Clinical and radiographic outcomes in children with or without prescribed bracing for stable thoracolumbar compression fractures.

Abstract

Objective: The role of bracing in stable pediatric thoracolumbar compression fractures remains uncertain, with limited pediatric-specific evidence to guide practice. Therefore, the aim of this study was to determine the impact of prescribed bracing on symptom recovery, return to activity (RTA), radiographic remodeling, and reinjury in children and adolescents with this common injury.

Methods: The authors performed a retrospective cohort analysis with AO Spine type A1 stable vertebral compression fractures treated at a single academic children's hospital in 2016-2025. Inclusion criteria comprised an age ≤ 18 years, radiographically confirmed type A1 thoracic or lumbar compression fracture, and adequate follow-up with radiographic documentation. Outcomes included symptoms at follow-up, RTA clearance, and vertebral height restoration. Cohort comparisons were performed, as were region-stratified analyses. Both univariate and multivariable analyses along with interaction models were performed, and random forest classifiers were trained.

Results: Two hundred three pediatric patients with a median age of 12 years (range 2-18 years) were included in this study. The braced group was slightly older (median age 13 vs 11 years, p = 0.004). Forty-eight percent of the entire cohort was female (52% vs 43%, p = 0.132). Bracing was prescribed in 56% of cases. Injury severity was similar between groups (median height loss: 19.7% braced vs 20.4% unbraced, p = 0.261). At the first follow-up (FU1) 4-6 weeks postinjury, 42% of braced patients remained symptomatic versus 31% of unbraced patients, with braced patients with thoracic fractures showing more than 3 times higher odds of persistent symptoms (OR 3.2, 95% CI 1.48-6.67, p = 0.003). This effect persisted at the second follow-up (FU2) 3-6 months postinjury (p = 0.026). Bracing was also associated with a delayed RTA at FU1 (p = 0.001), although this effect diminished by FU2. Radiographically, braced patients demonstrated vertebral height restoration significantly sooner (brace × time interaction, p = 0.002), but this did not correspond to improved symptoms or function. Reinjury within 1 year was also more common in braced patients (11.5% vs 3.3%, OR 3.77, 95% CI 1.04-13.67, p = 0.04).

Conclusions: In a pediatric cohort with stable thoracolumbar compression fractures, prescribed bracing was not associated with symptomatic or functional improvement and was correlated with delayed recovery and increased reinjury risk, despite accelerated radiographic remodeling. These findings add to the growing literature questioning a default brace prescription in thoracolumbar compression fractures. Future prospective studies will be necessary to validate these findings.