SPINAL ORTHOTICS

SPINAL ORTHOTICS

An orthotic device (commonly referred to as an orthotic or an orthosis) is an external apparatus that is applied to the body to limit the motion of, correct deformity in, reduce axial loading on, or improve the function of a particular segment of the body. 

    Design characteristics of an orthosis are crucial to function.

The most important features include the following:

v  Weight

v  Adjustability

v  Functional use

v  Cosmesis

v  Cost

v  Durability

v  Material

v  Ability to fit patients of various sizes

v  Ease with which the device can be put on (donned) and taken off (doffed)

v  Provision of access to a tracheostomy site, peg tube, or other drains

v  Provision of access to surgical sites for wound care

v  Provision of aeration in order to avoid skin maceration from moisture

Indications for recommending the use of orthoses include :

• Pain relief

• Mechanical unloading

• Scoliosis management

• Spinal immobilization after surgery

• Spinal immobilization after traumatic injury

• Compression fracture management

• Kinesthetic reminder to avoid certain movements

The duration of orthosis use is determined by the individual situation, as in the following examples:

• In situations where spinal instability is not an issue, the patient should be advised to use the orthosis until he/she can tolerate discomfort without the brace.

• When employed for stabilization after surgery or acute fractures, 6-12 weeks of use should be allowed to permit ligaments and bones to heal.

The use of an orthosis is associated with several drawbacks, including

the following:

• Discomfort

• Local pain

• Osteopenia

• Skin breakdown

• Nerve compression

• Ingrown facial hair in men

• Muscle atrophy with prolonged use

• Decreased pulmonary capacity

• Increased energy expenditure with ambulation

• Difficulty in donning and doffing the orthosis

• Difficulty with transfers

• Psychological and physical dependency

• Increased segmental motion at the ends of the orthosis

• Unsightly appearance

• Poor patient compliance

The successful use of an orthosis may lead to any of the following:

v  Decreased pain

v  Increased strength

v  Improved function

v  Increased proprioception

v  Improved posture

v  Correction of spinal curve deformity

v  Protection against spinal instability

v  Minimized complications

v  Healing of ligaments and bones

Physicians must understand the biomechanics of the spine and of each orthosis.

The cervical spine is the most mobile spinal segment, with greater flexion than extension.

The occiput and C1 have significant flexion and extension, with limited side bending and rotation. The C1-C2 complex accounts for 50% of rotation in the cervical spine. The C5-C6 region has the greatest amount of flexion and extension. The C2-C4 region has the most side bending and rotation.

When compared with the cervical and lumbar spine, the thoracic spine is the least mobile. The thoracic spine has greater flexion than extension. In the caudal direction, lateral bending increases and axial rotation decreases.

The lumbar spine has minimal axial rotation. The greatest movements in the lumbar spine are flexion and extension.

Immobilization of the spine increases erector spinae muscle activity because normal rotation that occurs with ambulation is limited by the orthosis.

The biomechanical principles of orthotic design include balance of horizontal forces, fluid compression, distraction, construction of a cage around the patient, placement of an irritant to serve as a kinesthetic reminder, and skeletal fixation.

Construction of a cage around the patient, like a thoracolumbar brace, increases intra-abdominal pressure. Increased intra-abdominal pressure converts the soft abdomen into a semirigid cylinder, which helps to relieve part of the vertebral load.

In general, structural damage to posterior elements of the spine creates more instability with flexion, whereas damage to anterior elements creates more instability with extension.

Coverage for spinal orthoses will vary according to the insurance carrier. Prefabricated spinal orthoses should be utilized first unless failure occurs or their use is contraindicated. 

Custom-fitted spinal orthoses should primarily be used for scoliosis management, postsurgical stabilization, or spinal fractures. 

Key elements of medical necessity include the need to restrict spinal mobility to control pain, to facilitate postoperative or fracture healing, or to support weak spinal musculature that impairs activities of daily living. 

Orthoses are generally named according to the body regions that they span.

For example, a cervical orthosis (CO) is applied to the cervical spine, while a cervicothoracolumbosacral orthosis (CTLSO) spans the entire length of the spine.

CERVICAL ORTHOSES

Several drawbacks to CO use have been noted, as follows:

• The soft-tissue structures around the neck (eg, blood vessels, esophagus, and trachea) limit the application of aggressive external force.

• The high level of mobility at all segments of the cervical spine makes it difficult to restrict motion.

• Cervical orthoses offer no control for the head or thorax; therefore, motion restriction is minimal. (Cervical orthoses serve as a kinesthetic reminder to limit neck movement.)

Appropriate precautions associated with orthotic use should be observed. It should be kept in mind that the long-term use of orthoses has been associated with decreased muscle function and dependency.

The soft collar is a common, lightweight orthotic device made of polyurethane foam rubber with a stockinette cover; Velcro closure straps are used for easy donning and doffing.

Patients find the collar comfortable to wear, but it is easily soiled with long-term use. The average soft collar costs $50.

