What is the recommended evaluation and treatment for a burst fracture, including imaging, neurologic assessment, and criteria for non‑operative versus surgical management?

Evaluation and Management of Burst Fractures

Initial Evaluation

For any patient with a suspected burst fracture, immediately obtain CT imaging to characterize the fracture pattern, assess canal compromise, vertebral collapse, and kyphotic deformity, followed by a thorough neurological examination to document any deficits—this single determination fundamentally dictates all subsequent management. 1

Critical Assessment Components

• Neurological status: Document any motor, sensory, or sphincter deficits, as even minor neurological compromise mandates surgical evaluation 2
• Fracture morphology: Use CT to assess vertebral body comminution, posterior wall involvement, and retropulsed fragments 2, 1
• Stability indicators: Evaluate for significant vertebral collapse, angulation, canal compromise, or evidence of shear/rotation/translational injury 2
• Classification scoring: Calculate TLICS (Thoracolumbar Injury Classification and Severity) score to guide treatment decisions 1

Treatment Algorithm

For Neurologically Intact Patients

Management with or without external bracing produces equivalent outcomes—the decision is entirely at the treating physician's discretion based on patient comfort, not medical necessity. 2, 3

Evidence Supporting This Approach

• Level I randomized controlled trial evidence demonstrates no difference in pain, disability, or radiographic outcomes between braced and non-braced patients at 6 months 2, 3
• Both treatment approaches show equivalent improvement in Roland Morris Disability Questionnaire scores, visual analog pain scales, and SF-36 quality of life measures 2
• The Congress of Neurological Surgeons provides a Grade B recommendation that either approach is acceptable 2

Conservative Management Protocol

• Pain control: Initiate analgesics and allow early mobilization as tolerated 1
• Bracing decision: If choosing to brace, use TLSO for thoracolumbar fractures (T11-L3), but limit duration to maximum 8 weeks to prevent trunk muscle atrophy and weakness 4, 1
• Follow-up imaging: Obtain repeat imaging to monitor for progressive vertebral collapse, increasing kyphotic deformity, or delayed instability 1

Important Caveats

• Approximately 40% of conservatively treated patients may have persistent pain at 1 year, and one in five will develop chronic back pain despite conservative treatment 1
• TLICS scores ≤3 suggest conservative management is appropriate, while scores ≥5 indicate surgical intervention 1

Absolute Indications for Surgical Management

Any of the following findings mandate immediate surgical consultation:

• Any neurological deficit present (motor, sensory, or sphincter dysfunction) 2, 1
• Significant vertebral collapse, angulation, or canal compromise 2, 1
• TLICS score >4 suggesting instability 3, 1
• Evidence of shear, rotation, or translational injury components 3, 4

Surgical Approach Selection

For patients requiring surgery, instrumentation without fusion produces equivalent outcomes to instrumentation with fusion, with the added benefits of shorter operative time, less blood loss, and no donor site morbidity. 2

Surgical Strategy Evidence

• Two Level I randomized controlled trials and three Level II prospective studies demonstrate no difference in outcomes between fusion and nonfusion groups 2
• Anterior, posterior, or combined approaches may be used with no significant impact on clinical or neurological outcomes (Grade B recommendation) 1
• The posterior approach is preferred for most thoracolumbar pathology due to greater surgeon familiarity and lower complication rates 1

Load Sharing Classification Guidance

• For burst fractures with LSC scores of 7-9 points, consider combined anterior-posterior fixation 2, 1
• Fractures with LSC scores >6 points can be treated with posterior short-segment fixation alone 2

Percutaneous vs. Open Fixation

• Level III evidence shows no difference in outcomes between percutaneous and open fixation 2
• Open fixation demonstrates better deformity correction and maintenance compared to percutaneous techniques (Level II evidence) 2
• Both approaches are acceptable, with percutaneous fixation offering reduced blood loss and operative time 2

Common Pitfalls to Avoid

• Do not assume bracing is mandatory: High-quality evidence supports early mobilization without orthosis as equally effective as bracing 3, 4
• Do not order TLSO for patients with neurological deficits: These patients require surgical evaluation, not conservative management 3
• Do not continue rigid bracing beyond 8 weeks: This leads to trunk muscle weakening and learned non-use, potentially worsening functional outcomes 4
• Do not use preoperative brace therapy to predict surgical outcomes: It has poor predictive value (sensitivity 61%, specificity 35%) 4
• Do not assume canal compromise correlates with neurological injury: Neurological damage occurs at the moment of injury when anatomy is most distorted, not from static fragment position 5