The primary goals of spinal orthoses are to aid a weakened muscle group, correct a deformed body part, and maintain the stability of a fractured spine. The orthosis can protect a body part from further injury or can correct the position of a body part. Technology has revamped the field of orthotics, with newer orthoses that are stronger and lighter.
History of Spinal Orthotic Management (eSlide 13.1)
The first evidence of the use of spinal orthoses can be traced back to Galen (c. ad 131–201). Primitive orthotic devices were made of items that were readily available during this period.
Terminology of Spinal Orthoses (eSlide 13.2)
The most standard way to name an orthosis is by the joints that it encompasses and the motion it controls.
Prefabricated or Custom Orthoses
Orthoses can be prefabricated to fit a large variety of patients of various sizes and can be fitted to patients often with little or no adjustment. Orthoses that are custom molded to a specific patient provide a more comfortable fit with a higher degree of control and can be designed to accommodate a patient’s unique body shape or deformities.
Orthotic Prescription
Orthotic prescription should include the following items: patient identifiers, date, date the orthosis is needed, diagnosis, functional goal, orthosis description, and precautions. Prescriptions should include a justification for the orthosis, such as to correct alignment, decrease pain, or improve function. Established acronyms are acceptable [e.g., TLSO (thoracolumbosacral orthosis)]. Detailed descriptions of the orthoses, joints involved, and functional goals are important. Before the prescription is finalized, inputs from the patient, physician, therapist, and orthotist are needed. It is especially important for physicians to review the use or lack of use of past orthoses because this will help in writing the new prescription. It enables improved communication among clinicians and serves as a justification for funding the orthosis.
Spinal Anatomy
The vertebral column not only bears the weight of the body but also allows motion between body parts and serves to protect the spinal cord from injury. The three-column stability concept includes (1) the anterior column consisting of the anterior longitudinal ligament, annulus fibrosus, and anterior half of the vertebral body; (2) the middle column consisting of the posterior longitudinal ligament, annulus fibrosus, and posterior half of the vertebral body; and (3) the posterior column consisting of the interspinous and supraspinous ligaments, facet joints, laminas, pedicles, and spinous processes. It reveals that if the middle column and either the anterior or posterior column are compromised, the spine may be unstable. This concept helps to ensure that a proper orthosis is prescribed.
Spine motion can be classified with reference to the horizontal, frontal, and sagittal planes (eSlide 13.3) .
In the cervical spine, extension occurs predominantly at the occipital-C1 junction. Lateral bending mainly occurs at the C3-C4 and C4-C5 levels. Axial rotation occurs mostly at the C1-C2 level. In the thoracic spine, flexion and extension occur primarily at the T11-T12 and T12-L1 levels. Lateral bending is fairly evenly distributed throughout the thoracic levels. Axial rotation occurs mostly at the T1-T2 level, with a gradual decrease toward the lumbar spine. In the lumbar spinal segment, movement in the sagittal plane occurs more at the distal segment, with lateral bending predominantly at the L3-L4 level. There is insignificant axial rotation in the lumbar spinal segments. Range of motion helps in understanding how the various cervical orthoses can limit that range (eSlide 13.4) .
Soft collars provide very little restriction in any plane. The Philadelphia collar mostly limits flexion and extension. The four-poster brace has better restriction, especially for flexion-extension and rotation. The halo brace and Minerva body jacket have the most restriction in all planes of motion.
The coupling phenomenon that is related to movement in the spine occurs during motion. If the movement along one axis is consistently associated with movement around another axis, coupling occurs (eSlide 13.5) .
Description of Orthoses
Head Cervicothoracic Orthoses
Type: Halo Orthosis (eSlide 13.6)
Biomechanics
This orthosis provides flexion, extension, and rotational control of the cervical region. Pressure systems are used for control of motion, as well as to provide slight distraction for immobilization of the cervical spine.
