Spinal Orthoses PDF

Spinal Orthoses All spinal orthoses have several common effects on the spinal region they treat. Their primary action is to reduce gross spinal motion, and the degree to which they accomplish this depends on both their materials and their design. Secondary effects include the stabilizati...

Spinal Orthoses All spinal orthoses have several common effects on the spinal region they treat. Their primary action is to reduce gross spinal motion, and the degree to which they accomplish this depends on both their materials and their design. Secondary effects include the stabilization of individual functional spinal units, reducing the range of motion of one vertebra relative to another. Spinal orthoses also apply closed chain forces designed to counter a deforming force, such as providing hyperextension to a fracture that is vulnerable in flexion. Finally, they reduce loads on the spine itself by preventing specific actions, such as preventing bending and twisting to reduce stress on surgical implants. Braces often help restore or exaggerate natural spine structure. When thoracolumbar body casts were more commonplace in clinical practice, the casts were applied with the patient positioned supine on a casting table with a belt under their lumbar spine such that they were casted in a position of hyperextension. Page 1 of 18  This hyperextension (hyperlordosis) has been used in many types of braces (i.e., Jewett and CASH) because it removes or decreases the amount of flexion, which reduces compressive force on the fractured vertebral body and limits distraction of the posterior elements. Jewett Brace CASH Hyperextension Spinal Orthosis (Brace) Page 2 of 18  Hyperextension braces achieve the intended positioning by using a three-point mold. A three-point mold refers to three points of applied force: one posteriorly and two anteriorly, with one located cephalad to the level of the posterior force and one caudal. The desired result is prevention of progressive kyphotic deformity that is associated with significant compression and burst fractures. Another example of three-point molding is seen in corrective braces used for scoliosis, except that the forces are directed in a coronal plane instead of a sagittal plane. The ability of a brace to apply appropriate forces, either stabilizing or corrective, depends on its ability to act on the structures of the spine. This in turn depends on the soft tissue envelope in the contact areas around the spine. Too little or excessive pressures transmitted through soft tissues can result in significant physical complications including: ▪ Skin breakdown. ▪ Pain due to the brace. ▪ Soft tissue contractures. ▪ Loss of reduction or spinal alignment. ▪ Weakening of the immobilized muscles. The prescription and use of a spinal orthotic should always be prescribed with an appropriate monitoring system and rehabilitation program. Page 3 of 18  Orthoses must be modified periodically, and a comfortable and appropriate fit is critical to preventing skin problems and ensuring compliance. Regional Orthoses Cervical The complexity of the cervical soft tissues—vessels, airway, esophagus—is a disadvantage, in that significant forces cannot be applied directly to the spine without significant visceral effects. Orthoses for the cervical spine can be limited to the subaxial spine itself—a cylinder that fits around the neck with a trimline at the occiput, mandible, and sternoclavicular structures—or may extend proximally and distally (halo vest) or distally onto the thoracic cage for additional control (cervicothoracic orthosis [CTO]). Soft Collars Soft collars tend to be the most comfortable of the available cervical collars but provide little stability to the cervical spine. These collars have been shown to provide up to 10% restriction to cervical motion in all planes. Page 4 of 18  The soft cervical orthosis is used primarily as a comfortable reminder to the patient to limit exaggerated neck movements and may be useful in cases of minor whiplash, cervical spondylosis, or as a postoperative adjunct with a stable spine. Soft collars are inappropriate for an unstable cervical spine. Rigid Collars Many different types of reinforced collars are available, such as the Philadelphia, Aspen, Miami J, NecLoc, and Stifneck. Page 5 of 18  Most reinforced collars have anterior and posterior shells with inner padding and trim that close around the neck and fasten with Velcro- type fasteners. The collars are contoured such that they abut the sternum, clavicles, trapezius, and upper thoracic spine inferiorly and the mandible and occiput superiorly, which provides some degree of end-point control. Most have openings anteriorly to accommodate respiratory and ventilator equipment. Although there are many similarities between the different cervical collars, studies have found significant differences in the degree to which different collars restrict cervical spine motion. The ability for a cervical collar to provide cervical stability is very important in that approximately 3% to 25% of spinal cord injuries occur after the initial spine injury. The ability of various reinforced collars to promote cervical stability as well as avoid complications. The NecLoc is statistically superior with respect to limitation of cervical motion in all planes, followed by the Miami J collar, when compared the Philadelphia and Aspen collars. Stifneck NecLoc Page 6 of 18  The NecLoc provide superior restriction of motion versus the Philadelphia collar and a soft collar. The NecLoc and Miami J collars are statistically superior to the Stifneck, Philadelphia, and soft collars. The differences between collars in the amount of pressure exerted on the tissues. The Stifneck