Study design <p>A single-center prospective comparative analysis. Level II evidence.</p> Objective <p> To compare the surgical and short-term clinical–radiological outcomes of anterior versus posterior decompression and stabilization for thoracolumbar burst fractures.</p> Materials and methods <p>This single-center prospective comparative analysis included 43 consecutive patients with thoracolumbar burst fractures (AO type A3/A4) at the T10–L2 junction, TLICS ≥ 4, and neurological deficit. Twenty-eight patients underwent posterior decompression with pedicle-screw fixation (posterior group) and 15 underwent anterior decompression with anterior instrumentation (anterior group). Outcomes assessed included operative parameters, canal clearance on CT, kyphotic correction, neurological improvement (ASIA), and functional recovery (VAS, ODI, SCIM) over a six-month follow-up.</p> Results <p>The posterior group had significantly shorter operative time and hospital stay (<i>p</i> &lt; 0.05). Mean blood loss was comparable between groups (<i>p</i> = 0.10). Canal clearance was significantly greater in the anterior group (90.2%) than the posterior group (48.0%, <i>p</i> &lt; 0.001). Mean kyphosis correction (posterior 12.7° ± 7.2 vs. anterior 9.9° ± 5.3, <i>p</i> = 0.10) and loss of correction at six months (posterior 6.3° ± 5.0 vs. anterior 2.0° ± 1.0, <i>p</i> = 0.07) were similar. Neurological and functional improvements were comparable (<i>p</i> &gt; 0.05). Complications occurred in two posterior cases (infection, screw pull-out) and four anterior cases (two SPAM, two chest complications, one death).</p> Conclusion <p>Both approaches provided effective decompression and stabilization. The anterior approach achieved superior canal clearance but required longer operative time and hospitalization, while posterior surgery offered shorter procedures with similar short-term neurological and functional outcomes.</p> <i>Level II evidence</i> <p> Study design: A single-center prospective comparative analysis</p>