Design and Fabrication
The halo orthosis consists of prefabricated components, such as halo rings, pins, uprights (or superstructures), and vests. The design is used to effectively immobilize the cervical spine. It provides maximum restriction of motion of all the cervical orthoses. A halo is used for approximately 3 months (10-12 weeks) to ensure healing of a fracture or spinal fusion. All pins on the halo ring should be checked to ensure tightness 24–48 hours after application and retorqued if necessary.
Cervical Orthoses
Type: Philadelphia, Miami J, and Aspen Collars (eSlide 13.6)
Biomechanics
These orthoses provide some control of flexion, extension, and lateral bending, as well as minimal rotational control of the cervical region. Pressure systems are used for control of motion, as well as to provide slight distraction for immobilization of the cervical spine. Circumferential pressure is also intended to provide warmth and act as a kinesthetic reminder for the patient.
Design and Fabrication
These orthoses are prefabricated and consist of one or two pieces that are usually attached with Velcro straps. The anterior aspect supports the mandible and rests on the superior edge of the sternum. The posterior aspect of the collar supports the head at the occipital level.
Type: Soft Cervical Collar
The soft collar is usually used as a kinesthetic reminder for patients to limit their neck motion. It does not provide any mechanical restriction to the head motion. It can provide some warmth and comfort for patients with muscle strain.
Cervicothoracic Orthoses
Type: Sternal Occipital Mandibular Immobilizer (eSlide 13.7)
Biomechanics
The sternal occipital mandibular immobilizer (SOMI) provides control of flexion, extension, lateral bending, and rotation of the cervical spine. Pressure systems are used for control of motion, as well as to provide slight distraction for immobilization of the spine. It can be donned while the patient is in the supine position (which is useful for patients who are restricted to bed) because there are no posterior rods to interfere with the comfort of the patient. A headband can be added so that the chin piece can be removed. This maintains stability but improves accessibility for daily hygiene and eating.
Design and Fabrication
The SOMI is prefabricated and consists of a cervical portion with a removable chin piece and bars that curve over the shoulders. The anterior section supports the mandible and rests on the superior edge of the sternum, with the inferior anterior edge terminating at the level of the xiphoid. The posterior aspect of the orthosis supports the head at the occipital level.
Four-Poster Orthosis
This is a rigid cervical orthosis with anterior and posterior sections that consist of pads that lie on the chest and are connected by leather straps. The struts on the anterior and posterior sections are adjustable in height. Straps are used to connect the occipital and mandibular support pieces by over-the-shoulder method.
Cervicothoracolumbosacral Orthoses
Type: Milwaukee Orthosis
Biomechanics
The Milwaukee orthosis provides control of flexion, extension, and lateral bending of the cervical, thoracic, and lumbar spine. It also provides some rotational control of the thoracic and lumbar spine. Pressure systems are used for control of motion, as well as to provide correction of the spine. It is a good choice for patients who need correction in the higher thoracic region of the spine.
Design and Fabrication
This orthosis is custom-made and consists of a cervical portion with the option of a removable cervical ring. There is also a thoracolumbar section, which helps achieve the correction of the lower thoracic and lumbar spine regions.
Indications
The Milwaukee orthosis is used primarily for scoliosis management of the higher thoracic curves along with thoracic and lumbar curves of the spine.
Contraindications
This orthosis is not indicated for lower thoracic and lumbar curves. With lower thoracic and lumbar curves, a thoracolumbar orthosis could be used, without using a cervical component.
Thoracolumbosacral Orthoses
Type: Thoracolumbosacral Orthosis (Prefabricated) (eSlide 13.8)
Biomechanics
Prefabricated TLSO provides control of flexion, extension, lateral bending, and rotation using a three-point pressure system and circumferential compression.
Design and Fabrication
These orthoses can be designed in modular forms, with anterior and posterior sections connected by padded lateral panels and fastened with Velcro straps or pulley systems. Many of these orthoses are covered in breathable fabric and have varieties of different shapes and options, such as sternal pads or shoulder straps.
Type: Thoracolumbosacral Orthosis (Custom-Fabricated Body Jacket) (eSlide 13.8)
Biomechanics
This type of TLSO provides control of flexion, extension, lateral bending, and rotation using the three-point pressure system and circumferential compression.