Indications for the use of a soft collar include the following benefits for the patient:

• Warmth

• Psychological comfort

• Head support when acute neck pain occurs

• Relief from minor muscle spasm associated with spondylolysis

• Relief from cervical strain

The soft collar provides some motion limitations for the patient, including the following:

• Full flexion and extension are limited by 5-15%.

• Full lateral bending is limited by 5-10%.

• Full rotation is limited by 10-17%.

Hard cervical collars are similar in shape to soft collars but are made of Plastizote, a rigid polyethylene material.

Hard collars are ring-shaped with padding; some of these have an adjustable height, providing patients with a better fit. Velcro straps are used for easy donning and doffing.

Several problems can be alleviated with the use of a hard collar.

Indications for the orthosis include the following:

v  Head support when acute neck pain occurs

v  Relief of minor muscle spasm associated with spondylosis

v  Psychological comfort

v  Interim stability and protection during halo application

Motion restrictions associated with the hard collar include the following:

• Full flexion and extension are limited by 20-25%.

• The hard collar is less effective in restricting rotation and lateral bending.

• It is better than a soft collar in motion restriction.

HEAD CERVICAL ORTHOSES

Head cervical orthoses (HCOs) include the occiput and chin in order to decrease range of motion (ROM).

A supported chin area is a common place for skin breakdown and, for men, the development of ingrown hair. The clavicle is another area where HCOs can cause skin breakdown and discomfort.

HCOs generally are used in stable spine conditions. As in the case of cervical orthotics, the long-term use of HCOs has been associated with decreased muscle function and dependency.

PHILADELPHIA COLLAR

The Philadelphia collar is a semirigid HCO with a 2-piece system of Plastizote foam. Plastic struts on the anterior and posterior sides are used for support.

The upper portion of the orthosis supports the lower jaw and occiput, while the lower portion covers the upper thoracic region.

The Philadelphia collar comes in various sizes and is comfortable to wear, improving patient compliance.

Velcro straps are used for easy donning and doffing.

The Philadelphia collar is difficult to clean and becomes soiled very easily.

An anterior hole for a tracheostomy is available. A thoracic extension can be added to increase motion restriction and treat C6-T2 injuries.

Motion restrictions provided by the Philadelphia collar include the following:

• Flexion and extension are limited by 65-70%

• Rotation is limited by 60-65%.

• Lateral bending is limited by 30-35%.

The goal of the Philadelphia collar is to provide immobilization; its use is indicated in relation to certain injuries or after various procedures, as follows:

• Anterior cervical fusion

• Halo removal

• Dens type I cervical fractures of C2

• Anterior diskectomy

• Suspected cervical trauma in unconscious patients

• Teardrop fracture of the vertebral body (Note: Some teardrop fractures require anterior decompression and fusion.)

• Cervical strain

MIAMI J COLLAR

A semi-rigid HCO, the Miami J collar is another commonly used orthosis.

The device consists of a 2-piece system made of polyethylene, with a soft, washable lining.

The anterior piece has a tracheostomy opening similar to that in the Philadelphia collar.

Velcro straps are used for easy donning and doffing.

A thoracic extension can be added to increase support and treat C6-T2 injuries.

Available in various sizes, the Miami J collar can be heated and molded to a contoured fit.

Motion restrictions associated the Miami J collar include the following:

• Flexion and extension are limited by 55-75%.

• Rotation is limited by 70%.

• Lateral bending is limited by 60%.

Indications for the use of a Miami J collar are the same as those for the Philadelphia collar.

MALIBU COLLAR

The Malibu collar is another semi-rigid, 2-piece orthosis with an anterior opening for a tracheostomy.

The device comes in only 1 size, but it is adjustable in multiple planes to ensure proper fit.

Anterior chin support height is also adjustable. Straps around the chin, occiput, and lower cervical area provide for tightening.

Padding around the chin can be trimmed to ensure proper fit. A thoracic extension can be added to increase support and treat C6-T2 injuries.

Motion restrictions associated with the Malibu collar include the following:

• Flexion and extension are limited by 55-60%.

• Rotation is limited by 60%.

• Lateral bending is limited by 60%.

Indications for the use of a Malibu collar are similar to those for the Miami J and Philadelphia collars.

ASPEN COLLAR

The Aspen collar is a semi-rigid, 2-piece HCO made of polyethylene, with a soft foam liner, an anterior opening for a tracheostomy, and Velcro straps for easy donning and doffing.

Motion restrictions associated with the Aspen collar, which mirror those provided by the Malibu orthosis, are as follows:

• Flexion and extension are limited by 55-60%.

• Rotation is limited by 60%.

• Lateral bending is limited by 60%.

Indications for the use of an Aspen collar include the same ones for the above-listed HCOs.

JOBST VERTEBRACE

The Jobst Vertebrace is made of high-density polyethylene, with a soft polyethylene foam liner.

A semi-rigid HCO, it is designed for use in emergent transport situations. The Jobst Vertebrace provides full contact along its costal ends to the sternum and cradles the mandible for stability.

Motion restrictions associated with the Jobst Vertebrace include the following:

• Flexion and extension are limited by 55-60%.

