19 Bracing for Spinal Fractures

10.1055/b-0040-175468

19 Bracing for Spinal Fractures

Aaron L. Cross and Andrew L. Sherman

Summary

Spine bracing has undergone extensive updates since the introduction of bracing in the 1930s and are now commonly recommended for patients undergoing rehabilitation from surgery or spine injury. Bracing is commonly employed after vertebral compression fractures but its effectiveness is still in question. The goal of bracing is to limit spine motion as much as possible and various types of braces exist for each anatomic segment of the spine. There are different types of cervical braces which are most commonly employed after a traumatic injury when nonsurgical management is the preferred method of treatment. Thoracic and lumbar braces are commonly used for compression fracture bracing. They can be either rigid or soft and provide varying degrees of spinal stability. Generally the spinal braces used for osteoporotic vertebral compression fractures (VCFs) have been shown to provide limited benefits in regard to pain and functional improvement or no benefit. Despite literature evidence supporting the use of bracing, it remains a common initial treatment for those patients with painful VCFs. There are also some potential complications of bracing that clinicians should be aware of including an increased risk of skin breakdown in the locations of the brace’s pressure points. As opposed to osteoporotic VCFs, bracing is generally recommended in cases of traumatic VCFs where surgery is performed or as an adjunct to surgical fixation. While bracing may confer mild benefit in regard to patient comfort or slightly reduced healing time, additional investigation will need to be done to determine the effectiveness of spinal bracing in the treatment of patients with painful VCFs.

19.1 Introduction

Before the year 1931, spine braces were not patented and nor were they sold for use. Physicians would make them for specific patients. These early braces tended to be painful and not very functional and most of the bracing at that time was done to treat adolescent scoliosis. The Milwaukee brace, a removable cervicothoracolumbosacral orthosis (CTLSO) was invented in 1946. ¹ The brace was cumbersome and the metal bars went from the neck down the lower lumbar spine. The result was that a person wearing the brace could not look down for balance and the brace could not be fitted under clothing. In 1972, an adolescent female in Boston diagnosed with idiopathic scoliosis refused to wear the Milwaukee brace because of the neck strap. Her father made some adjustments by cutting off the top part of the brace, changing the metal to plastic and adding padding at the pressure points. This was subsequently dubbed the Boston brace and since then, numerous adjustments and alterations have improved the comfort and functionality of the brace. ²

Spine braces are routinely recommended for patients during rehabilitation from back injuries and surgeries either as the primary treatment method for a less severe spine fracture or after a surgical repair. For more serious fractures, bracing is felt to be an important adjunct to surgical management. Despite its acceptance, bracing is not without controversy; it is has not been shown that any back brace actually improves outcomes. This chapter will explore the main uses of braces and some of the published evidence regarding their use.

The goal of any brace, spine or otherwise, is immobilization. Immobilization allows for bone healing to occur. Some braces are better at immobilizing spines than others and custom-fitted “clamshell” braces that encompass your entire trunk in rigid plastic are more likely to reduce spinal movement, especially bending and twisting, than loose-fitting metal braces. Even the most aggressive braces, however, can probably only do so much to stabilize the spine and mitigate further vertebral compression or collapse of the vertebral body.

19.2 Cervical Fracture Bracing

Most fractures in the cervical spine are related to trauma and when neurological compromise or frank instability is present, surgery is usually the treatment of choice. When nonsurgical management (NSM) is the optimal course of treatment, a cervical orthosis is usually utilized. Johnson et al described four types of cervical braces: cervical collars, poster braces, cervical-thoracic braces, and the halo vest. ³ Each brace is utilized in specific situations as described below.

