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Objectives and questions: This analysis examined geographic differences in treatment and clinical outcomes of AO Spine A3 and A4 burst fractures treated globally, including patients from Europe, North America, India, the Middle East, and Australia.

Material and methods: This prospective, multicenter study analyzed data from 14 international sites. Patients with a type A3 or A4 thoracolumbar burst fracture without neurologic deficit were included in the study and treated according to the site’s standard of care and surgeon preference including both operative and non-operative management. Patients were organized into 5 geographical groups: Europe, North America, India, the Middle East, and Australia. Clinical outcomes included time to return to work, disability (ODI), opioid use, patient satisfaction and quality of life, pain, and PROST scores. Data analysis included descriptive statistics and unadjusted p-values for group comparisons. For comparative analyses, India, the Middle East, and Australia were combined into a single group (IMEA) due to small sample sizes.

Results: In total, 198 patients were included (Europe: 93, North America: 36, India: 26, Middle East: 27, Australia: 16). Whether surgical intervention was performed varied widely across regions (p<0.001); this was true for both A3 (p<0.001) and A4 fractures (p=0.013). Rates of surgical treatment were highest in India (92.3%) and the Middle East (92.6%), and lowest in Australia (12.5%). There were also significant differences in surgical approach (p < 0.001). An open posterior approach was most common (78.63% across all regions), but minimally invasive surgery was more common in Europe (34.48%) compared to other regions (0.00–11.11%). Time from injury to treatment, estimated blood loss, surgery duration, and use of bone substitutes all showed regional differences (p<0.05). For patients receiving non-surgical treatment, the use of bracing also differed (p<0.001); bracing was universal for non-surgical patients in India (n=2), the Middle East (n=2), and Australia (n=14). The median time to return to work in each region ranged from 45–112 days, with a significant regional difference among surgical patients only (p=0.024). Europe and IMEA showed lower ODI disability by the 1-year follow-up than North America (p=0.002).

Discussion and conclusions: Treatment selection varied across regions, with the highest rates of surgical intervention in India and the Middle East and the lowest rates in Australia. Non-operative management also differed regionally, with bracing universal for non-operative management in India, the Middle East, and Australia. However, the small sample sizes in these regions limits generalizability. Clinical outcomes like disability, quality of life, and pain were generally more favorable in Europe and IMEA than North America; these regional differences may reflect geographic variation in patient profiles, care approaches, and follow-up, in addition to psychosocial and cultural factors, including health system expectations.