The Best Spinal Orthosis: Deciding Factors
Jennifer Fawcett, Resident Orthotist
Residency Research
Metropolitan Orthotic Laboratory
Minneapolis, Minnesota
Abstract
How do professionals, specifically physicians, come to the decision as to what is the best orthosis for their patient with low back pain? By looking at five different diagnoses, five spinal orthosis and five orthopaedic surgeons a conclusion will be drawn. The diagnoses that will be covered are: Spondylolisthesis, Spondylolysis, Stenosis, Degenerative Disc Disease, and Herniated Nucleus Pulposus. All will be explained in reference to the lower spine. The orthoses are all indicated for use with the lumbosacral region of the spine and include: Softec Lumbo, Lumbosacral Corset, Warm and Form, Cybertech Chairback 2000, and custom made TLSO. The referral base for the doctors is large; therefore their names will not be identified at this time. However, it will be specified that they are orthopaedic surgeons that specialize in spine. The conclusion will be drawn from this information and will present statistical results as well as an opinion poll. The goal is to determine what factors are used to decide what the best orthosis is for the patient.
Introduction to Diagnoses
As with many orthotic treatments the use of orthoses in treatment of the lower spine is fairly controversial. At this facility a majority of the patients that are seen have diagnoses that pertain to the spine. This study will look at the lumbar and sacral spine. To better understand the findings of this study here are definitions of the five diagnoses observed.
Spondylolisthesis is the anterior displacement of one vertebra on another. Most commonly this occurs at levels L5 slipping over S1 or L4 over L5. Symptoms include back and/or leg pain. Some people may experience change in posture and gait pattern. The cause is usually a defect that may be present at birth, occurring as the vertebra develops, or be a result of degeneration or trauma. Treatment of Spondylolisthesis depends on the amount of slippage, severity of symptoms and age at the time of diagnosis. Non-surgical treatments include bracing, cast application, physical therapy, anti-inflammatory medicines, and monitoring symptoms and slippage. For surgical treatment the most common is a fusion of the affected area.
Spondylolysis is a stress fracture or defect in the pars interarticularis of the vertebra. The defect may be unilateral or bilateral. Symptoms and treatments are similar to those of Spondylolisthesis.
Narrowing of the spinal canal is called Spinal Stenosis. This condition most often develops as a person ages. However, it can also be caused by arthritic changes, injury, or surgery. There are many symptoms that may be experienced. As the spinal canal narrows, the nerves that pass through can be compressed. This, in turn, causes them to become inflamed, which may cause pain in the low back or legs. Specific symptoms include pain in the legs during ambulation or just after, leg pain at night, feeling of coldness in legs, leg weakness, leg numbness, and/or leg cramping. The treatment for Stenosis depends on the number of levels involved, amount of pain and condition of the patient's general health. Non-surgical treatments include anti-inflammatory medicine, physical therapy, rest, injections, and/or bracing. The surgical treatment commonly done is the removal of the bone compressing the spinal cord or nerves. A fusion is also done in situations where the spine is weakened by the opening of the spinal column.
As a part of aging or trauma, discs can degenerate. This occurrence is diagnosed as Degenerative Disc Disease. As degeneration occurs the discs become more susceptible to injuries that can cause compression of nerves or nerve roots causing pain. These injuries may include tears to the annulus, bulging, and herniation of the disc. Symptoms are identified as pain in the affected area of the spine or pain and numbness in the arms and legs. Non-surgical treatments are physical therapy, anti-inflammatory drugs, and bracing for support and posture correction. Surgery performed involves the removal of a disc, decompression of the nerves or a spinal fusion.
The fifth diagnosis that pertains to this research is a Herniated Nucleus Pulposus. This is a condition in which part or all of the soft gelatinous central portions of an intervertebral disc is forced through a weakened part of the disc, herniating into the spinal canal. The symptoms include general pain that may worsen when coughing or laughing, pain radiating to limbs, muscle spasm, and/or muscle weakness. Non-surgical treatments are medications, physical therapy, muscle strengthening, and bracing. Surgical treatment is a discectomy, removal of the protruding disc.
Materials
All of the orthoses included in this study are indicated for treatment of the previous diagnoses. They are also indicated for use in situations without surgery and for post-operative use.
The SofTec Lumbo orthosis has an elastic knit base and stabilizing outer knitted fabric with a plastic half shell between. There is also an abdominal pad that targets supra pubic support of the abdominal wall for further relief and stabilization of the lumbar spine (see picture 1). This orthosis has a center Velcro in front with two side fasteners to tighten down. The SofTec works to support and provide relief by elevating intracavity pressure and decreasing the loading on the vertebrae and discs.
The LS Corset provides support to the lumbosacral spine (see picture 2). It is used to un-weight the spine by increasing abdominal compression. There are many different varieties of this orthosis. In the study, the style used has front Velcro closures and lace fasteners on the sides. There are also paraspinal rigid stays that are contoured to the patients back.
The Warm and Form and the Sport Support are essentially the same orthosis (see picture 3). Two names are used to differentiate between the times that a panel is used and the times when it is not. The Sport Support is the elastic corset only. This orthosis has an elastic and Velcro closure in front with double elastic side pulls. It is used to increase lumbar support through abdominal pressure. When a Warm and Form is fit the panel is heated and contoured directly to the patients back. The panel is then placed in a neoprene back pocket, made specially to hold the panel and to provide warmth in this region. This provides firmer support to the spine in addition to the compressive force and so prevents some motion.