Most stable cervical spine fractures are placed in rigid or semirigid collars. The most common of these is the Philadelphia collar. The Philadelphia collar is a two-piece semirigid orthosis made of Plastazote and reinforced with anterior and posterior plastic struts. The Philadelphia collar restricts motion much better than a soft collar but is less comfortable. Other similar collars are the Miami J collar (▶Fig. 19.1) and the Aspen collar. Despite their stiffness, the rigid collars lack the ability to effectively immobilize the lower cervical spine. ⁴

**Fig. 19.1** Miami J orthosis. This image is provided courtesy of Stephen R. Dsida, LP, CPO.

The SOMI (Sterno-Occipito-Mandibular Immobilizer) orthosis provides better restriction of motion of the low-cervical spine and cervicothoracic junction compared to the collar option. The SOMI brace provides good restriction to flexion (93% restriction of motion), but is less beneficial for control of neck extension (42% restriction of motion), lateral bending (66% restriction of motion), and axial rotation (66% restriction of motion). ⁵ ^, ⁶ This brace is good for providing additional support to stable mid and lower cervical spine fractures.

For unstable upper cervical spine fractures, the orthosis most often utilized is the halo orthosis (▶Fig. 19.2). The use of a halo vest is usually confined to injuries with limited displacement. The duration of treatment varies between 6 weeks and 4 months. ⁶ A halo vest is the most rigid external immobilizer, especially for the upper cervical spine. It restricts up to 75% of flexion–extension at C1–C2, and offers superior control of lateral bending and rotation compared to other cervical braces. ⁷ As effective as the halo vest is at immobilizing the cervical spine, it can limit pulmonary function. Taitsman et al found that the halo vest leads to increased risk of pulmonary complications including pneumonia. ⁸

**Fig. 19.2** Halo orthosis. This image is provided courtesy of Össur.

Bracing treatment of lower cervical and upper thoracic spine fractures may also be done by using the Minerva brace, a cervical collar jacket. ⁹ Sharpe et al found that for cervical fractures, except for above C1, the Minerva provided “improvement in control of flexion/extension of the upper cervical spine and in control of rotation.” ⁹

19.3 Lumbar and Thoracic Compression Fracture Bracing

19.3.1 Introduction

Spinal orthoses have been widely used in the management of thoracolumbar fractures. A large variety of braces are available as either prefabricated from numerous manufacturers or custom-fabricated units created with the assistance of a prosthetist/orthotist. The following is a review of the types of braces available and evidence regarding their efficacy in traumatic and osteoporotic fractures.

19.3.2 Types of Thoracolumbar Braces

Thoracolumbosacral Orthosis

TLSOs can be either rigid or soft. Both prefabricated and custom-fabricated options are available. The rigid-type design controls extension, flexion, lateral bending, and rotation. The TLSOs are primarily used in the management of VCFs with significant deformity or stable burst fractures from T6 to L4 that do not require surgical intervention. ¹⁰ Examples of TLSOs in order of increasing immobilization include the dorsal lumbar corset, the Jewett hyperextension brace, the cruciform anterior sternal hyperextension (CASH) brace (▶Fig. 19.3), and the custom-molded thermoplastic TLSO (▶Fig. 19.4).

**Fig. 19.3** Cruciform anterior spinal hyperextension (CASH) thoracolumbar orthosis. This image is provided courtesy of Stephen R. Dsida, LP, CPO.

**Fig. 19.4** Custom-fabricated thoracolumbar sacral orthosis (TLSO). This image is provided courtesy of Stephen R. Dsida, LP, CPO.

Lumbosacral Orthosis

Lumbosacral-type orthoses can also be either rigid or soft. Both prefabricated and custom-fabricated options are available. A rigid lumbosacral orthosis (LSO) provides the most restriction of motion and is typically used to immobilize the lumbar spine at the L3 segment and below. If there is a need to provide significantly more immobilization to the L4–L5 and L5–S1 segments, a unilateral thigh extension can be added. ¹¹ The lumbosacral corset is a typically made from cloth and is most often used as an adjunctive support for individuals with low back pain (▶Fig. 19.5). The lumbosacral chairback orthoses (▶Fig. 19.6) are designed with a circumferential band that typically starts at the lower thoracic levels and extends down midway between the iliac crest and the greater trochanter. Chairback orthoses are also often used to provide support for those with low back pain or postoperatively following lumbar fusion surgery.