Design and Fabrication
This orthosis is molded to fit the patient and designed as per the patient’s needs. Anterior and posterior trim lines are adjusted during fitting to allow patients to sit comfortably and use their arms as much as possible without compromising the function of the orthosis.
Type: Cruciform Anterior Spinal Hyperextension Thoracolumbosacral Orthosis (eSlide 13.9)
Biomechanics
The cruciform anterior spinal hyperextension (CASH) TLSO provides flexion control for the lower thoracic and lumbar regions via the three-point pressure system. The system consists of posteriorly directed forces through sternal and suprapubic pads and an anteriorly directed force applied through a thoracolumbar pad attached to a strap that extends to the horizontal anterior bar.
Design and Fabrication
This orthosis is prefabricated and consists of an anterior frame in the form of a cross, from which pads are attached laterally on a horizontal bar and at the sternal and suprapubic areas. When properly fitted, the sternal pad is 0.5 inch below the sternal notch, and the suprapubic pad is 0.5 inch above the symphysis pubis.
Type: Jewett Hyperextension Thoracolumbosacral Orthosis (eSlide 13.10)
Biomechanics
This type of TLSO provides flexion control for the lower thoracic and lumbar regions via the three-point pressure system that consists of posteriorly directed forces through sternal and suprapubic pads and an anteriorly directed force applied through a thoracolumbar pad attached to a strap that extends to the lateral uprights.
Design and Fabrication
This orthosis is prefabricated and consists of an anterior and lateral frame to which the pads are attached laterally on and at the sternal and suprapubic areas. The Jewett TLSO has more lateral support than the CASH TLSO.
Type: Taylor and Knight-Taylor Thoracolumbosacral Orthoses
Biomechanics
These TLSOs provide control of flexion, extension, and a minimal amount of axial rotation by means of the three-point pressure system for each direction of motion. For example, flexion is controlled by the posteriorly directed forces applied through the axillary straps and abdominal apron and an anteriorly directed force through the paraspinal uprights.
Design and Fabrication
The design of the Taylor orthosis consists of two paraspinal uprights extending to the spine of the scapula and a series of straps from the paraspinal to pelvic regions. A posterior pelvic band extends past the midsagittal plane and across the sacral area. This band provides additional lateral support and motion control to the trunk.
Indications
These orthoses are used for postsurgical support of traumatic fractures, spondylolisthesis, scoliosis, spinal stenosis, herniated disks, and disk infections.
Contraindications
They are contraindicated for unstable fractures that require maximum stabilization.
Special Considerations
The pressure per square inch is high for these orthoses because of the width of the bands and uprights.
Lumbosacral Orthoses
Type: Lumbosacral Corset (eSlide 13.11)
Biomechanics
The lumbosacral corset provides anterior and lateral trunk containment and assists in elevating intraabdominal pressure. Restriction of flexion and extension can be achieved with the addition of steel straps posteriorly.
Design and Fabrication
This orthosis is usually made from a cloth that wraps around the torso and hips. Adjustments are made with laces on the sides, back, or front. Custom corsets can be fabricated on the basis of careful measurements of the individual patient.
Type: Lumbosacral Chairback Orthoses (eSlide 13.12)
Biomechanics
These orthoses provide limitation of flexion, extension, and lateral flexion. They also provide elevation of intraabdominal pressure.
Design and Fabrication
These types of orthoses have pelvic and thoracic bands that are connected by two paraspinal uprights posteriorly and a lateral upright on each side at the midsagittal line. They can be fabricated from a traditional aluminum frame that is covered in leather or thermoplastic material molded into the same shape.
Sacroiliac Orthoses
Type: Sacroiliac Orthosis or Sacral Orthosis
Biomechanics
This type of orthosis provides anterior and lateral trunk containment and assists in restriction of some pelvic flexion and extension. It also aids in compression of the pelvis.
Design and Fabrication
This orthosis is usually made from a cloth that wraps around the pelvis and hips. Custom orthoses can be fabricated based on careful measurements of the individual patient.
