Although much has been written regarding treatment of thoracolumbar fractures, questions remain concerning even the most basic issues. This article reviews classification systems, bony stability, the need for neural decompression in thoracolumbar spine fractures, and the literature comparing conservative treatment versus surgical treatment and evaluating various surgical approaches and fixation devices. Finally, data in the available literature and the results of the neurologic examination, radiographic studies, and the magnetic resonance imaging scan are used as the basis for a proposed classification system and a treatment algorithm.