The surgeon who treats patients with spine trauma must be able to apply a variety of management techniques to achieve optimal care of the patient. The anterior surgical approach is appropriate for some thoracolumbar burst fractures in patients with neurologic deficit and without posterior ligamentous injury. Surgery is most often indicated for patients with incomplete deficit, especially those with a large retropulsed fragment, marked canal compromise, severe anterior comminution, or kyphosis < 30 degrees. This approach provides excellent visualization of the anterior aspect of the dura mater for decompression. Reconstruction of the anterior body defect can be done with autograft, allograft, or a cage. Supplementation of the graft with anterior internal fixation helps prevent kyphosis. Clinical results demonstrate improved neurologic function in most patients as well as low pseudarthrosis rates. In patients with incomplete deficit, improvement in neurologic function usually can be expected with few complications.