1. SPINE ORTHOSES Michael Zlowodzki MD University of Minnesota Department of Orthopaedic Surgery

2. OUTLINE  History & Epidemiology  Indications  Principles  Current orthotic devices  Current Evidence

3. History of Bracing Hippocrates 650 bc

4. 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

5. Indications  Fractures  Infammatory conditions  Infectious disorders  Paralytic disorders  Spondylolisthesis  Scoliosis

6. Epidemiology  79000 spinal fractures per year (1995)  50% between T11 and L2  48% compression fx Tran et al. Spine 1995 Denis. Spine 1983

7. What brace to use?  How many vertebrae are involved?  What level?

8. Role of Braces  Temporary stabilization  Definitive primary treatment  Adjunctive treatment

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

10. Types  Halo  SOMI  Cervical Collar (Miami-J)  CTO  TLSO with proximal extension  TLSO  TLSO with leg extension  Chairback cervical thoracal lumbar

11. HALO

12. SOMI

13. TLSO with SOMI extension

14. Cervical Collars

15. CTO

16. 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

17. How much motion is too much???

18. TSLO

19. Chairback

20. Jewitt

21. CURRENT EVIDENCE

22. 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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. Conclusions  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 OPERATIVE TREATMENT HAS NO MAJOR ADVANTAGES

30. 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

31. 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

32. 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

33. 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

34. Conclusion  One-column fractures of the thoracolumbar spine with <30% compression can be treated with early ambulation and hyperextension exercises Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000 ORTHOSIS HAS NO BENEFIT

35. Types  Halo  SOMI  Cervical Collar (Miami-J)  CTO  TLSO with proximal extension  TLSO  TLSO with leg extension  Chairback cervical thoracal lumbar

36. THANK YOU