• Rotation is limited by 60%

• Lateral bending is limited by 60%

Indications for the use of a Jobst Vertebrace are similar to those for the Miami J and Philadelphia collars.

CERVICOTHORACIC ORTHOSES

Cervicothoracic orthoses (CTOs) provide greater motion restriction in the middle to lower cervical spine from the added pressure on the body.

The upper cervical spine has less motion restriction.

CTOs are used in minimally unstable fractures.

STERNAL-OCCIPITAL-MANDIBULAR IMMOBILIZER

The sternal-occipital-mandibular immobilizer (SOMI) is a rigid, 3-poster CTO that has an anterior chest plate extending to the xiphoid process, as well as metal or plastic bars that curve over the shoulder.

Straps from the metal bars go over the shoulder and cross to the opposite side of the anterior plate for fixation. A removable chin piece attaches to the chest plate with an optional headpiece that can be used when the chin piece is removed for eating.

The 2-poster CTOs start from the chest plate and attach to the occipital component. The SOMI is ideal for bedridden patients because it has no posterior rods.

The SOMI is relatively comfortable to wear. Proper adjustment is crucial for motion restriction, which may be minimal if the orthosis is incorrectly applied.

The SOMI controls extension less effectively than the other braces do, but it very effectively controls flexion at the atlantoaxial and C2-C3 segments. The SOMI controls flexion in the C1-C3 segments better than does the cervicothoracic brace.

Indications for immobilization with the SOMI include the following:

• Atlantoaxial instability caused by rheumatoid arthritis (Note that ligamentous disruption in rheumatoid arthritis affects flexion more than extension, because extension is held in check by the intact dens.)

• Neural arch fractures of C2, because flexion causes instability

Motion restrictions associated with the SOMI include the following:

• Cervical flexion and extension are limited by 70%-75%

• Lateral bending is limited by 35%

• Rotation is limited by 60-65%

YALE BRACE

The Yale orthosis is a modified Philadelphia collar. It has fiberglass thoracic extensions that extend anteriorly and posteriorly, with midthoracic straps on the sides connecting them. The thoracic component helps to treat C6-T2 injuries.

The occipital piece extends higher up on the skull posteriorly. An increased contact surface area improves the stability of the brace. Patients find the Yale orthosis comfortable to wear.

Indications for immobilization with the Yale orthosis include the following:

• C1 fractures with an intact transverse ligament

• Surgical fixation of dens type III fractures - Postoperative

• Dens type I fractures

• Hangman fractures (traumatic spondylolisthesis of C2)

• Jefferson fractures (multiple fractures of the C1 ring with spreading caused by axial loading)

• Immobilization to postoperative fixation

Motion restrictions associated with the Yale orthosis include the following:

• Flexion and extension are limited by 85%

• Rotation is limited by 70-75%

• Lateral bending is limited by 60%

4-POSTER BRACE

The 4-poster brace is a rigid orthosis with anterior and posterior chest pads connected by a leather strap. Molded occipital and mandibular support pieces, attached to each other with straps, connect to the chest pads and have adjustable struts.

The mandibular plate can interfere with eating. This brace uses shoulder straps, but it has no underarm support. The open design allows heat loss from the neck.

The brace is as effective as the cervicothoracic brace (and better than the Philadelphia collar) in controlling flexion in the midcervical area.

The 4-poster design limits lateral bending and rotation better than does the 2-poster brace.

Motion restrictions associated with the 4-poster orthosis include the following:

• Flexion and extension are limited by 80%.

• Lateral bending is limited by 55%-80%.

• Rotation is limited by 70%.

GUILFORD BRACE

The Guilford brace is a rigid CTO with a 2-poster design. It features anterior and posterior chest plates that are connected by shoulder straps, along with a chin plate and an occipital piece that connect to anterior and posterior struts. 

Underarm straps circle the lower chest wall for stability. The brace has poor control of flexion, extension, rotation, and lateral bending at C1-C2.

Motion restrictions afforded by the Guilford brace include the limitation of flexion and extension from C3-T2.

Indications for the use of a Guilford brace include the following:

• Minimally unstable fractures from C3-T2

• Internal fixation from C3-T2 - Postoperative

HALO DEVICE

The halo device is the most common device for treatment of unstable cervical and upper thoracic fractures and dislocations as low as T3.

The halo provides greater motion restriction than do other cervical orthoses. The halo ring is made of graphite or metal, with pin fixation on the frontal and parietal-occipital areas of the skull.

Development of lightweight composite material led to the design of radiolucent rings that are compatible with magnetic resonance imaging (MRI). The halo ring attaches to the vest anteriorly and posteriorly via 4 posters.

The halo vest has shoulder and underarm straps for tightening; it is usually made of rigid polyethylene and extends down to the umbilicus. Restriction in cervical motion depends on the fit of the halo vest. 

An improper fit can allow 31% of normal spine motion; compressive and distractive force can occur with variable fit of the vest.

Multidirectional shear forces can cause increased pinhole size with craterlike enlargement. Pin loosening occurs twice as frequently with heavier halo vests.