collar produced pressures in excess of capillary closing pressure at most collar-tissue interfaces, whereas the Miami J collar exerted pressures well below the capillary closing pressure. Halo Vest The halo vest is useful in providing provisional stabilization of injuries or conditions causing instability at the occipitocervical junction, and can be used to provide additional support after these patients have surgery. It is best used for reducing angular and translational deformities in cervical spinal fractures at the proximal and distal regions of the spine; in the midportion. It is commonly used for complex combined C1 and C2 fracture patterns where internal stabilization is not possible without extension to the occiput, which results in severe loss of motion for the patient. Page 7 of 18  It is used to provide additional stability after complex surgical reconstructions or non-instrumented fusion or wiring constructs after surgery at C1-2, and may be used to supplement instrumented fusions in situations with poor bone quality or significant instability, such as in osteoporosis or rheumatoid arthritis patients. The halo is no longer used as frequently in subaxial (i.e., C3-C7) trauma due to the advances in spinal instrumentation. It is still considered the treatment of choice for some types of fractures of the axis (hangman's fractures) and in some flexion-compression injuries. A fracture of the odontoid process at C2 is a common injury among older patients and historically has often been treated with a halo vest. Rehabilitation of the patient with a halo is challenging. The fixed head position results in a different ability to use visual cues, and the weight of the vest and position of the head combine to change the patient's center of mass. Ambulatory patients in halo vests may exhibit a forward-flexion posture to accommodate this; a cane or walker may be required while the halo is in place. Likewise, there is a readjustment period after the halo is removed that may require postural reeducation as part of the rehabilitation strategy. Cervicothoracic and Thoracic Orthoses (CTO) CTO can be divided into two categories: ▪ Those that use the thoracic spine to support treatment of a subaxial cervical spine or upper thoracic spine problem. ▪ Those that support treatment at the upper cervical spine. Page 8 of 18  Examples in the first category include thoracic extensions added to a cylindrical cervical orthosis (i.e., Extended Miami J), or an orthosis that utilizes pads on the chin and occiput to connect to the trunk by four stiff uprights or circumferential supports (i.e., Minerva). The Minerva brace is the most effective method for immobilizing C1- 2, and has been shown to limit flexion-extension by approximately 79%, axial rotation by 88%, and lateral bending by 51%. The cervicothoracic area is a particularly challenging area to immobilize in that it is a transitional area between the very mobile and lordotic cervical spine and the kyphotic thoracic spin. The Minerva brace, SOMI brace, or a custom-molded CTO can be used for conditions extending as far caudally as T5. Page 9 of 18  SOMI brace In general, increasing the length of the orthosis down the trunk enhances its capabilities. The most common condition that affects the thoracic spine is the vertebral compression fracture (VCF). Thoracolumbar The thoracolumbar region is the most common region of the spine affected by traumatic fracture, and the most likely region of the spine to benefit from orthotic support for the surgically treated spine. The integrity of the vertebral body is of primary importance to resisting compressive forces and axial loads, and this region is a transitional zone that should be neutral in alignment. Fractures involving the anterior body greatly decrease the spine's ability to withstand compressive load and tend to collapse into kyphosis, particularly if the posterior elements are also involved (i.e., a burst fracture). This results in displacement of the patient's sagittal balance, spinal deformity, pain, and in the worst cases, neurological deficit. Page 10 of 18 Orthoses used for thoracolumbar fracture management: Optimal management includes a strategy to resist anterior flexion and therefore prevent the development of kyphotic deformity. They are best used for fractures from T10 to L2, although some types of orthoses can be adjusted to control up to T8. Several thoracolumbar hyperextension orthoses are designed to unload the anterior column. The most common types are the Jewett brace and the cruciform anterior spinal hyperextension brace (CASH). The Jewett orthosis is suitable for patients with coexisting abdominal trauma or obesity. Trunk flexion is limited by a single three-point pressure system with posteriorly directed forces at the sternum and pubis opposing an anteriorly directed force applied by the posterior pad. Therefore, it is contraindicated in patients with sternal fractures or an inability to tolerate direct pressure from the posterior pad. The goal of the Jewett is to prevent flexion while still allowing active hyperextension. Jewett CASH Both the Jewett and the CASH are options for those patients who cannot tolerate the constriction of a molded thermoplast thoracolumbosacral orthosis (TLSO) but are contraindicated in patients with injuries including significant three-column instability such as the thoracolumbar burst fracture. Page 11 of 18  The TLSO is the recommended treatment for significant fractures at the thoracolumbar junction being treated conservatively. TLSOs can be used to manage fractures from T6 to L4. Molded TLSOs provide total contact designed to restrict range of motion in all planes. A custom-molded thermoplastic TLSO showed 94% restriction