Thoracolumbar spine injury. It would be much easier if we knew what was stable and unstable. That is the number one, biggest controversy. What is stable? We don't know.

Clinically, instability is the loss of the ability of the spine under physiologic loads to maintain its pattern of displacement so that there is no initial or additional neurologic deficit, no major deformity and no incapacitating pain. Great. What does that mean? Is it 25 degrees? Is it 30 degrees? Is it 5 mm of translation? Mahomar Punjabi may know but we don't.

The goal is to translate the generic formulae for spinal instability into usable radiologic criteria by which treatment decisions can be made. Very hard. In 1998 most people feel that 25 degrees of kyphosis or 25 degrees of change in sagittal spinal alignment is the operative threshold for treating patients who are neurologically intact.

Obviously, those with neurologic deficit are predominantly going to be treated operatively. That is easy. However, most patients with thoracolumbar spine injuries are neurologically intact and this is where the uncertainty lies. 25 degrees of sagittal malalignment is pretty much the lower level of cut-off in 1998. It use to be 15 degrees, then it was 20 degrees and some people will say 30 degrees. That is the present state of affairs in the controversy of operative vs. non-operative treatment for thoracolumbar injuries.