Generally, upper cervical spine injuries are treated best with a full-length vest extending to the iliac crest. The average cost of the halo device with vest is $2800.

Indications for immobilization with a halo device are as follows:

• Dens type I, II, or III fractures of C2 (Note: Dens type III fractures of C2 are treated more successfully with surgery.)

• C1 fractures with rupture of the transverse ligament

• Atlantoaxial instability from rheumatoid arthritis, with ligamentous disruption and erosion of the dens

• C2 neural arch fractures and disc disruption between C2 and C3. (Note: Some patients may need surgery for stabilization.)

• Bony, single-column cervical fractures

• Cervical arthrodesis - Postoperative

• Cervical tumor resection in an unstable spine - Postoperative

• Debridement and drainage of infection in an unstable spine - Postoperative

• Spinal cord injury (SCI)

Contraindications for the use of a halo device include the following:

• Concomitant skull fracture with cervical injury

• Damaged or infected skin over pin insertion sites

• Cervical instability with ligamentous disruption

• Cervical instability with 2- or 3-column injury

• Cervical instability with rotational injury involving facet joints

The application process for the halo device consists of several steps. Optimal placement for the anterior pins is the anterolateral aspect of the skull, 1 cm above the orbital rim on the lateral part of orbit (because this prevents penetration into the orbit).

Avoid placing pins in the temporalis muscle and through zygomaticotemporal nerve, which supplies sensation to the temporal area. Pins inserted into the temporalis muscle affect mandibular motion and cause pain.

Placement away from the medial one third on the orbital rim preserves the supraorbital and supratrochlear nerves and decreases the risk of entering the frontal sinus.

The insertion of posterior pins on the posterolateral aspect of the skull is less crucial. Skin incisions are not necessary prior to pin placement.

The halo ring should be 1 cm above the top of the ear.

Place all pins perpendicular to the skull, and allow 1-2 cm clearance with the halo ring along the skull perimeter.

In adults, pin insertion should be performed with a torque wrench set at 8 inches per pound in order to decrease the incidence of pin infection and loosening.

In children, the torque wrench should be set at 2-5 inches per pound, since the skull is too weak to sustain heavier forces. Multiple pin sites should be used in children, because youngsters have a weaker skull.

Determine the halo vest size by measuring chest circumference at the xiphoid process. Elevate the patient at 30-40° for vest placement. Secure the posterior portion of the vest first to the halo and then to the anterior part of the vest.

Tighten the bolts on the vest to a torque setting of 28 feet per pound. Tools for the vest sometimes are taped to the anterior part of the vest in case of emergency.

Recheck all pins for loosening 24-48 hours after placement. Use saline or soap and water on a sterile swab to clean the pin sites. Take radiographs immediately after halo placement or any adjustment in order to check spinal alignment.

Shaking of the cervical spine because of forced movement against the orthosis or changes in pin tightening can cause some segmental motion.

Symptoms of dysphagia may result if, owing to its placement, extension of the neck is too great. Repositioning of the halo, if possible, can eliminate dysphagia.

Motion restrictions provided by the halo include the following:

• Flexion and extension are limited by 90-96%

• Lateral bending is limited by 92-96%.

• Rotation is limited by 98-99%

Complications associated with halo placement include the following:

• Neck pain or stiffness - 80%

• Pin loosening - 60%

• Pin site infection - 22%

• Scarring - 30%

• Pain at pin sites - 18%

• Pressure sores - 11%

• Redislocation - 10%

• Restricted ventilation - 8%

• Dysphagia - 2%

• Nerve injury - 2%

• Dural puncture - 1%

• Neurological deterioration - 1%

• Avascular necrosis of the dens

• Ring migration

• Inadequate bony healing

• Inadequate ligamentous healing

When using the halo device, the following important considerations should be kept in mind:

v  The halo fixation device is used for 3 months to allow adequate time for bone healing.

v  The use of an HCO after removal of the halo, when the neck muscles are weak and stiff, provides some support for the head.

v  Approximately 40-45% of patients with facet joint dislocations achieve stability with the halo vest; 70% of patients without facet joint dislocations achieve stability.

v  Nearly 75% of patients without facet joint dislocation achieve good anatomic results.

v  In cases of facet joint dislocation, surgical stabilization improves the outcome.

v  Patients with facet joint dislocation have a higher likelihood of SCI.

v  Thorough neurologic examination before and after the reduction of facet joint dislocation is important.

The best orthotic devices for use in controlling specific cervical regions are indicated as follows:

• All orthoses tend to control flexion better than extension.

• The halo is the most effective orthosis for use in controlling flexion and extension at C1-C3, followed by the 4-poster brace and then the CTOs.

• CTOs are best for use in controlling flexion and extension at C3-T1, while the SOMI is best for use in controlling flexion at C1-C5.

• The SOMI controls extension less effectively than do other orthoses.

• The halo is the best orthosis for use in controlling rotation and lateral bending at C1-C3.

• The CTO brace is the second best orthosis for use in controlling rotation and lateral bending in the cervical spine.

