Management of Thoracolumbar Burst Fracture Without Posterior Column Involvement
For neurologically intact patients with thoracolumbar burst fractures without posterior column involvement, nonoperative management with early mobilization is recommended, and external bracing is optional with no proven benefit over mobilization alone. 1
Initial Assessment
Confirm the absence of neurological deficit through comprehensive motor, sensory, and reflex examination. 2, 3 Any neurological deficit immediately changes management to surgical consideration. 4, 2
Verify posterior column integrity on imaging studies. 5 The posterior column—not the middle column—is the critical determinant of burst fracture stability. Biomechanical studies demonstrate that burst fractures with intact posterior ligamentous complex are inherently stable injuries. 5
Calculate the TLICS (Thoracolumbar Injury Classification and Severity) score if available. 4, 3 Scores ≤3 support conservative management, while scores >4 indicate surgical evaluation is needed. 4, 3
Nonoperative Management Protocol
Initiate early mobilization as tolerated without mandatory bracing. 1 The Congress of Neurological Surgeons provides a Grade B recommendation based on Level I randomized controlled trial evidence showing that both external bracing and no brace produce equivalent outcomes in pain, disability, and radiographic parameters at 6 months and beyond. 1
If bracing is chosen for early pain control or patient comfort, limit duration to maximum 8 weeks. 4 Beyond 8 weeks of continuous bracing, there is increased risk of trunk muscle atrophy, weakness, and learned non-use that can worsen functional outcomes. 4
Prescribe NSAIDs as first-line analgesics for pain control. 3 Reserve opioids for severe pain only, using them cautiously due to risks of sedation, nausea, and falls. 3
Evidence Supporting Conservative Management
The decision between bracing and no bracing is at the treating physician's discretion, as high-quality evidence demonstrates no difference in outcomes. 1, 2 Three studies including one Level I randomized controlled trial and one Level II pilot study showed equivalent improvement in Roland Morris Disability Questionnaire scores, visual analog scale pain scores, and SF-36 quality of life measures between braced and non-braced cohorts. 1
Classic burst fractures with anterior and middle column compromise but intact posterior column are stable injuries that heal satisfactorily with nonoperative treatment. 5 Biomechanical testing reveals that posterior column integrity—not middle column status—determines stability, with statistically significant increases in motion only occurring when the posterior column is compromised. 5
Absolute Contraindications to Conservative Management
Proceed directly to surgical evaluation if any of the following are present:
- Any neurological deficit whatsoever 4, 2, 3
- Significant vertebral collapse, angulation, or canal compromise 1, 4
- TLICS score >4 suggesting instability 4, 2, 3
- Evidence of shear, rotation, or translational injury components 1, 4
- Posterior ligamentous complex disruption 2, 6
Expected Outcomes and Follow-Up
Most patients experience spontaneous resolution of fracture-related pain within 6-8 weeks. 3 However, approximately 40% may have some persistent pain at 1 year, and one in five (20%) may develop chronic back pain despite conservative treatment. 3
Schedule repeat imaging to monitor for progressive vertebral collapse, increasing kyphotic deformity, or delayed instability. 3 These findings would prompt reconsideration of surgical intervention.
Surgical Considerations (If Indicated)
If surgery becomes necessary due to instability or neurological compromise, the Congress of Neurological Surgeons provides a Grade B recommendation that anterior, posterior, or combined approaches may be used, as the selection of approach does not appear to impact clinical or neurological outcomes. 1 However, the posterior approach offers greater surgeon familiarity and typically lower complication rates. 3
Common Pitfalls to Avoid
Do not assume bracing is mandatory. 2 High-quality Level I evidence supports early mobilization without orthosis as equally effective to braced management. 1, 2
Do not continue rigid bracing beyond 8 weeks continuously. 4 This leads to trunk muscle weakening and potentially worsens functional outcomes. 4
Do not use preoperative brace therapy to predict surgical fusion outcomes. 4 It has poor predictive value with sensitivity of only 61% and specificity of 35%. 4
Do not order TLSO for patients with neurological deficits. 2 These patients require immediate surgical evaluation, not conservative management. 2