duration

Brace Type

• TLSO (thoracolumbosacral orthosis) is the standard brace type when external immobilization is chosen for thoracolumbar burst fractures. 1, 2
• Total contact orthosis designs have been used successfully in clinical series. 3

Duration

• Maximum bracing duration should not exceed 8 weeks continuously to avoid trunk muscle atrophy, weakness, and learned non-use that can worsen functional outcomes. 4
• Historical protocols used 6 months of bracing, but this is no longer supported by current evidence. 3
• Beyond 8 weeks, there is increased risk of trunk muscle deconditioning that may paradoxically impair recovery. 4

Absolute Contraindications to Conservative Management

These findings mandate immediate surgical evaluation, not conservative treatment:

• Any neurological deficit present 1, 2, 4, 5
• Significant vertebral collapse, angulation, or canal compromise 1, 2, 5
• TLICS score >4 indicating instability 2, 4, 5
• Evidence of shear, rotation, or translational injury components (not pure axial compression) 1, 2
• Fractured or dislocated pedicles and facet joints 6

Clinical Decision Algorithm

Step 1: Confirm Stability Criteria

The patient must meet ALL of the following:

• Neurologically intact on examination 1, 2
• Kyphosis angle <35 degrees 3, 6
• Intact posterior tension band (no pedicle or facet fractures/dislocations) 6
• ≤30% canal compromise (per your question parameters)
• Minimal vertebral body height loss (per your question parameters)

Step 2: Choose Management Strategy

Either approach is acceptable:

Option A: No Brace with Early Mobilization

• Immediate ambulation as tolerated 6
• Pain control with analgesics 5
• Activity modification based on comfort 6
• This approach has Level I evidence showing equivalent outcomes to bracing 1

Option B: TLSO Bracing

• Use for early pain control if patient prefers 4
• Limit to maximum 8 weeks duration 4
• Allow mobilization as tolerated even with brace 3
• Discontinue earlier if pain resolves 4

Step 3: Follow-Up Monitoring

• Repeat imaging is necessary to monitor for progressive vertebral collapse, increasing kyphotic deformity, and delayed instability 5
• Maximum kyphosis progression averages 4-6 degrees in conservatively managed cases 3, 6
• Approximately 40% may have persistent pain at 1 year, and 20% develop chronic back pain despite conservative treatment 5

Important Clinical Nuances

The Posterior Column Controversy

• Classic teaching that posterior column involvement (lamina fractures, spinous process fractures) mandates surgery is not supported by evidence. 7, 6
• Biomechanical studies demonstrate that the condition of the posterior ligamentous complex, not the middle column or bony posterior elements, is the better indicator of burst fracture stability. 7
• Vertical lamina fractures and spinous process fractures are not contraindications to conservative management if the posterior ligamentous complex is intact. 6

Canal Compromise is Not Predictive

• The degree of canal stenosis (retropulsion) does not correlate with neurological outcome or need for surgery in neurologically intact patients. 3, 8, 6
• Canal compromise ranging from 20-90% has been successfully managed conservatively in neurologically intact patients. 8
• Some degree of retropulsed fragment resorption occurs naturally in 92% of cases (35/38 patients in one series). 6

L5 Burst Fractures: Special Consideration

• L5 burst fractures may have superior outcomes with nonoperative management compared to operative treatment, showing better radiographic alignment and clinical satisfaction. 9
• The unique anatomy and biomechanics of L5 make it particularly amenable to conservative treatment. 8, 9

Common Pitfalls to Avoid

• Do not assume bracing is mandatory—high-quality evidence supports that it is optional. 1, 2
• Do not continue rigid bracing beyond 8 weeks—this causes muscle deconditioning. 4
• Do not order TLSO for patients with neurological deficits—these require surgical evaluation. 2
• Do not use preoperative brace therapy to predict surgical fusion outcomes—it has poor predictive value (61% sensitivity, 35% specificity). 4
• Do not deny conservative treatment based solely on CT findings of canal compromise—neurological status is the critical factor. 3, 8