Indications
This orthosis is most frequently prescribed as a support for patients with pelvic fractures or symphysis pubis fractures or strains. It is useful to control motion and pain.
Contraindications
This type of orthosis should not be used for unstable fractures and for fractures or other conditions in the lumbar region.
Scoliosis
Patients with idiopathic scoliosis, the most common form of scoliosis, should be evaluated to ensure that they do not have anomalous vertebrae, spinal tumors, or other neurologic abnormalities. Progressive curves need to be treated; nutritional supplementation, exercise, or chiropractic treatment may be appropriate. There is strong evidence to indicate that an orthosis can slow the progression of idiopathic scoliosis, and therefore use of an orthosis is the nonoperative treatment of choice. Juvenile idiopathic scoliosis is more likely to be associated with adult cor pulmonale and death. Treatment should begin when curves reach approximately 25 degrees. Because thoracic curves predominate, a Milwaukee brace, which has the pelvic section in close contact with the iliac crest and lumbar spine, might be more effective than a TLSO. Three uprights (one anterior and two posterior) typically connect to a neck ring, throat mold, and occipital pad. The Boston brace uses symmetric standardized modules, eliminating the need for casting. It extends from below the breast to the beginning of the pelvic area and below the scapulae posteriorly. It maintains flexion of the lumbar area by increasing pressure on the abdomen and is a popular TLSO brace. Adolescent idiopathic scoliosis is the most common type of scoliosis for which an orthosis is indicated, usually for curves between 25 and 45 degrees. Curves with an apex at T9 or lower can be managed with a TLSO. Curves with a higher apex require a Milwaukee brace. Single lumbar curves are treated with a lumbosacral orthosis.
Type: Thoracolumbosacral Low-Profile Scoliosis Orthoses (eSlide 13.13)
Boston Brace, Miami Orthosis, and Wilmington Brace
Biomechanics
These orthoses provide dynamic action using three principles (end-point control, transverse loading, and curve correction) to prevent curve progression and stabilize the spine.
Design and Fabrication
The main use of these orthoses or other devices is to halt the curve progression of structural scoliosis. The Milwaukee orthosis is the most popular orthosis for scoliosis. The effectiveness of any orthotic system depends on compliance with the wearing schedule. Most patients should wear the orthosis 23–24 hours per day for it to be effective.
Emerging Technology
Computer-Aided Design and Computer-Aided Manufacturing
Technology is available to help the practitioner improve efficiency in design and fabrication, as well as reduce the invasiveness of orthotic measurements of patients. The BioScanner BioSculptor, one of the computer-aided design (CAD)/computer-aided manufacturing (CAM) systems (eSlide 13.14) , enables accurate measurement and detailed surface information, which is often not provided with a cast or mechanical digitizer. The digital scans may be easily recalled or modified for rapid refitting, and medical justification of new devices can be given by showing volumetric changes.
Bone Stimulation (eSlide 13.15)
The CMF SpinaLogic bone growth stimulator is a portable, battery-powered, micro-controlled, noninvasive bone growth stimulator indicated for adjunct electromagnetic treatment after primary lumbar spinal fusion surgery at one or two levels.
Three-Dimensional Clinical Ultrasound
Recent advances in three-dimensional clinical ultrasound have allowed estimation of the spinous process angle (SPA) in patients with adolescent idiopathic scoliosis. This in turn has been able to provide orthotists with a fast and safe method to assess the SPA in real time and determine the optimal placement of pressure pads to maximize the effectiveness of the orthosis in correcting the spinal deformity.
Summary
Proper prescription, construction, and fitting of a spinal orthosis are complicated processes that require consideration of biomechanics, designs and fabrications, indications, and contraindications. A complete, clear, and agreed plan of care should be constructed. The patient and experienced, knowledgeable providers (including the orthotist, rehabilitation physician, and therapist) working in a team approach provide the maximum likelihood that an orthosis will contribute to the overall therapeutic goals for the patient. Advanced technology is available to help practitioners improve the efficiency of orthosis design and fabrication.
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