Burst fractures of the thoracolumbar spine are perhaps the best documented and the most frequent among spine fractures. Yet several areas remain unclear to us. The AO adaptation of Magerl’s classification offers a good prognostic and therapeutic guide though tends to be a bit cumbersome. Most neurologically intact stable burst fractures can be managed nonoperatively. The current understanding of instability is rather imperfect but significant load-bearing column and ligamentous disruption makes a fracture unstable and is best managed surgically. Neural injuries demand decompression of the cord to prevent secondary damage as well as to allow the best possible chance for recovery. The presence or absence of neurological injury further complicates the issue when it comes to choosing management strategies. This chapter is an attempt to simplify some of these issues related to burst fractures in the thoracolumbar region of the spine. The authors’ view is that fusion is to be performed only selectively in significant ligamentous injuries and the others may be managed without it.