Two braces in one is the advertisement for the Cybertech Chairback bi-modular system (see picture 4). This orthosis combines a chair back and a belt to provide rigid anterior-posterior, medial-lateral control with abdominal compression. It has a single front fabric fastener and a convenient pulley system to tighten down and maximize compression.
In this study there were three types of custom TLSO's used. They are the low profile #5 or LSO, the high profile #6 with sternal bar, or TLSO, and the TLSO with leg extension (see pictures 5 and 6). The #5 maintains trunk alignment, immobilization and motion control in all planes of the lumbo sacral spine. The #6 includes the thoracic spine in its control. A leg extension is added most commonly to the #6. This limits motion even more in the lumbosacral spine. The joint used with the leg extension is generally an adjustable flexion extension control with a drop lock.
Methodology
Between January 2002 and January 2003 this orthotic facility fit over 600 orthoses for diagnoses pertaining to the lumbosacral spine. The criteria the patient had to meet to be included in this data was that they had to have one or more of the five diagnoses previously listed and they were seen by one of five orthopaedic surgeons. This data was collected by reviewing patients' charts and by verbally receiving opinions from patients and doctors.
A sample of 423 patients was gathered. This sample represents approximately 90 percent of the 2002 patients that fit the criteria. The ratio of males to females was 56 percent female and 44 percent male. The average age was 54 with a range of 17 to 90 years old. 94 percent of the patients under went surgery of which 86 percent included fusions. All patients were instructed to wear the orthosis for a minimum of 6 weeks; individual doctors provided instructions on specific time of wear.
Data
Most doctors have their favorite orthosis and it is the one that they are going to prescribe most often (see table 1).
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Table 1. This represents the number of each orthosis that the individual doctor prescribed. |
Doctor A doesn't commonly brace his post-operative patients. When some support is needed, he tends to use the Warm and Form. Doctor B has read a number of studies on bracing the lumbosacral spine using a TLSO and leg extension. The leg extension has a drop lock with an adjustable flexion extension stop, generally stopped at 60 degrees of flexion. In surgical cases where previous fusions have failed or where there is instability in the area of surgery, patients are fit with this orthosis. Doctor B generally has his patients wear their brace for 6 weeks to 6 months. Commonly they are in the TLSO with leg extension for 10 weeks and then just in the TLSO for the remainder of the time.
Referring back to the table, Doctor C used Warms and Forms 84 percent of the time, while Doctor D used the Sport Support 88 percent of the time. Then throw any theory off balance with Doctor E who used a little bit of everything.
A comparison was also done by looking at the data on type of orthosis, diagnosis, and surgical procedure (see table 2 and 3).
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Table 2. This represents the number of each orthosis fit for each diagnosis. Notice that the non-surgical cases are listed in a separate row. |
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Table 3. They types of surgical procedures and orthoses used for each. |
Orthoses were most commonly prescribed to those patients with 2 or more diagnoses. Also commonly braced post-operatively were the patients with Stenosis or Degenerative Disc Disease. Most often fit were Sport Supports and Warm & Forms.
The different types of surgical procedures draw their own conclusions. In cases where fusions were performed, a good variety of orthoses were used. In decompressions it was most common to see a Sport Support fitted to the patient. The surgeries that combined both procedures had a large number of TLSO #6 fit and also Warm & Forms and Sport Supports. For hardware removals, braces were not commonly used.
Discussion
More often our doctors are now prescribing the SofTec Lumbo orthosis. This is not only a supportive brace; it is also a comfortable one. Our patients seem to really like it. The only complaint received has been its bulkiness. As made obvious in the data, all of the doctors use the Sport Support and/or Warm & Form.
The connection found in the procedure and orthoses table, table 3, lead more to the conclusion that it is not the procedure that determines the brace, it is the doctor. The discussions that have taken place with the various doctors have also brought together this thought. Doctors A, B, and C prefer not to use braces when they are not structurally needed. When the spine and procedure is stable they go without. On the other side are doctors D and E who prefer almost all of their patients to have some external support.
Conclusion
The best orthosis is decided by each individual doctor for each individual patient. They take in factors that include lifestyle, stability of spine before surgery, stability after surgery, diagnosis, and personal preference. Each doctor has developed his preferences by patient feedback, orthotist feedback, and success of the orthosis. The most obvious conclusion from this study is that what is right for one person is not necessarily right for the next.
When the doctors decide what is the right orthosis for the patient may even take place in the operating room once they see what is inside. This time is often a good time to really know how much support is needed. The doctors used in this data are all very distinguished in their fields. They have all been doctors for many years. It was previously surprising to have the doctors consult the orthotist on such a seldom basis. Now it is obvious that as long as they understand the parameters and ability of the orthosis, in combination with their own deciding factors, they are able to prescribe that correct orthosis for each patient.
References
L.G.F. Giles, K.P. Singer. The Clinical Anatomy: Management of Back Pain Series Volume 2: Clinical Anatomy and the Management of the Thoracic Spine. 2000; Butterworth Heinmann. Weinstein, Stuart L., Buckwalter, Joseph A. Turek's Orthopaedics Principles and Their Application. Fifth Edition, 1994. JB Lippincott Company Phili. Winter, Lonstien. Moe's Textbook of Scoliosis and Other Spinal Deformities. Second Edition. 1987. W.B. Saunders Company. www.nismat.org/ptcor/spondylo www.nlm.nih.gov/medlineplus/ency./article/000442.htm Patient information handouts, Twin Cities Spine Center, Minneapolis, 2003.
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