Distraction injuries in type B1 to B3 are instable. Highest instability is seen in type C fractures with rotational moment. Conservative treatment is feasible in type A1, A2 and some lower rated A3 fractures. In these patients axial alignment and log-roll are pursued during ICU stay with subsequent mobilization and ambulation under supervision of a physiotherapist. Secondary anterior vertebral replacement might be needed in A2.3 pincer fractures. Burst fractures (A3) are characterized by their incapability to withstand anterior load that assigns them instable injuries. In A3 fractures,

the high rates of overseen posterior injury should lead to liberate indication for posterior instrumentation. In B type fractures the posterior ligament complex definitely

is in need of posterior instrumentation. For decompression and for insufficient buy Compound C reduction, open approach should be preferred, since anatomical restoration of the spinal column is the prerequisite. Rotationally instable fractures type C should be assigned to open reduction, predominantly. In addition, decompression for spinal cord injury in C-type injuries should be performed from posterior to limit second hit in polytraumatized patients. Anterior surgery in C-type fractures should be carried out in a safe period following restoration of immunologic homeostasis. Type Trichostatin A A fractures Pure axial compression forces generate type A fractures. Whereas Cyclin-dependent kinase 3 endplate fractures (type A1) and split fractures (type A2) fractures might withstand physiological axial forces and thus can be regarded stable and treated conservatively [85], vertebral burst fractures (type A3) are known for their lack of anterior support und thus are classified as instable fractures. In addition, many A3 fractures, especially type A3.3 are characterized by a substantial impairment

of the spinal reserve space due to a posterior wall fragment leaking into the spinal canal. Restoration of anterior support to regain sagittal alignement of the vertebral column is generally recommended via anterior spinal surgery, e.g. corporectomy and vertebral replacement following the initial stabilization of the patient [23, 26, 86]. In contrast, some authors favour posterior instrumentation only [79, 87] and even non-operative treatment [80], although it was shown that e.g. instrumentation without anterior column support and the intact posterior ligament complex cannot prevent posttraumatic kyphosis sufficiently, leading to posttraumatic kyphosis with potential for consecutive problems [88–91]. Regarding damage control spine surgery, the question arises, whether instable A3 fractures rendered for secondary anterior surgery should be stabilized in the trauma setting via open or minimal-invasive posterior instrumentation, first.