Thoracolumbar Trauma Stabilisation

Not every thoracolumbar fracture needs an operation. The key questions are whether the spine is mechanically stable, whether the neural structures are being compressed, and how much deformity there is. Classification tools such as the Thoracolumbar Injury Classification and Severity Score (TLICS) help weigh the fracture pattern, the integrity of the ligaments at the back of the spine, and the neurological status to guide the decision. Stable fractures without neurological problems can often be managed without surgery; unstable injuries, or those with neural compression, are more likely to benefit from stabilisation.

When surgery is indicated, the spine can be realigned and fixed with pedicle screws and rods, usually from the back, holding the injured level while it heals. This can be done through an open approach — which also allows direct decompression of the neural structures when needed — or, for suitable fractures that do not require the canal to be opened widely, through a minimally invasive percutaneous approach. For the most destructive injuries, where the vertebral body is shattered, reconstruction from the front (with a corpectomy and cage) may be combined with posterior fixation. The technique is matched to the injury.

For some thoracolumbar fractures — particularly burst fractures in people who are neurologically intact — there is genuine debate about whether surgery offers an advantage over bracing and rehabilitation, and the honest answer is that both can give good long-term results in the right patients. This is why the decision is individualised, weighing the stability of the injury, the deformity, the person's circumstances and their preferences. Being candid about this evidence is part of good, shared decision-making.

The evidence supports a selective, individualised approach. Systematic reviews and a long-term randomised trial comparing operative with non-operative treatment of thoracolumbar burst fractures without neurological deficit show that both can achieve good outcomes, underlining the importance of patient selection. Studies of the TLICS system support its role in guiding the decision to operate. This literature underpins careful judgement about who benefits from stabilisation and how it is best achieved.

Whether a thoracolumbar fracture needs stabilising, and how, depends on the stability of the injury, the neurology, the degree of deformity and the individual's circumstances. Where surgery is appropriate, it realigns and fixes the spine, with the least disruptive technique that will do the job safely; where non-operative care is reasonable, that is discussed openly. The plan, realistic expectations and risks are set out individually.

• —Chou TY, et al. Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit: systematic review and meta-analysis. Global Spine J 2024. (PMID 37294595)
• —Wood KB, et al. Operative versus non-operative treatment of thoracolumbar burst fracture without neurological deficit: 16-22 year follow-up. J Bone Joint Surg Am 2015. (PMID 25568388)
• —Abudou M, et al. Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit: meta-analysis. Int Orthop 2011. (PMID 22057820)
• —Koh YD, et al. Reliability and validity of the Thoracolumbar Injury Classification and Severity Score (TLICS). Asian Spine J 2010. (PMID 21165314)