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Orthoses for Spinal Trauma and Postoperative Care
Key Points
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The treatment team must define traumatic fractures as stable vs. unstable.
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With the exception of upper cervical spine fractures, only stable spine fractures can be considered for orthotic treatment.
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The primary goal of orthotic interventions is to increase spinal stability in all three anatomical planes by immobilization.
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Orthotic immobilization may assist with healing and limit progression of a spinal deformity.
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An understanding of the mechanism of injury with traumatic spine fractures and associated sequelae is necessary before orthotic management is pursued as a treatment pathway.
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When orthotic management is selected as an alternative to surgery, standards for orthotic outcomes should be similar to the standards for surgical outcomes.
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Scientific evidence supporting or refuting the efficacy of postoperative orthotic management is limited.
Historical Perspective
Orthotic treatment for spinal trauma has evolved over many centuries. Orthoses were initially used to immobilize fractures to reduce the pain and risk of deformities associated with particular injuries. Early devices were made of materials such as whalebone and wood, followed by metal components. Plaster body casts eventually became popular, and by the mid 20th century, these were replaced by orthoses constructed from thermoplastics.
Historical approaches to orthotic treatment have related specifically to the mechanism of injury and the mechanism of action for the orthotic addressing the injury. The mechanism of injury is routinely categorized by terms such as lateral flexion, compression, rotation, and extension . Although this approach can have a meaningful clinical application, it also runs the risk of oversimplifying complex injuries.
In the early days of spinal fusion, body jackets were commonly used postoperatively to provide additional stability to the surgical construct to allow proper healing. Today, the role of postoperative orthoses remains controversial. Some argue that modern surgical techniques and devices provide the stability necessary to allow for proper healing without an orthosis. On the other hand, surgical failures still occur, especially when postoperative bracing is omitted from the treatment plan. Although limited, some research demonstrates the efficacy of nonoperative orthotic management as well as postoperative spinal orthoses, thus confounding the controversy further.
Introduction
Nonoperative management of spinal trauma consists of relative rest, physical therapy, and/or orthotic management. For certain fracture types, nonoperative treatment is a reasonable alternative to surgery and offers comparable long-term results. For other stable fracture types, the choice between operative and nonoperative treatment remains controversial. Consideration for orthotic management should be based on stability, fracture type, comorbidities, and intended outcomes. With the exception of some fractures of the upper cervical spine and bilateral facet fractures, orthotic treatment of spinal trauma may be indicated only for clinically stable spinal fractures. Many studies have compared nonoperative and operative treatment, but few have compared the various types of orthotic treatments with one another.
The treatment team must have a common understanding of the definitions of the terms clinical “stability” and “instability” of the spine. The Denis Three-Column Theory states that the anterior column comprises the anterior longitudinal ligament and the anterior half of the vertebral body; the middle column comprises the posterior half of the vertebral body and the posterior longitudinal ligament; and the posterior column comprises the pedicles, the facet joints, and the supraspinous ligaments ( Fig. 9.1 ). Each column has different contributions to stability, and damage may affect stability differently. Generally, if two or more of these columns are damaged, or if the middle column disrupts the posterior longitudinal ligament, the spine is considered unstable. However, it depends on the characteristics of the fracture.
To appreciate the efficacy of orthotic management, it is necessary to review management based on individual fracture types. Fracture types can be divided into cervical and thoracolumbar injuries. Cervical injuries are identified by the site that is fractured. For thoracolumbar injuries, the Denis classification further describes four major types of spinal fractures: (1) compression fractures, (2) burst fractures, (3) seatbelt fractures, and (4) fracture dislocation ( Table 9.1 ).
TABLE 9.1
Summary of Main Fracture Types
From Malas BS, Meade KP, Patwardhan AG, et al. Orthoses for spinal trauma and postoperative care. In Hsu JD, Michael JW, Fisk JR, eds. AAOS Atlas of Orthoses and Assistive Devices . 4th ed. Philadelphia: Mosby; 2008.
