Open Posterior Stabilisation

In open posterior stabilisation, the muscles are elevated to expose the back of the spine, and pedicle screws are placed into the vertebrae above and below the injury (and sometimes into the fractured level itself), connected by rods. This allows the spine to be realigned and held firmly. Because the canal can be accessed directly, any bone or disc material compressing the spinal cord or nerves can be removed at the same time. The open approach gives excellent visualisation and control, which is valuable for complex or badly displaced injuries.

Open posterior stabilisation can be used for a wide range of unstable thoracolumbar and cervicothoracic fractures, and it is particularly useful where the neural structures need to be decompressed, where there is significant deformity to correct, or where the injury pattern is complex. It can be used alone or combined with an anterior operation for the most destructive fractures. Where a fracture is unstable but does not need the canal opened widely, a minimally invasive percutaneous approach may be an alternative — the choice is made on the individual injury.

An important decision in posterior stabilisation is how many levels to include. Short-segment fixation — spanning just above and below the fracture — preserves more movement but relies on a smaller construct. Long-segment fixation spans more levels, sharing load more widely and offering greater stability for severe injuries or poor bone, at the cost of fusing more of the spine. Including the fractured level itself in the construct can improve the strength of a short-segment fixation. The right balance depends on the fracture, the bone quality and the degree of instability, and is chosen individually.

The evidence informs these choices. Meta-analyses comparing short-segment with long-segment pedicle screw fixation for thoracolumbar burst fractures show that both can be effective, with the balance depending on the injury and technique, and that including the fracture level can enhance a short construct. Studies of posterior fixation for unstable thoracolumbar fractures support its role in realignment and stabilisation. This literature underpins a tailored approach to the length and configuration of fixation.

Whether open posterior stabilisation is the best option, and how it is configured, depends on the fracture pattern, the neurology, the degree of deformity and the bone quality. Where it is appropriate, it offers powerful realignment, fixation and, where needed, decompression; where a smaller approach would suffice, that is considered. The plan, realistic expectations and risks are discussed individually.

• —Aly TA. Short-segment versus long-segment pedicle screw fixation in thoracolumbar burst fractures: a meta-analysis. Asian Spine J 2017. (PMID 28243383)
• —Guo H, et al. Short-segment versus long-segment fixation for thoracolumbar burst fractures: systematic review and meta-analysis. Medicine (Baltimore) 2025. (PMID 40489858)
• —Tezeren G, et al. Posterior fixation of thoracolumbar burst fracture: short-segment versus long-segment instrumentation. J Spinal Disord Tech 2005. (PMID 16306834)
• —Kanna RM, et al. Unstable thoracolumbar junction fractures: short-segment with fracture-level inclusion versus long-segment fixation. Spine J 2016. (PMID 27541493)