Thoracolumbar fracture is a common injury in clinical work, and its injury pathology is complex, and different types of injuries require different treatment principles and methods. At the same time, many clinical treatment methods have their own strong indications. With the development of medical fundamentals, related disciplines and industrial technology, many basic concepts, diagnostic criteria, therapeutic concepts and treatment methods in the field of spine surgery have been continuously improved. Especially in the last two decades, the progress in the diagnosis and treatment of spinal surgery has been very encouraging, such as the 3D CT and MRI, which treat the human body as a transparent body, and the clinical application of C-arm fluoroscopy, navigators, endoscopes, various spinal surgical tools and built-in objects, which have led to satisfactory clinical results in the surgical treatment of thoracolumbar fractures. However, there are still some debates on how to accurately determine the type of thoracolumbar fracture and select a reasonable treatment method. Denis typing: The concept of three columns was introduced to further deepen the understanding of the structure of the spine and its functional units. It divides thoracolumbar fractures into 4 major categories: (1) Class A: compression fractures; (2) Class B: burst fractures; Class B is further divided into 5 types: (1) upper and lower endplate type; (2) upper endplate type; (3) lower endplate type; (4) burst rotation type; (5) burst lateral flexion type. (3)Class C: seat belt fracture; Class C fracture is divided into single horizontal type and double horizontal type of fracture line, and each type is divided into bony injury and soft tissue injury, which are combined into 4 types. (4) Class D: fracture dislocation. There are three types of Class D: (1) flexion-rotation fracture dislocation; (2) shear fracture dislocation; (3) flexion-distraction fracture dislocation. McAfee’s typing: The cross-sectional scan image of CT enables more accurate evaluation of the degree of injury of thoracolumbar fractures and understanding of the status of the three columns, so McAfee et al. classified thoracolumbar fractures into 6 major categories according to the performance of CT of thoracolumbar fractures and the status of the force on the middle column: (1) wedge compression fractures; (2) stable burst fractures; (3) unstable burst fractures; (4) Chance fractures; (5) flexion-distraction injuries; and displacement injuries. The displaced injuries include “slice” fractures, rotational fracture dislocations, and simple dislocations. AO classification: Since the 1990s, in view of the deficiencies of the existing classification of thoracolumbar fractures, the AO school and the American orthopedic authority have introduced their own classification method. (1) Class A: vertebral compression: ①A1: extrusion fracture; ②A2: split fracture; ③A3: burst fracture. (2) Class B: distraction bicolumn fracture: ①B1: ligament-based posterior column injury; ②B2: bone-based posterior column injury; ③B3: injury by the anterior transsphenoidal disc. (3) Class C: rotational double column injury: ①C1: Class A fracture with rotation; ②C2: Class B fracture with rotation; ③C3: rotation 2 shear injury. (2) Class B: distraction type, including posterior soft tissue type (subluxation), posterior arch type (Chance fracture), and anterior disc type (extension slip); (3) Class C: multi-directional displacement type, including anterior-posterior type (dislocation), lateral type (lateral shear), and rotational type (rotational dislocation). In China, Zhang Guangbo et al. classified thoracolumbar fractures based on the Denis classification, focusing on three-column injuries and supplemented by the condition of spinal canal obstruction. Rao Shucheng combined several common classifications to classify thoracolumbar fractures into five major categories: (1) flexion compression fractures, of which the typology was divided into three types using Ferguson and Allen’s classification of third degree compression; (2) burst fractures, of which the typology was based on the five types of burst fractures of Denis classification; (3) flexion distraction injuries, of which the typology was based on Gertzbein’s (4) flexion-rotation fracture dislocation, of which there are two types: transvertebral disc dislocation and “slicing” fracture; (5) shear dislocation. TLICS staging: The SpineTraumaStudyGroup (STSG) in the United States has proposed a new staging method for thoracolumbar spine injuries, the Thoracolumbar Injury Scoring System (TIS). The TLISS scoring system is based on three main aspects: (1) the mechanism of injury of the fracture based on imaging data; (2) the integrity of the posterior ligamentous complex of the vertebral body; and (3) the neurological function status of the patient. Each item was scored separately and summed to obtain the total TLISS score, which was used to develop treatment strategies. Later, the STSG improved the TLISS by replacing the subjective injury mechanism with a more objective description of the fracture pattern, and called the Thoracolumbar Injury Classification and SeverityScore System (TLICS) [14]. The specific criteria were (1) morphological presentation of the fracture: 1 point for compression fracture; 2 points for burst fracture; 3 points for rotational fracture; and 4 points for distraction fracture. In case of duplication, the highest score was taken. (2) Integrity of the posterior ligamentous complex structure of the vertebral body: 0 points for intact; 3 points for complete fracture; 2 points for incomplete fracture. (3) Neurological functional status of the patient: 0 points for no neurological damage; 2 points for complete spinal cord injury; 3 points for incomplete injury or cauda equina syndrome. The sum of the scores is the total TLISS score. The system recommends that those with scores greater than or equal to 5 should be considered for surgical treatment, those with scores less than or equal to 3 for non-surgical treatment, and those with scores of 4 for either surgical or non-surgical treatment. The Load-Sharing Spinal Load Scoring System: The Load-Sharingscoringsystem has received more attention, and Parker et al. scored the vertebral body according to the degree of comminution, the extent of entry of the bone mass into the spinal canal, and the degree of posterior convexity deformity, with a minimum of 3 points and a maximum of 9 points for each item. DaiLiyang reported that this scoring system is more reliable. The surgical approach for thoracolumbar fractures A posterior fracture reduction, internal fixation with pedicle nail (percutaneous pedicle screw fixation)/posterior canal decompression, fracture reduction, internal fixation with pedicle screw and bone graft fusion (including intervertebral CAGE fusion, iliac bone graft/titanium mesh bone graft fusion, PLIF/TLIF) B anterior subtotal resection, decompression, titanium mesh bone graft or autologous bone graft C combined anterior-posterior approach Thoracic Lumbar fracture surgical selection The surgical approach is selected according to the classification of the fracture, the occupancy of the spinal canal as shown by imaging, the integrity of the posterior ligamentous complex structure of the vertebral body, and the neurological functional status of the patient. Anterior decompression, posterior surgery and combined anterior and posterior surgery are usually performed. Vaccaro et al. concluded that the two most important factors affecting the choice of surgical approach for thoracolumbar fractures are the integrity of the posterior ligamentous complex of the vertebral body and the functional status of the nervous system. The basic principles are: anterior decompression is usually required for incomplete neurological impairment with imaging confirmation of compression from the anterior spinal canal; posterior surgery is usually required for disruption of the posterior ligamentous complex; and combined anterior and posterior surgery is usually required for both types of impairment. The anterior approach allows for the removal of the compressive material under direct vision, resulting in complete decompression of the anterior spinal canal. The anterior decompression results in support implants between adjacent vertebrae above and below the injured segment, restoring vertebral height and sagittal balance of the spine, providing maximum space in the spinal canal and intervertebral foramina for nerve recovery, and restoring near-normal load distribution in the spine. Anterior internal fixation can effectively increase the stability of the fused spinal segment and promote implant fusion. The disadvantage is that the anterior approach sometimes cannot correct scoliosis, kyphosis, and fracture dislocation combined with small joint interlocking; it is also not easy to deal with multiple or jumping spinal fractures because of the short fixation segment. The indications for anterior surgery are: (1) old fractures of the thoracolumbar spine (more than 2 weeks after injury) with anterior spinal compression; (2) severe fracture dislocation with 50% canal encroachment, 70% loss of vertebral body height, and 20°-30° of retroflexion; (3) unsatisfactory reset by posterior internal fixation and failure to release anterior spinal compression; (4) failure of posterior internal fixation and recompression of the spinal cord; (5) old thoracolumbar fracture with retroflexion deformity complicated by delayed paraplegia. Posterior surgery is the traditional procedure for the treatment of thoracolumbar fractures. The posterior approach to internal fixation of the vertebral arch, which achieves three-column fixation through the vertebral arch, can be used for thoracolumbar fractures using the principle of ligamentous correction, i.e., restoring the tension of the anterior and posterior longitudinal ligaments of the spine and the intervertebral fibrous ring to restore the height of the compressed or burst injured vertebrae and achieve a repositioning effect. Posterior surgery should generally consider the need for decompression of the vertebral plate and whether short or long segmental fixation is required. Simple arch internal fixation without posterior decompression is feasible in the following cases: (1) compression fractures with 50% loss of height of the vertebral body front and 20% occupancy of the spinal canal; (2) preoperative CT and MRI confirm the integrity of the posterior ligamentous complex structure of the vertebral body; (3) no manifestation of neurological impairment of the spinal cord. For burst fractures or jump fractures with severe dislocation, posterior reduction and long-segment (3-4 pairs of pedicle nails) fixation is adopted to increase their stability. Combined anterior-posterior approach: Most thoracolumbar fracture dislocations can be treated with simple anterior or posterior surgery and adequate decompression, repositioning, and fixation can be achieved. It is believed that combined anterior and posterior approaches are indicated for: (1) thoracolumbar burst fractures caused by flexion or vertical violence with significant intradural occupancy and collapse of the vertebral plate; (2) posterior spinal fractures caused by extension violence with vertebral fractures and significant bony occupancy of the vertebral canal; (3) anterior and posterior spinal structural injuries with rotational dislocation caused by axial rotational violence; (4) repositioning and fixation by purely anterior or posterior approaches (4) Failure of the anterior or posterior repositioning and fixation. The posterior approach is the most widely used technique, and the key to the procedure is the accurate placement of the spinal arch nail. (1) Familiarity with the anatomy of the spine, especially the anatomy of the vertebral arch, is essential. Initially, we apply spinal bone specimens to familiarize with anatomy, cadaveric specimens for nail implantation, experience nail implantation techniques, and then carefully observe vertebral bone specimens before surgery to have a good idea. (2) Understand the nailing method of pedicle screws. Be familiar with the commonly used nailing methods, and master the one you are most familiar with. Lumbar arch nail into the nail, you can choose the “herringbone crest” positioning method recommended by the Union Hospital, the thoracic arch nail into the nail to choose the level of the lower edge of the inferior articular eminence and the intersection of the vertical line of the inner 1/3 of the transverse process as the nailing point, into the nail angle of 15 ° with the sagittal plane. (3) Intraoperative technique: each arch to be fixed is drilled with an open cone to a depth of about 3 cm, and the bone around the inner wall of the arch is probed with a ball probe; if the bone is felt all around, the position is proved to be accurate and a positioning pin is placed. Intraoperative C-arm fluoroscopy was used to understand the position of each positioning pin. According to the fluoroscopic situation, the appropriate screw is selected, and the screw is screwed into about 3 cm and then withdrawn (at this time, it is usually past the arch), and then the inner wall of the arch is probed with a ball probe, and if there is still solid bone, it further proves that the position is good, and the screw is screwed in completely. Here emphasize the importance of “feel”, that is, the feeling of “sand sand” when drilling with the hand cone, and no obvious resistance, probe probe when the inner wall of the bone, without the feeling of emptiness or rubbing soft.