Sixty-eight patients with thoracolumbar spinal fractures were randomized to receive either minimally invasive percutaneous pedicle screw fixation (MIPSF) alone (n=34) or MIPSF combined with posterior decompression and bone grafting (n=34). The primary outcome of interest was pain and functional recovery, measured by VAS and ODI scores. Secondary outcomes included ASIA sensory and motor scores, spinal morphological indices (vertebral anterior height, sagittal index, Cobb’s angle), serum stress markers (SP, cortisol, CRP), perioperative metrics (operation time, blood loss, drainage, hospital stay), and postoperative complications. Outcomes were assessed preoperatively, at 7 days, and up to 3 months postoperatively. Overall, the results of the study revealed that the combined treatment group experienced significantly greater reductions in pain and disability, better neurological and anatomical recovery, and lower stress biomarker levels (all p < 0.05). The findings suggest that adding posterior decompression and bone grafting to MIPSF enhances postoperative outcomes in thoracolumbar fractures.