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OUTLINE
History & Epidemiology Indications Principles Current orthotic devices Current Evidence
History of Bracing
Hippocrates 650 bc
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
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
Cervical Collars
CTO
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
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
Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003
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)
Conclusions
Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003
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
Nonoperative Treatment vs. Posterior Fixation for Thoracolumbar Junction Burst Fractures without Neurological Deficit. Shen et al. Spine 2001
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)
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
Types
Halo SOMI Cervical Collar (Miami-J) CTO TLSO with proximal extension TLSO TLSO with leg extension Chairback
cervical
thoracal lumbar
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