Thoracolumbar fractures are among the most common spinal injuries encountered in clinical practice and account for approximately 60%–70% of all traumatic spinal fractures. The thoracolumbar junction (T11–L2) is particularly susceptible to injury because it represents a biomechanical transition zone between the relatively rigid thoracic spine and the highly mobile lumbar spine. High-energy trauma, including road traffic accidents, falls from height, sports injuries, and occupational accidents, is the leading cause of these fractures, particularly among young adults of working age. Owing to the associated risk of neurological impairment, spinal deformity, chronic pain, and long-term disability, thoracolumbar fractures remain a significant cause of morbidity worldwide and impose a considerable socioeconomic burden on healthcare systems and affected individuals [1,2].The primary objectives in the management of thoracolumbar fractures are preservation of neurological function, restoration of spinal stability, prevention of progressive deformity, early mobilization, and pain relief. Treatment options include conservative management using thoracolumbosacral orthosis (TLSO) bracing and activity modification or surgical stabilization with decompression and instrumentation. The choice of treatment depends on several factors, including fracture morphology, integrity of the posterior ligamentous complex, neurological status, degree of vertebral body collapse, and kyphotic deformity. Appropriate patient selection is therefore essential to optimize clinical outcomes while avoiding unnecessary surgical intervention [2,3]. Several classification systems have been developed to guide the management of thoracolumbar injuries. Earlier systems, such as the Denis three-column theory and the AO Spine classification, primarily focused on fracture morphology and biomechanical instability but had limited ability to predict treatment strategies because neurological status and ligamentous injuries were not adequately incorporated. To overcome these shortcomings, the Thoracolumbar Injury Classification and Severity Score (TLICS) was introduced, integrating three clinically important parameters: fracture morphology, neurological status, and integrity of the posterior ligamentous complex. This scoring system has become one of the most widely accepted tools for determining appropriate management of thoracolumbar fractures [3,4]. According to the TLICS algorithm, patients with scores of ≤3 are generally treated conservatively, whereas those with scores≥5 are recommended for surgical stabilization. However, patients with a TLICS score of 4 remain a therapeutic challenge because either operative or non-operative management may be appropriate depending on individual patient characteristics and surgeon preference. Consequently, considerable variation exists among spine surgeons regarding the optimal treatment of these patients. Although surgery offers immediate stabilization and facilitates early mobilization, it is also associated with increased costs, perioperative complications, implant-related problems, and longer hospital stays. Conversely, conservative management avoids surgical risks but raises concerns regarding progressive kyphotic deformity, delayed neurological deterioration, and persistent pain [4-6]. Several recent studies have demonstrated favorable outcomes with conservative treatment in carefully selected patients with thoracolumbar burst fractures who have preserved neurological function and stable posterior ligamentous structures. These patients often achieve satisfactory pain control, acceptable spinal alignment, and good functional recovery without the risks associated with operative intervention. Nevertheless, conflicting evidence persists, particularly among patients with intermediate TLICS scores, and there is no universal consensus on the most appropriate treatment strategy for TLICS score 4 injuries. This uncertainty highlights the need for additional clinical studies evaluating the effectiveness of conservative management in this subgroup of patients [5-8].In Pakistan, limited published data are available regarding the outcomes of conservative management in thoracolumbar fractures with a TLICS score of 4. Differences in trauma patterns, healthcare resources, patient compliance, and access to rehabilitation may influence treatment outcomes compared with those reported in developed countries. Generating local evidence is therefore essential for guiding evidence-based clinical decision-making and optimizing patient care. The present study was undertaken to evaluate the outcomes of conservative management of thoracolumbar fractures with a TLICS score of 4, including neurological recovery, kyphotic angulation, and pain, among patients treated at a tertiary care neurosurgical center. The findings of this study may help clinicians make informed treatment decisions for patients with borderline TLICS scores and contribute to the growing body of evidence regarding the role of conservative treatment in thoracolumbar spinal trauma [9].

 Study  objective

To determine the outcome of conservative management of thoracolumbar fractures with TLICS score 4 in terms of neurology, kyphotic angulation, and pain.

 

 

