In a patient with an L1 burst fracture, when is a thoracolumbosacral orthosis (TLSO) appropriate and what criteria must be met for its use?

TLSO Brace for L1 Burst Fracture

Direct Answer

For neurologically intact patients with L1 burst fractures and an intact posterior ligamentous complex, a TLSO brace is optional and provides no clinical benefit over early mobilization without bracing—the decision is entirely at physician discretion. 1, 2

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Evidence-Based Framework for Decision-Making

When TLSO is NOT Required (Preferred Approach)

Level I randomized controlled trial evidence demonstrates that braced and non-braced patients achieve identical outcomes at 6 months and beyond in pain (VAS), disability (Roland-Morris), quality of life (SF-36), and radiographic parameters. 3, 4, 5

• The Congress of Neurological Surgeons provides a Grade B recommendation that management with or without external bracing produces equivalent outcomes 1, 2
• Early mobilization without orthosis is recommended as first-line treatment for neurologically intact patients with intact posterior ligamentous complex 2
• The no-brace approach results in shorter hospital stays (mean 2.8 days vs 6.3 days with TLSO) without increased complications 4
• Avoiding bracing eliminates costs, patient deconditioning, and trunk muscle atrophy associated with prolonged orthosis use 5

When TLSO May Be Considered

If a brace is selected for patient comfort or short-term pain control, limit continuous use to ≤8 weeks to prevent trunk muscle atrophy and functional decline. 6, 2

• The decision to use TLSO should be based on physician discretion considering patient comfort and early pain control needs 2
• Beyond 8 weeks of continuous bracing, there is increased risk of trunk muscle weakness and learned non-use 2
• Patients in TLSO protocols begin weaning at 8 weeks over a 2-week period 3

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Absolute Contraindications to Conservative Management (Require Surgery)

Any of the following findings mandate immediate surgical evaluation rather than TLSO consideration:

• Any neurological deficit present 1, 6, 2
• Significant vertebral collapse, angulation, or canal compromise 1, 6, 2
• TLICS score >4 indicating instability 1, 6
• Evidence of shear, rotation, or translational injury components 1, 2
• Posterior ligamentous complex disruption on MRI 2, 3

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Clinical Algorithm for L1 Burst Fracture Management

Step 1: Perform Neurological Examination

• Document any motor, sensory, or sphincter deficits 6
• If any deficit present → immediate surgical consultation 6, 2

Step 2: Obtain CT Imaging

• Assess fracture morphology using AO Classification (Type A3 burst fractures are typical candidates) 7, 3
• Measure canal compromise, vertebral body height loss, and kyphotic angle 6, 8
• If significant collapse, angulation, or canal compromise → surgical consultation 1, 2

Step 3: Obtain MRI

• Evaluate posterior ligamentous complex integrity 3
• If posterior ligamentous complex disrupted → surgical consultation 2, 3

Step 4: Calculate TLICS Score

• Score ≤3 → conservative management appropriate 6
• Score 4 → gray zone, physician discretion 1
• Score ≥5 → surgical intervention 6

Step 5: Choose Conservative Approach (if criteria met)

• Option A (Preferred): Early mobilization without brace, maintaining neutral spinal alignment for 8 weeks 2, 3, 5
• Option B: TLSO for patient comfort, with weaning at 8 weeks 6, 2
• Both options produce equivalent clinical and radiographic outcomes 1, 2, 3

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Critical Pitfalls to Avoid

Do not assume bracing is mandatory—high-quality evidence supports early mobilization without orthosis as equally effective and avoids brace-related complications 1, 2

Do not order TLSO for patients with neurological deficits—these require surgical evaluation, not conservative management 1, 6

Do not continue rigid bracing beyond 8 weeks continuously—this leads to trunk muscle weakening and potentially worsens functional outcomes 6, 2

Do not use preoperative brace therapy to predict surgical fusion outcomes—it has poor predictive value (sensitivity 61%, specificity 35%) 2

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Expected Outcomes with Conservative Management

Most patients achieve complete symptom resolution, though some persistent pain is common:

• Majority experience spontaneous pain resolution within 6–8 weeks 6
• Approximately 40% may retain some pain at 1 year post-injury 6
• Around 20% (one in five) may develop chronic back pain despite conservative treatment 6
• Mean return to work is 3.6 months (range 2–6 months) with good functional outcomes 8

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Radiographic Considerations

Some loss of vertebral height and kyphotic progression is expected and does not correlate with clinical outcomes:

• Local kyphosis angle, sagittal index, and height loss percentage increase significantly during follow-up even with TLSO 8
• No significant difference in kyphotic progression between braced (5.3°±4.4°) and non-braced (5.2°±3.6°) groups 4
• Conservative treatment produces effective functional results despite loss of vertebral body height 8