in lateral bending and 69% restriction of flexion-extension in the lumbar spine. In the thoracic spine, there was 49% restriction of flexion-extension and 38% restriction of lateral bending. Lumbosacral Immobilization of the lumbosacral spine presents a unique set of challenges. It is a transition zone between the highly mobile, lordotic, lumbar spine and the rigid sacropelvic structures; it has the largest absolute range of flexion-extension motion, and it bears the most load of any of the spinal regions. A rigid LSO, which is simply a shorter version of the TLSO braces described earlier, is appropriate for bracing fractures at L2, L3, and L4, but the functional spinal unit at L4-5 and L5- S1 require special treatment. Page 12 of 18  The mean percentage of motion allowed in the brace was 32% at L4- 5 and 70% at L5-S1 in a brace without the extension; adding the extension resulted in an additional 15% to 30% reduction of motion Lumbar Corset Today, postoperative bracing is reserved for patients who feel more comfortable with support (a lumbar corset) or those with poor bone quality or technical issues leading to concerns about healing or the stabilization provided by the instrumentation. Patients with acute low back pain may find the additional support and postural reminder of a lumbar corset helpful for pain reduction. Lumbar corsets are generally semirigid or flexible braces. Their function is to reduce gross trunk motion and increase intracavitary pressure in the abdomen by transmitting a three-point pressure system to the lumbar spine. They are designed to support the trunk in a neutral sagittal alignment and provide a kinesthetic reminder to limit motion. The lumbar corset has little resistance to gross body motion during sitting and standing. The Chairback Orthosis The Chairback orthosis is an LS corset with both a thoracic and a pelvic band connected by two paraspinal bars for optimized sagittal control. Page 13 of 18  Chairback orthosis Knight orthosis A pair of lateral bars can also be added for improved coronal control (the Knight orthosis). Scoliosis Scoliosis is a general term that refers to a three-dimensional spinal deformity characterized by coronal displacement of vertebral bodies away from the axis of gravity combined with abnormal vertebral rotation. There are many types of scoliosis as well as many etiologies. In current times, the only type of scoliosis that is typically and frequently managed with spinal orthoses is the idiopathic curve. Adolescent idiopathic scoliosis (AIS) refers to a curvature and rotational deformity of the spine that develops with growth. It can occur in the upper thoracic, thoracic, thoracolumbar, or lumbar spine or some combination of these. Page 14 of 18  There is often a primary curve (the curve with abnormal growth) and a compensatory curve, which is a second region of the spine curving in the opposite direction to the primary curve to keep the head centered over the pelvis. The age of the child, growth remaining, and curve pattern all have implications for prognosis. Types of Braces Milwaukee Brace The Milwaukee brace, a cervicothoracolumbosacral orthosis (CTLSO), was initially employed as a postoperative modality but soon found a more important role and used in the nonoperative treatment of idiopathic scoliosis. Page 15 of 18  The brace consists of a pelvic section, which helps reduce lumbar lordosis, and an attached “superstructure.” The superstructure consists of three metal uprights that are attached to a neck ring superiorly. It provides an end point of control to make the spine structurally more rigid, better aligned, and provide a means of attachment for the spinal pads. This style is considered a full-time brace and should be worn 23 hours each day. Most of these spinal orthoses are named for the city in which they were developed (e.g., Boston brace, Miami orthosis, Wilmington brace, Lyon brace). Page 16 of 18  These spinal orthoses share one characteristic: All control the alignment of the thoracolumbosacral spine but have no superstructure. The Milwaukee brace remains the most effective brace for upper thoracic curves but requires a dedicated patient and family for compliance Boston Thoracolumbosacral Orthosis In 1972, Hall created a more low-profile, modular TLSO known as the Boston brace in response to patient concerns about the bulkiness and neck ring of the Milwaukee brace. The Boston is a rigid underarm TLSO that has become the most prevalent form of orthosis used, with various modifications. The original Boston brace consisted of multiple modules that were fabricated in different sizes and could be combined to provide a custom-fitted brace that did not require as much time or expertise on the part of the orthotist. Several studies have demonstrated equivalent results with the use of the Boston brace or its related products compared with the Milwaukee brace, with the possible exception of use for high thoracic curves. Boston braces are popular due to their low-profile and partially open design, which is comfortable and well-tolerated. Page 17 of 18 Charleston Nighttime Brace This orthosis is manufactured so that curve is maximally corrected while the patient sleeps; the correction is so significant that an upright position is not comfortable. The studies reported on the prevention of progression of curvature in 66% of patients with curves less than 49 degrees and significant growth remaining. One comparative study between the Boston and the Charleston orthoses showed the Boston orthosis to be more effective in all curve patterns but the Charleston orthosis to have equal efficacy in 25- to 35-degree single thoracolumbar or lumbar curves. Thank You Click Here To Take The Quiz Page 18 of 18