Therapeutic study, Level II-1 (prospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

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Surgical decompression of the spinal canal is presently accepted worldwide as the method of treatment for thoracolumbar burst fractures with neurological deficit in the belief that neurological recovery may be produced or enhanced. Our clinical and laboratory experience, however, indicates that the paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Since the preoperative geometry of the fracture may be of no relevance, our hypothesis, backed by more than two decades of operative experience, is that alteration of the canal by 'surgical clearance' does not affect the neurological outcome. We have reviewed the existing world literature in an attempt to find evidence-based justification for the variety of surgical procedures used in the management of these fractures. We retrieved 275 publications on the management of burst fractures of which 60 met minimal inclusion criteria and were analysed more closely. Only three papers were prospective studies; the remainder were retrospective descriptive analyses. None of the 60 articles included control groups. The design of nine studies was sufficiently similar to allow pooling of their results, which failed to establish a significant advantage of surgical over non-surgical treatment as regards neurological improvement. Significant complications were reported in 75% of papers, including neurological deterioration. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons. This information should not be withheld from the patients.

Surgical decompression of the spinal canal is presently accepted worldwide as the method of treatment for thoracolumbar burst fractures with neurological deficit in the belief that neurological recovery may be produced or enhanced. Our clinical and laboratory experience, however, indicates that the paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Since the preoperative geometry of the fracture may be of no relevance, our hypothesis, backed by more than two decades of operative experience, is that alteration of the canal by 'surgical clearance' does not affect the neurological outcome.We have reviewed the existing world literature in an attempt to find evidence-based justification for the variety of surgical procedures used in the management of these fractures. We retrieved 275 publications on the management of burst fractures of which 60 met minimal inclusion criteria and were analysed more closely. Only three papers were prospective studies; the remainder were retrospective descriptive analyses. None of the 60 articles included control groups. The design of nine studies was sufficiently similar to allow pooling of their results, which failed to establish a significant advantage of surgical over non-surgical treatment as regards neurological improvement. Significant complications were reported in 75% of papers, including neurological deterioration. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons. This information should not be withheld from the patients. There are many different classifications of thoracolumbar spinal injuries but the most popular is that of Denis 1 which is based on the three-column theory as considered in the sagittal plane. The three columns are the anterior, which comprises the front half of the bodies and the anterior longitudinal ligament, the middle, namely the back half of the bodies and the posterior longitudinal ligament, and the posterior, which includes the laminae, facet joints and spinous processes plus the ligaments and muscles attached to them. The more columns which are damaged the more unstable is the injury. Four fundamental types of fracture can be distinguished: 1) a simple, stable anterior wedge compression fracture with compression of the anterior column; 2) distraction injuries, referred to as seat-belt injuries; 3) burst fractures with compression of both the anterior and middle columns; and, finally, 4) fracture-dislocations of the spine which are unstable and involve all three columns.Burst fractures are produced by vertical compressive loads, usually with some degree of flexion, since the anterior column is squashed down more than the middle column. Although bone bursts in all directions, one of the compelling images of a burst fracture can be seen on transverse CT which shows bone retropulsed into the spinal canal. Such scans may show a range o...

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