Burst fractures of the thoracolumbar spine are common, but no consensus has been reached as to the best treatment. Although all burst fractures are characterized by the common finding of retropulsion of the posterior vertebral body wall into the spinal canal, burst fractures vary in severity with respect to amount of comminution, canal narrowing, associated neurologic deficit, and involvement of posterior structures. The latter structures are of primary importance in defining stability.

To determine the best treatment, the authors conducted a randomized clinical trial from 1992 to 1998 in which they compared the outcomes of forty-seven patients who received either surgical or nonoperative treatment of a stable thoracolumbar burst fracture. This type of fracture has an intact posterior osteoligamentous complex. Nonoperative care consisted of bracing or casting. The surgical group was treated by anterior corpectomy and fusion with a plate or short-segment (two to four-level) posterior pedicle-screw instrumentation and arthrodesis. The four-year results showed no difference in clinical or radiographic outcomes but higher complications among the operatively treated patients. This was an important result and led to a decrease in operative treatment in these patients.

The authors followed the patients from sixteen to twenty-two years and currently report the results for thirty-seven of the original randomized forty-seven patients. Of those who were lost to follow-up, three had died and seven could not be contacted. Contrary to the findings at earlier follow-up, long-term outcomes for pain and function were significantly better for the nonoperatively treated patients. A greater number of patients in the nonoperative group were working: 72% compared with 47% in the operative group. Radiographic results showed no significant differences between the two groups in final kyphotic angulation, overall sagittal balance, and degeneration of segments adjacent to the fracture level. However, greater degenerative disease in the lower lumbar spine was noted in the operatively treated patients. The radiographic results other than degeneration did not change over time.

These findings show that, in properly selected neurologically intact patients, stable thoracolumbar burst fractures are best treated nonoperatively. These results became more important with long-term follow-up.