The treatment of thoracolumbar burst fractures is based on two principles, neurological “optimization” and biomechanical stability. Neurologic “optimization” includes prevention, limitation, and neurologic reversal through decompression of the spinal segments for stabilization. Unstable thoracolumbar burst fractures carry the risk of symptomatic kyphosis, prolonged bed rest, and delayed neurological deterioration. Non-operative treatment includes pain control, prophylaxis (pulmonary function therapy, prevention of venous thromboembolism), and brace braking. Going back to Watson Jones, fractures secondary to flexion-compression stress have decreased, while hyperextension injuries have gradually increased. Traditional casts have gradually been replaced by functional braces. These include the cross-shaped anterolateral spinal hyperextension brace, the Jewett hyperextension brace, or the custom-made polypropylene thoracolumbosacral brace (TLSO). Although the TLSO is more expensive than existing braces, we continue to recommend the TLSO because of its better stability in all directions and ease of donning and doffing and cleaning. Our strategy consists of wearing the TLSO 24 hours a day for 3 months, with routine standing radiographs taken at 3, 6, 9 and 12 weeks to assess the kyphosis. Other risks of non-surgical treatment include deterioration of neurological function, skin breakdown, respiratory and abdominal limitations, and noncompliance. It should be noted that surgical treatment does not mean that bracing can be dispensed with, as many surgeons still choose brace protection postoperatively. no conclusive evidence was found in a recent systematic review by Giele et al. to support the use of bracing for thoracolumbar fractures. In general the surgical treatment of thoracolumbar burst fractures includes anterior and/or posterior decompression, and anterior and/or posterior fixation. Neural decompression can be performed anteriorly by subtotal vertebral body resection, followed by cage or autogenous bone block grafting and anterior rod/plate fixation. In our experience, posterior short-segment fixation should be used if there is a combined posterior collateral ligament complex injury. It has been our experience that if an anterior subtotal laminectomy is performed within 48 hours of acute injury, it will bring about a significant increase in intraoperative bleeding as well as an increased morbidity and mortality rate. Therefore, we believe it is more prudent to use a posterior approach to remove the occupying bone mass for decompression or indirect fracture reduction via a posterior approach. The fracture is then fixed with a posterior short-segment pedicle nail, and 48-72 hours later, it is supported with a first-stage anterior subtotal resection of the vertebral body with bone grafting. The humeral stem as well as the autologous iliac crest is preferred for bone grafting. Various treatment strategies have been reported in the literature, including anterior subtotal vertebral body resection, simple posterior instrumentation, vertebroplasty repositioning, and cement injection to strengthen the anterior column. Of note, Dai et al. recently reported on 73 patients with thoracolumbar burst fractures treated with posterior pedicle nailing with or without fusion and followed up for 5 years. No significant differences in imaging and clinical outcomes were found between the two groups. The non-fusion group showed a significant reduction in operative time as well as bleeding compared to the fusion group.