• The 4-poster brace is slightly better than the CTO brace for use in controlling lateral bending in the cervical spine.

THORACOLUMBAR ORTHOSES

Thoracolumbar orthoses (TLOs) are used mainly to treat fractures between T10 and L2, because their mobility is not restricted by the ribs, unlike fractures between T2 and T9.

Immobilization at T10-L2 helps to prevent further collapse.

CASH BRACE

The cruciform anterior spinal hyperextension (CASH) brace (see Image 8) features anterior sternal and pubic pads to produce force opposed by the posterior pad and strap around the thoracolumbar region.

Sternal and pelvic pads attach to the anterior, metal, cross-shaped bar, which can be bent to reduce excess pressure on the chest and pelvis. The brace is easy to don and doff, but it is difficult to adjust.

It provides greater breast and axillary pressure relief than does the Jewett hyperextension brace (described below). Two round upper chest pads can be used instead of the sternal pad to decrease discomfort around the breast area.

Indications for the use of a CASH brace include the following:

• Flexion immobilization to treat thoracic and lumbar vertebral body fractures

• Reduction of kyphosis in patients with osteoporosis

Motion restrictions provided by the CASH brace include the following:

• Limits flexion and extension at T6-L1

• Ineffective in limiting lateral bending and rotation of the upper lumbar spine

Contraindications to the use of a CASH brace include the following:

• Three-column spinal fractures involving anterior, middle, and posterior spinal structures

• Compression fractures caused by osteoporosis

JEWETT HYPEREXTENSION BRACE

The Jewett hyperextension brace (see Image 7) uses a 3-point pressure system with 1 posterior and 2 anterior pads.

The anterior pads place pressure over the sternum and pubic symphysis. The posterior pad places opposing pressure in the midthoracic region. The posterior pad keeps the spine in an extended position, and its lightweight design makes it more comfortable than the CASH brace.

Pelvic and sternal pads can be adjusted from the lateral axillary bar, where they attach. The pads can cause discomfort from pressure applied to a small surface area.

No abdominal support is provided with this device. When the patient is seated, the sternal pad should be half an inch inferior to the sternal notch, and the pubic pad should be half an inch superior to the pubic symphysis.

Indications for the use of a Jewett brace include the following:

• Symptomatic relief of compression fractures not caused by to osteoporosis

• Immobilization after surgical stabilization of thoracolumbar fractures

Motion restrictions provided by the Jewett brace include the following:

• Limits flexion and extension between T6-L1

• Ineffective in limiting lateral bending and rotation of the upper lumbar spine

Contraindications for the use of a Jewett brace include the following:

• Three-column spinal fractures involving anterior, middle, and posterior spinal structures

• Compression fractures above T6, because segmental motion increases above the sternal pad

• Compression fractures caused by osteoporosis

One important consideration in the use of the Jewett brace is that it is more effective than the CASH brace.

The Korsain brace is a modification of the Jewett brace, with added abdominal support for increased rigidity. The cost of the Korsain brace is similar to that of the Jewett brace.

Indications for the Korsain brace include the following:

• Symptomatic relief of compression fractures not caused by osteoporosis

• Immobilization after surgical stabilization of thoracolumbar fractures

• Flexion immobilization to treat thoracic and lumbar vertebral body fractures

KNIGHT-TAYLOR BRACE

The Knight-Taylor brace features a corset-type front with lateral and posterior uprights and shoulder straps to help reduce lateral bending, flexion, and extension.

The shoulder straps may cause discomfort in some patients. The brace can be prefabricated and made with polyvinyl chloride or aluminum. The posterior portion of the brace has added cross supports below the inferior angle of the scapula and features a pelvic band fitted at the sacrococcygeal junction.

The anterior corset is made of canvas and provides intracavitary pressure. The anterior corset is laced to the lateral uprights.

Use of the brace is indicated when flexion immobilization is required to treat thoracic and lumbar vertebral body fractures.

Motion restrictions associated with the Knight-Taylor brace include the following:

• Limits flexion, extension, and lateral bending

• Poor rotation control

THORACOLUMBOSACRAL ORTHOSIS

A custom-molded plastic body jacket, or thoracolumbosacral orthosis (TLSO), is fabricated from polypropylene or plastic. It offers the best control in all planes of motion and increases intracavitary pressure.

This orthosis has a lightweight design and is easy to don and doff. The material is easy to clean and comfortable to wear. This brace sometimes is referred to as the clamshell.

The TLSO provides efficient force transmission, with pressure distributed over a wide surface area; it is therefore ideal for use in patients with neurologic injuries.

The brace may have a tendency to ride up on the patient when he/she is in a supine position. Plastic retains heat, but an undershirt will help to absorb perspiration and protect the skin.

Frequent checks to ensure proper fit will aid in preventing pressure ulcers. Velcro straps are used to tighten the brace.

