Orthoses for Spinal Pain

Key Points

Causation of back pain is often multifactorial and may be unidentifiable.
Although there is only limited evidence of benefit, the most consistent recommendation is that lumbar orthoses can be used in subacute back pain for a period of no more than 3 weeks to avoid paraspinal atrophy.
When used specifically for the treatment of pain, cervical orthoses have demonstrated limited benefit and may lead to worsening function.

Although general splinting can be seen in early Egyptian culture, the use of spinal orthoses is noted to at least have an origin around the time of Hippocrates before the onset of the Common Era, and the time of Galen in the 2nd century. Although these early attempts at bracing were primarily used for clear spinal deformities, it appears that very tight corsets were also likely used to treat back pain. Although these early orthoses and treatments were made out of natural materials, modern spinal bracing often contains synthetic materials ranging from corsets to off-the-shelf braces and includes custom-molded thermoplastics. The current use of back bracing for pain is controversial at best.

Orthoses in Low Back Pain

Epidemiology

Back pain is very prevalent among Americans, and internationally it represents the largest disease contributor to global disability. The highest prevalence of it was in Europe in 2002, whereas the lowest was in the Caribbean. Although a quarter of Americans have experienced back pain in the last 3 months, the prevalence in the United States was not as high as many other countries. Astonishingly, significantly disabling back pain did rise from 3.2% to 10.2% in North Carolina, comparing 1992 data to 2006 data. These authors implicate rising obesity and depression but also the possibility of increased symptom awareness. Although this does not seem to affect health care utilization, the growing prevalence does affect health care spending and the overall volume of surgery.

Identification of the pathology includes a thorough history; a physical examination looking for the presence of neurologic compromise such as weakness or numbness; and, if specific pathology is suspected, additional, confirmatory testing. This testing may include radiographs, magnetic resonance imaging, or electromyography, but imaging is not typically indicated for nonspecific back pain. Causation in low back pain does seem to have a correlation with intervertebral disc pathology, although this is clearly unreliable as a predictor. Other causes seem to be facet pathology and sacroiliac dysfunction, and radiculopathy and myofascial disorders can play some role. Its incidence is predominantly in the fourth decade, with a higher rate among those with lower education.

Treatments of Low Back Pain

General management of back pain can be differentiated based on whether the pain is acute or chronic. In general, self-care is the first step for all types of back pain, including staying active, providing education, and application of modalities such as heat. Medications such as nonsteroidal antiinflammatory drugs and acetaminophen are considered first line for all types of back pain. For acute pain, muscle relaxants may be indicated, whereas antidepressant and antiepileptic medications may be more useful in chronic disease. In difficult cases, spinal cord stimulators have been shown to be efficacious in chronic low back pain. Although 36% of rehabilitation physicians surveyed in France would use lumbar orthoses for treatment in back pain, the indications for use are neither clear nor rigorously studied. For neurosurgeons, orthoses may provide an alternative to surgery. Examples of two styles of lumbar orthoses are presented in Figs. 7.1 and 7.2 , which show nonrigid and rigid braces, respectively. Fig. 7.1 is a corset style and Fig. 7.2 is a custom-molded, clam-shell–style orthosis.

Figure 7.2, Rigid lumbar brace: prefabricated thoracolumbosacral orthosis.

A proposed prominent mechanism of action for the use of lumbar spine orthoses in pain management is to decrease motion over individual segments of the spine, allowing reduction of inflammation and encouraging the process of healing. In some regards, this is similar to bracing for spinal fracture, which is also limited in evidence and has been shown to improve short-term and medium-term function, even compared with surgery. Decisions to brace, in a limited survey of physiatrists, were often related to the functional examination, radiographic findings, or magnetic resonance imaging (MRI) findings. Other mechanisms that have been suggested range from increasing intraabdominal pressure to reducing muscle fatigue, but research supporting these has been inconclusive.

Range-of-Motion Restrictions

Significant reduction of range of motion, particularly axial rotation, is an assumed mechanism for treatment of back pain with bracing. With immobilization being the primary goal of lumbar bracing, the studies are unconvincing and variable regarding its ability to reduce range of motion. A review of the literature demonstrated control could be achieved in flexion, extension, and lateral bending, but not rotation. Although larger gross limitation occurred with lumbar orthoses restricting extension motion, the results did vary, and a custom-made stay brace seemed to provide the greatest ROM limitation. In an older study, smaller, intersegmental motion could not be controlled with bracing. Additionally, the loss of range of motion causing the symptoms to worsen or causing further injury is a concern with orthoses. Thus their use has been controversial in the literature. Last, in healthy subjects, studies have shown that flexible and rigid lumbar orthoses have no effect on gait initiation or dynamics.

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