Posterior-only versus combined anterior-posterior approaches for thoracolumbar burst fractures: a meta-analysis

Abstract

Background: Thoracolumbar burst fractures are among the most common spinal injuries, and optimal surgical management remains controversial. Evidence comparing posterior-only and combined anterior-posterior fixation strategies remains inconsistent.

Methods: A systematic search of PubMed, Scopus, Cochrane Library, and Google Scholar was conducted up to November 2025 to identify comparative studies evaluating posterior-only versus combined anterior-posterior fixation for thoracolumbar burst fractures. Nineteen studies (predominantly retrospective; 15 non-randomized and 4 randomized) met inclusion criteria, comprising 1553 patients. Outcomes included perioperative parameters (operative time, blood loss, hospital stay), neurological recovery (Frankel scores), pain and functional outcomes (VAS, ODI, RMDQ, return-to-work rates), radiological parameters (Cobb angle correction, canal compromise recovery), and complication rates (infection, instrumentation failure, pulmonary complications).

Results: Posterior-only fixation was associated with significantly reduced blood loss (MD = - 438.21 mL, p < 0.001), shorter operative time (MD = - 121.66 min, p < 0.001), and shorter hospital stay (MD = - 5.62 days, p < 0.001), although heterogeneity was substantial for perioperative outcomes. Pulmonary complications were also lower in the posterior group (RR = 0.16, p = 0.009). No significant differences were found between approaches in neurological improvement, pain scores, functional recovery, radiological correction, infection rates, or instrumentation failure.

Conclusions: Both posterior-only and combined anterior-posterior fixation show broadly similar neurological, radiological, and functional outcomes in thoracolumbar burst fractures. Posterior-only fixation was associated with perioperative advantages and a lower risk of pulmonary complications. Surgical decision-making should therefore be individualized based on fracture morphology, neurological status, and patient-specific factors, particularly given that most included evidence remains observational.

Keywords: Anterior–posterior fixation; Combined approach; Posterior fixation; Spinal surgery; Thoracolumbar burst fracture.