Indications for the TLSO include the following:

• Immobilization for compression fractures from osteoporosis

• Immobilization after surgical stabilization for spinal fractures

• Bracing for idiopathic scoliosis

• Immobilization for unstable spinal disorders at T3-L3

Motion restrictions for the TLSO include the following:

• Limits sidebending

• Limits flexion and extension

• Limits rotation to some extent

Clinical information on the custom-molded TLSO suggests that it is more effective in the prevention of idiopathic scoliosis curve progression than are the Milwaukee brace and the Charleston bending brace (described below).

A retrospective cohort study found that the mean curve progression with a TLSO was less than 2°, while curve progression with the Charleston and Milwaukee braces was greater than 6°.

According to the report, fewer than 18% of patients treated with a TLSO brace required surgery for scoliosis, compared with 23% of patients treated with a Milwaukee brace and 31% of patients treated with a Charleston brace.

LUMBOSACRAL ORTHOSES

CHAIRBACK BRACE

The chairback brace is a short, rigid lumbosacral orthosis (LSO) with 2 posterior uprights that have thoracic and pelvic bands. The abdominal apron has straps in front for adjustment in order to increase intracavitary pressure.

The thoracic band is located 1 inch below the inferior angle of the scapula. The thoracic band extends laterally to the midaxillary line, and the pelvic band extends laterally to the midtrochanteric line.

Place the pelvic band as low as possible without interfering with sitting comfort. Position the posterior uprights over the paraspinal muscles. Uprights can be made from metal or plastic. The brace uses a 3-point pressure system and can be custom molded to improve the fit for each patient.

Indications for the use of a chairback brace include the following:

• Unloading of the intervertebral disks and the transmission of pressure to soft-tissue areas

• Relief of low back pain (LBP)

• Immobilization after lumbar laminectomy

• Kinesthetic reminder to the patient following surgery

Motion restrictions associated with the chairback brace include the following:

• Limits flexion and extension at the L1-L4 level

• Minimally limits rotation

• Limits lateral bending by 45% in the thoracolumbar spine

CHAIRBACK ORTHO-MOLD BRACE

The chairback Ortho-Mold brace is similar to the chairback brace, but it has a rigid plastic back piece custom-molded to the patient. The plastic back can be inserted into the canvas-and-elastic corset.

WILLIAMS BRACE

The Williams brace is a short LSO with an anterior elastic apron to allow for forward flexion. Lateral uprights attach to the thoracic band, and oblique bars are used to connect the pelvic band to the lateral uprights.

The abdominal apron is laced to the lateral uprights. The brace limits extension and lateral trunk movement but allows forward flexion.

The brace is indicated for the treatment of spondylolysis and spondylolisthesis, being used to provide motion restriction during extension. The device is contraindicated in spinal compression fractures.

Motion restrictions of the Williams brace include the following:

• Limits extension

• Limits side bending at the terminal ends only

MACAUSLAND BRACE

The MacAusland brace is an LSO that limits only flexion and extension. This brace has 2 posterior uprights but no lateral uprights.

The 3 anteriorly directed straps connect with the abdominal apron to provide increased support.

Indications for the use of a MacAusland brace are similar to those for the chairback brace. Motion restrictions include limitation of flexion and extension at the L1-L4 level.

STANDARD LUMBOSACRAL ORTHOTIC CORSET

The standard lumbosacral orthotic corset has metal bars within the cloth material posteriorly that can be removed and adjusted to fit the patient. The anterior abdominal apron has pull-up laces in the back that are used to tighten the orthosis.

The abdominal apron can come with a Velcro closure for easy donning and doffing. The corset, which increases intracavitary pressure, has a lightweight design and is comfortable to wear.

Anteriorly, the brace covers the area between the xiphoid process and the pubic symphysis. Posteriorly, it covers the area between the lower scapula and the gluteal fold.

Indications for the use of a standard lumbosacral orthotic corset include the following:

• Treatment of LBP

• Immobilization after lumbar laminectomy

Motion restrictions associated with the corset include the limitation of flexion and extension.

RIGID LSO

The rigid LSO is a custom-made orthosis that is molded over the iliac crest for an improved fit. Plastic anterior and posterior shells overlap for a tight fit. Velcro closure in the front is designed for easy donning and doffing.

Multiple holes can be made for aeration to help decrease moisture and limit skin maceration. The rigid LSO can be trimmed easily to make adjustments for patient comfort, and it may be used in the shower if necessary.

Indications for the use of a rigid LSO brace include the following:

• Postsurgical lumbar immobilization

• Treatment of lumbar compression fractures

Motion restrictions provided by the rigid LSO brace include the following:

• Limits flexion and extension

• Limits some rotation and side bending

RIGID LSO WITH HIP SPICA

A rigid LSO with hip spica uses a thigh piece on the symptomatic side and extends to 5 cm above the patella. The hip is held in 20° of flexion to allow sitting and walking. After the orthosis is applied, some patients require a cane for ambulation.

Indications for immobilization with the rigid LSO with hip spica include the following:

• Lumbar instability at L3-S1

• Lumbosacral fusion with anchoring to the sacrum - Postoperative

Motion restrictions associated with the rigid LSO with hip spica include the following:

• Limits flexion and extension

• Limits some rotation and side bending

New brace designs for LSOs include strapping systems that pull the brace inward and up, improving the hydrostatic effect in order to relieve pressure on the lumbar spine.

