SPINE ORTHOSES

Michael Zlowodzki MD University of Minnesota Department of Orthopaedic Surgery

OUTLINE
History & Epidemiology Indications Principles Current orthotic devices Current Evidence

History of Bracing
Hippocrates 650 bc

How do Braces work?

Trunk Support
Increase intra-cavitary pressure
Decreases vertical loading of the spine Reduces demands on spinal musculature

3-point force system

Spinal re-alignment
Shift of gravitational forces from diseased to more normal skeletal components

Motion control

Indications
Fractures Infammatory conditions Infectious disorders Paralytic disorders Spondylolisthesis Scoliosis

Epidemiology
79000 spinal fractures per year (1995) 50% between T11 and L2 48% compression fx

Tran et al. Spine 1995

Denis. Spine 1983

What brace to use?

How many vertebrae are involved? What level?

Role of Braces
Temporary stabilization Definitive primary treatment Adjunctive treatment

Definitions
SOMI = Sterno Occipital Mandibular Immobilizer CTO = Cervico Thoracic Orthosis TLSO = Thoraco Lumbar Sacral Orthosis

Types
Halo SOMI Cervical Collar (Miami-J) CTO TLSO with proximal extension TLSO TLSO with leg extension Chairback

cervical

thoracal lumbar

HALO

SOMI

TLSO with SOMI extension

Cervical Collars

CTO

Cervical Collars vs. Cervical Thoracic Orthoses (CTO)

CTOs provide significantly more restriction of intervertebral flexion and extension

Biomechanical analysis of cervical orthoses in flexion and extension: a comparison of cervical collars and cervical thoracic orthoses. Gavin et al. J Rehabil Res Dev 2003

How much motion is too much???

TSLO

Chairback

Jewitt

CURRENT EVIDENCE

HIERARCHY OF EVIDENCE
Level 1: RCT / Meta-analyses of RCTs Level 2: Cohort studies Level 3: Case-control studies Lever 4: Case series Level 5: Expert opinion

T/L Burst Fractures without Neurological Deficit: RCT Op vs. Brace

65 randomized 47 followed up T10-L2 fracture Similar pre-injury scores

Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

T/L Burst Fractures without Neurological Deficit: RCT Op vs. Brace

OP: anterior or posterior fusion Non-op: Orthosis or Body Cast FU: 44m (all >24m)

Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

Outcome Parameter
Pain VAS Disability questionnaire (Roland & Morris) Back-pain questionnaire (Oswestry) SF-36 Return to work Alignment Canal compromise

Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

Canal Compromise
Operative
Initial canal compromise: 39% Final canal compromise: 22%

Brace/Cast
Initial canal compromise: 34% Final canal compromise: 19%

Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

Kyphosis
Operative
initial fracture kyphosis: 10.1 deg final fracture kyphosis: 13 deg

Brace/Cast
initial fracture kyphosis: 11.3 deg final fracture kyphosis: 13.8 deg

Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

Results
Non-Operative group (n=23):
Significantly less disability Significantly lower pain scores Significantly higher physical functioning scores Lower cost ($11k vs. $49k)

Complications more frequent in Op group ALL PATIENTS REMAINED NEUROLOGICALLY INTACT

Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

Conclusions

OPERATIVE TREATMENT HAS NO MAJOR ADVANTAGES

Braces/Casts avoid surgical complications

Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

T/L Burst Fractures without Neurological Deficit: RCT Op vs. Brace

N=80 Op: Posterior 3-level fixation Non-op: Hyperextension brace

Nonoperative Treatment vs. Posterior Fixation for Thoracolumbar Junction Burst Fractures without Neurological Deficit. Shen et al. Spine 2001

Results
Operative Treatment:
earlier pain relief and partial kyphosis correction (gradually lost) Earlier pain relief

FUNCTIONAL OUTCOME AT 2 YEARS SIMILAR

Nonoperative Treatment vs. Posterior Fixation for Thoracolumbar Junction Burst Fractures without Neurological Deficit. Shen et al. Spine 2001

Compression Fractures (<30%): Bracing vs. No external support

Retrospective comparison 110/129 isolated one vertebral anterior column fx T12-L5; Mostly L1

Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000

Results
Avg. initial Compression:
Braced: 19% (15% at 1y) Non-braced: 11% (11% at 1y)

Avg. initial Kyphosis:

Braced: 9.7 deg (no change at 1y) Non-braced: 5.7 deg (no change at 1y)

Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000

Conclusion
One-column fractures of the thoracolumbar spine with <30% compression can be treated with early ambulation and hyperextension exercises

ORTHOSIS HAS NO BENEFIT

Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000

Types
Halo SOMI Cervical Collar (Miami-J) CTO TLSO with proximal extension TLSO TLSO with leg extension Chairback

cervical

thoracal lumbar

THANK YOU