Thoracolumbar fractures are among the most frequently encountered spinal injuries and predominantly affect young adults involved in high-energy trauma, resulting in substantial functional impairment and socioeconomic burden. The optimal management of patients with a Thoracolumbar Injury Classification and Severity Score (TLICS) of 4 remains controversial, as both operative and conservative treatment strategies are considered acceptable, depending on the patient's neurological status, fracture morphology, and posterior ligamentous complex integrity [10,11]. The present study evaluated the clinical outcomes of conservative management in patients with a TLICS score of 4. It demonstrated favorable neurological recovery, satisfactory maintenance of spinal alignment, and significant improvement in pain at three months of follow-up.The mean age of patients in the present study was 33.41 ± 9.36 years, and the majority (60.6%) belonged to the 18–30-year age group. These findings are consistent with previous studies reporting that thoracolumbar fractures predominantly occur in young, economically productive individuals because of their increased exposure to road traffic accidents, falls from height, and occupational trauma [10,11]. The predominance of male patients (68.2%) observed in our study is also comparable with previous reports, reflecting the greater occupational and environmental exposure of males to high-energy traumatic events [12,13].Neurological recovery remains the principal objective in the treatment of thoracolumbar fractures. In the present study, 71.2% of patients achieved favorable neurological recovery (Medical Research Council muscle power >3/5) following conservative treatment. These findings support the growing evidence that carefully selected patients with stable thoracolumbar fractures and preserved neurological function can achieve satisfactory neurological outcomes without surgical intervention. Similar observations have been reported in previous studies demonstrating that conservative management with thoracolumbosacral orthosis (TLSO) bracing provides acceptable neurological recovery while avoiding surgery-related complications [14-16].Radiological preservation of spinal alignment is another important determinant of treatment success. In our study, 62.1% of patients maintained a kyphotic angulation of <3° during follow-up, indicating satisfactory maintenance of sagittal alignment. Earlier studies evaluating non-operative treatment of thoracolumbar burst fractures have similarly reported only minimal progression of kyphotic deformity following conservative management. Mumford et al. observed limited vertebral collapse after non-operative treatment, while Cantor et al. reported an average kyphotic progression of approximately 1° following conservative treatment [17,18]. Our findings of a mean increase in kyphotic angulation of approximately 2.3° remain within an acceptable clinical range and support the effectiveness of brace-assisted conservative management in selected patients.Pain relief is an essential indicator of successful functional recovery following spinal trauma. In the present study, 75.8% of patients achieved significant pain improvement (VAS <4) after conservative treatment. Similar functional outcomes have been reported in previous investigations comparing conservative and operative management of thoracolumbar burst fractures, in which carefully selected patients managed non-operatively demonstrated satisfactory pain control and functional recovery comparable to that of surgically treated patients [19,20]. Conservative treatment also avoids implant-related complications, anesthesia-related risks, surgical site infection, and increased healthcare costs.The TLICS classification has become one of the most widely accepted decision-making tools for thoracolumbar injuries because it incorporates fracture morphology, neurological status, and posterior ligamentous complex integrity into a single treatment algorithm. Patients with scores of ≤3 are generally managed conservatively, whereas those with scores≥5 usually require surgical stabilization. However, patients with a TLICS score of 4 remain an area of clinical uncertainty. The favorable neurological, radiological, and pain outcomes observed in our study suggest that conservative treatment may be an appropriate option for carefully selected patients with a TLICS score of 4 who do not demonstrate progressive neurological deterioration or mechanical instability. Similar conclusions have been reported in recent studies evaluating conservative treatment protocols for thoracolumbar fractures [21-24].Overall, the findings of the present study support the role of conservative management as an effective treatment strategy for selected patients with thoracolumbar fractures and a TLICS score of 4. Careful patient selection, appropriate brace application, regular radiological follow-up, and close neurological monitoring remain essential to achieve favorable clinical outcomes while avoiding unnecessary surgical intervention.

 Limitations

This study has several limitations. First, it was conducted at a single tertiary care center, which may limit the generalizability of the findings to other healthcare settings. Second, the sample size was relatively small, reducing the study's statistical power. Third, the three-month follow-up period was relatively short and did not permit assessment of long-term functional outcomes, spinal stability, or late neurological deterioration. Finally, the absence of a comparison group undergoing surgical management limited direct evaluation of the relative effectiveness of conservative versus operative treatment in patients with a TLICS score of 4. Future multicenter studies with larger sample sizes and longer follow-up are recommended to validate these findings.

Conservative management of thoracolumbar fractures with a TLICS score of 4 was associated with favorable short-term outcomes, including neurological recovery, maintenance of kyphotic alignment, and pain reduction. Most patients achieved satisfactory functional recovery without neurological deterioration. These findings suggest that conservative treatment may be a safe and effective option in carefully selected patients. Nevertheless, larger prospective multicenter studies with longer follow-up periods are required to validate these findings further and establish evidence-based treatment recommendations for patients with intermediate TLICS scores.

 Recommendations

Based on the findings of this study, conservative management may be considered a safe and effective treatment option for carefully selected patients with thoracolumbar fractures and a TLICS score of 4, particularly those without progressive neurological deficits or significant spinal instability. Careful patient selection, early immobilization with a thoracolumbosacral orthosis (TLSO), regular clinical and radiological follow-up, and structured rehabilitation are essential for optimizing treatment outcomes. Future multicenter, prospective, randomized controlled studies with larger sample sizes and longer follow-up periods are recommended to compare conservative and surgical management, evaluate long-term functional outcomes, and establish standardized treatment guidelines for patients with intermediate TLICS scores.

 Ethical Approval

This study was approved by the Institutional Review Board (IRB)/Ethical Review Committee of Ayub Teaching Hospital–Medical Teaching Institution (ATH-MTI), Abbottabad, Pakistan. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

 Consent to Participate

Written informed consent was obtained from all participants before enrollment in the study. Participation was voluntary, and patient confidentiality and anonymity were maintained throughout the study.

 Consent for Publication

Written informed consent for publication of anonymized clinical data was obtained from all participants.

 Availability of Data and Materials

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

 Conflict of Interest

The authors declare no competing interests or conflicts of interest related to this study.

 Funding

The authors received no financial support from any funding agency in the public, commercial, or not-for-profit sectors for the conduct of this study.

 Acknowledgments

The authors sincerely thank the faculty members, nursing staff, and residents of the Department of Neurosurgery, Ayub Teaching Hospital–Medical Teaching Institution, Abbottabad, for their valuable support during patient management and data collection. We also express our gratitude to all patients who participated in this study.

 Authors' Contributions (According to ICMJE Criteria)

Baynazir Khan: Conceptualization, study design, patient management, supervision, data interpretation, critical revision of the manuscript, and final approval.

 Syed Kamal Shah: Study design, data collection, data analysis, manuscript drafting, interpretation of results, and final approval.

 Idrees Ahmad

Data collection, literature review, statistical analysis, manuscript editing, and final approval.

 Abdul Aziz Khan

Methodology development, data validation, critical review of the manuscript, and final approval.

All authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

 Clinical Trial Registration

Not applicable. This was a prospective observational study and did not require clinical trial registration.

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