The better fit helps limit migration. Some low-profile designs take pressure off the hip and rib area, which, in turn, improves patient compliance. Low-profile braces fit more easily under clothing. These braces can treat areas from L3-S1.

Some spinal braces have an interchangeable back with an open center or a flat back design for postoperative patients.

The same brace can be interchanged with a back that has an indentation to fit the lordotic curvature of the lumbar spine for pain management purposes.

Braces with interchangeable parts allow an LSO to be converted into a TLSO with a large back support and an attachment for a sternal extension to prevent unwanted flexion. The sternal extension has straps that attach to the LSO.

BRACING FOR SCOLIOSIS

The main goal of a brace in scoliosis is to prevent further deformity, as well as to prevent or delay the need for surgery.

If surgery is needed, delaying the procedure as long as possible helps to optimize spinal height and avoid stunting of truncal growth.

Assessing the degree of skeletal maturity in a child with scoliosis is important; with more advanced skeletal maturity, a reduction in skeletal growth and, consequently, a reduction in the progression of the scoliosis would be expected. This has obvious implications when forming a treatment plan.

Risser classification of ossification of the iliac epiphysis is used to evaluate skeletal immaturity. Ossification of the iliac crest occurs from the anterior superior iliac spine (ASIS) to the posterior superior iliac spine (PSIS).

When ossification is complete, fusion of the epiphysis occurs to the iliac crest.

Risser staging is based on the use of radiographs to determine what percentage of the excursion (along the length of the iliac epiphysis) has ossified.

A Risser score of 0-I with a curve of 20-30° indicates a nearly 70% chance of progression.

Risser stages are defined as follows:

v  Stage 0 - 0% excursion

v  Stage I - 25% excursion

v  Stage II - 50% excursion

v  Stage III - 75% excursion

v  Stage IV - 100% excursion; correlates with the end of spinal growth

v  Stage V - Fusion to the ilium, indicating the cessation of vertical height growth

The clinician must take into account several bits of clinical information about the use of braces in scoliosis, including the following:

• Only 3% of patients with prebrace curves of 20-29° require surgery, whereas 28% of patients with prebrace curves of 40-49° require surgery.

• Patients younger than 13 years with a 30-39° curvature require surgery 25% of the time, while surgery is needed in only 14% of patients who are older than 14 years and have a 30-39º curvature.

• The most common time to lose control of idiopathic curves is at puberty. Boys tend to show less curve progression than do girls. Boys also tend to have a later onset of curve progression (between 15 and 18 years).

• Younger patients show greater initial in-brace correction. Curve correction with bracing that is greater than 50% is expected to have a final net correction, whereas curve correction of less than 50% is expected to have limited progression.

• Generally, curves between T8-L2 have the best response to correction. Young patients with large curves usually fail treatment with a brace.

• Patients whose curve initially measures 20-45º and who successfully complete treatment for idiopathic scoliosis using a TLSO can anticipate that their scoliosis will remain stable until adulthood. The correction of the curvature can be lost over time, with the curve returning to its initial magnitude. Therefore, obtaining a spinal radiograph in the third or fourth decade of life to check progression is reasonable.

MILWAUKEE BRACE

The Milwaukee brace is a CTLSO that was originally designed by Blount and Schmidt to help maintain postoperative correction in patients with scoliosis secondary to polio.

The brace is designed to stimulate corrective forces in the patient. When the patient has been fitted properly with a brace, the trunk muscles are in constant use; therefore, disuse atrophy does not occur.

The brace has an open design, with constant force provided by the plastic pelvic mold. The pelvic portion helps reduce lordosis, derotates the spine, and corrects frontal deformity.

The uprights have localized pads that apply transverse force, which is effective for small curves.

The main corrective force is the thoracic pad, which attaches to the 2 posterior uprights and to 1 anterior upright.

Discomfort from the thoracic pad creates a righting response to an upright posture. In contrast to the thoracic pads, the lumbar pads play a passive role.

The uprights are perpendicular to the pelvic section, so any leg-length discrepancy should be corrected to level the pelvis.

The neck ring is another corrective force and is designed to give longitudinal traction.

Jaw deformity is a potential complication of the use of the neck ring. The throat mold, instead of a mandibular mold, allows the use of distractive force without the development of jaw deformity.

As a child grows, the brace length can be adjusted. In addition, pads can be changed to compensate for spinal growth. The brace needs to be changed if pelvic size increases.

Indications for the use of a Milwaukee brace include the following:

• Patients with a Risser score of I-II, as well as a curve that is greater than 20-30° and that progresses by 5° over 1 year

• Curves of 30-40°, but not curves of less than 20°.

Curves of 20-30°, with no year-over-year progression, require observation every 4-6 months. The Milwaukee brace is used for curves in which the apex is above T7.

The Milwaukee brace's duration of use is determined by the following criteria:

• Daily use ranges from 16-23 hours per day.

• Treatment should continue until the patient is at Risser stage IV or V.

• If the curve is greater than 30°, consider continued use of the brace for 1-2 years after maturity, because a curve of this magnitude is at risk of progression.

Problems that are associated with the use of a Milwaukee brace include the following:

• Jaw deformity

• Pain

• Skin breakdown

• Unsightly appearance

• Difficulty with mobility

• Difficulty with transfers

• Increased energy expenditure with ambulation

Failure to correct deformity can be caused by any of the following:

• Poor patient compliance

• Improper fit

• Curves below T7

Keep in mind clinical information regarding the use of the Milwaukee brace, including the following:

• Only 40% of patients with curves of 20-29° progressed with a Milwaukee brace, compared with 68% by natural history without bracing.

• When comparing the Milwaukee brace with the Boston brace (described below), note that curve progression beyond 45° occurred in 31% of patients with the Boston brace and in 62% with the Milwaukee brace.

• Radiographs that are used to evaluate scoliosis in the Milwaukee brace should be taken with the patient in a standing position.

• Successful outcomes with brace treatment show an in-brace curve reduction of greater than 50%.

• The Milwaukee brace and a custom-made TLSO can be used to treat Scheuermann kyphosis in children with pain or to treat pain associated with kyphosis of greater than 60°.

BOSTON BRACE

The Boston brace is a prefabricated, symmetric, thoracolumbar-pelvic mold with built-in lumbar flexion, that can be worn under clothes.

Lumbar flexion is achieved through posterior flattening of the brace and extension of the mold distally to the buttock.

Braces with superstructures have a curve apex above T7. Curves with an apex at or below T7 do not require superstructures to immobilize cervical spine movement.

Unlike the Milwaukee brace, the Boston brace cannot be adjusted if the patient grows in height. Both braces need to be changed if pelvic size increases.

Indications for the use of a Boston brace include the following:

• A curve of 20-25° with 10° progression over 1 year

• A curve of 25-30° with 5° progression over 1 year

• Skeletally immature patients with a curve of 30° or greater

Problems that are associated with the use of a Boston brace include the following:

• Local discomfort

• Hip flexion contracture

• Trunk weakness

• Increased abdominal pressure

• Skin breakdown

• Accentuation of hypokyphosis in the thoracic spine, above the brace

Certain preventive measures can reduce difficulties that are associated with the use of a Boston brace, including the following:

• A regimen of hip stretches decreases contractures at the hip.

• Exercise to promote active correction in the brace is suggested.

The presence of thoracic hypokyphosis is a relative contraindication for the use of a Boston brace.

Failure of the Boston brace to correct deformity can occur because of several factors, including the following:

• Curve above T7

• Improper fit

• Poor patient compliance

The Boston brace's duration of use is determined by several factors, including the following:

• Daily use ranges from 16-23 hours per day.

• Treatment should continue until the patient is at Risser stage IV or V.

• If the curve is greater than 30°, consider continued use for 1-2 years after maturity, because these curves are at risk of progression.

• The Boston brace is as effective without the superstructure as it is with the superstructure in the treatment of curves in which the apex is below T7.

Clinical information that is relevant to the use of the Boston brace includes the following:

• Use of a Boston brace is a more effective means of preventing curve progression and avoiding surgery than is the use of a Charleston bending brace.

• One study looked at skeletally immature patients with idiopathic scoliosis who were at least age 10 years when a brace was prescribed. In members of this group who had a curve of 36-45º, nearly 43% who used the Boston brace experienced a curve progression of more than 5°, compared with 83% of those using the Charleston bending brace.

• The use of a Charleston bending brace is indicated only with lumbar or small thoracolumbar curves; avoid use in thoracic curves.

• Radiographs used to evaluate scoliosis in the Boston brace are taken with the patient in a standing position.

• Successful outcomes with brace treatment show an in-brace curve reduction of greater than 50%.

CHARLESTON BENDING BRACE

The Charleston bending brace is a rigid, custom-made orthosis that is designed to improve patient compliance by correcting scoliosis at nighttime. This brace holds the patient in maximum side-bending

correction.

Indications for the use of this particular brace include the following:

• A curve of 20-25° with 10° progression over 1 year

• A curve of 25-30° with 5° progression over 1 year

• Skeletally immature patients with a curve of 30° or greater

Clinical information regarding the use of the Charleston bending brace includes the following:

• The Charleston bending brace is significantly less effective than the Boston brace in the treatment of double major curves and single thoracic curves in patients with Risser stage 0-I.

• Over 50% of patients with a single thoracic curve who were treated with a Charleston bending brace required surgery, compared with 24% of patients who were treated with a Boston brace.

  • As a result, the Charleston bending brace is not recommended for use in thoracic curves.

• The Charleston bending brace is less effective in the treatment of single thoracolumbar or lumbar curves, but the figures are not statistically significant compared with those for the Boston brace.

• Radiographs that are used to evaluate scoliosis with the Charleston bending brace are performed with the patient in a supine position, because the patient wears the brace while sleeping supine.

  • Successful outcomes with brace treatment show an in-brace curve reduction greater than 50%.