| Level | Type | Mechanism of Injury | Remarks | Orthoses | ||
|---|---|---|---|---|---|---|
| Upper cervical | C1 | Jefferson | Axial load. | Triplanar instability. | Halo vest | |
| C2 | Hangman | Hyperextension plus distraction. | Traumatic spondylolisthesis, triplanar instability. | Halo vest | ||
| Odontoid | Shear plus compression. | Type I: stable; types II and III: unstable. | Halo vest | |||
| Lower cervical | C3–7 | Anterior compression | Hyperflexion. | C5 most common level, possible brachial plexus involvement. | Rigid collar | |
| Whiplash | Hyperextension. | Soft tissue injury to anterior longitudinal ligament likely, long-term risk for chronic forward head posture. | Soft collar | |||
| Cervicothoracic Junction Injuries Spanning This Level Require a CTO or CTLSO | ||||||
| Upper thoracic | T1–8 | Denis classification applies to all thoracic and lumbar levels. | Denis I: anterior compression | Flexion plus compression. | Three fourths of thoracolumbar fractures are of this type, two thirds of those occur at T12–L1–2. Anterior column damage only in most cases. Posterior ligamentous injury may indicate instability. | Hyperextension is the mechanism of action. Common choices: corsets, Jewett (milder injuries), and TLSOs (custom or prefabricated). |
| Denis II: burst | Compression plus flexion. | Anterior and middle columns are damaged. Fracture of superior endplate is more common. There may be retropulsion of one or more fragments from the posterior wall. | ||||
| Lower thoracic | T9–12 | Denis III: chance and slice | Flexion plus distraction (“seat belt injury”). | Chance: posterior and middle column damage to vertebral body. Slice: posterior and middle column damage to intervertebral disc. Surgery is indicated. |
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| Thoracolumbar Junction (T12–L1–2) Are Very Common Fracture Sites and Require a TLSO | ||||||
| Upper lumbar | L1–2 | Denis IV: fracture dislocation | Translation, flexion, rotation, shear. | Complete disruption of anterior, middle, and posterior columns. Surgery is indicated. | N/A | |
| Lower lumbar | L3–5 | Other | Spondylolysis and spondylolisthesis | May be a sports-related injury from gymnastics. In adults, may cause chronic LBP. | Common in the lower lumbar spine, especially L4–5 and L5–S1. Spondylolisthesis usually requires posterior pelvic tilt in the orthosis. | Custom LSO or TLSO |
CTLSO, Cervicothoracolumbosacral orthosis; CTO, cervicothoracic orthosis; LBP, lower back pain; LSO, lumbosacral orthosis; TLSO, thoracolumbosacral orthosis.
For most spinal injuries at the macro level, the primary orthotic goal is protecting the spinal column from loads and stresses that would likely cause progression of the spinal deformity and not allow for adequate healing of the injury. To achieve this goal, the orthotic design should have the ability to (1) limit gross vertebral sway (motion) of the spinal column, (2) limit intersegmental motion at the injured site, and (3) provide proper spinal alignment or realignment as it relates to the injured site. Limitation of both gross and localized motion minimizes movements that could prevent healing and cause further deformity. Spinal alignment attempts to restore the anatomical geometry of the injured site and has the ability to shift the axial load away from the injured site. The measures for success are variable but should be held to the same rigorous standards that define success for similar spinal injuries managed surgically. These include geometric changes (kyphotic angle and restoration of vertebral height) of the fracture site in addition to long-term outcomes such as return to work, pain reduction, and restoration of activities of daily living.
Cervical Spinal Trauma
The primary orthotic goal is to immobilize a fracture of the cervical spine. The orthotist may be faced with decisions regarding which orthosis to recommend and, in particular, whether the recommended device should be a cervical orthosis ( Fig. 9.2 ) or a cervicothoracic orthosis ( Fig. 9.3 ). These devices are used for both nonoperative and postoperative care. To shed light on the issue, Gavin et al. analyzed two cervical orthoses (Aspen and Miami J) and two cervicothoracic orthoses (Aspen two-post and Aspen four-post) using videofluoroscopy. They concluded that cervicothoracic orthoses provided significantly more reduction of cervical intervertebral and gross range of motion in 20 normal subjects compared with cervical orthoses. An additional study by Ivancic revealed successive increased mobilization when moving from a cervical collar to a cervicothoracic orthosis with a middle and lower cervical spine injury. These findings may assist clinicians in selecting the most appropriate orthosis based upon patient-specific cervical spine injuries.
C1 or Jefferson Fracture
A hyperextension force or axial load applied to the top of the head and transferred through the condyles of the occiput can fracture the ring of the first cervical vertebra (atlas). This is known as a Jefferson fracture. The downward force of the occipital condyles causes the lateral masses of C1 to fracture and be displaced laterally ( Fig. 9.4 ). Associated with the lateral displacement are fractures of the anterior and posterior arches of C1. Stable fractures are those with an intact transverse ligament and minimal displacement (less than 7 mm). Unstable fractures occur when there is separation of the lateral masses, which implies that the transverse ligament is ruptured. In the absence of external support, the patient is at high risk for neurologic damage, because motion of the head is not constrained.
Recommended Orthotic
A soft collar is sufficient for an isolated posterior arch fracture that is minimally or nondisplaced. Use of a cervicothoracic brace for 3 months is recommended for fractures that are minimally displaced. Unstable fractures must be managed by prolonged cranial traction, adequate reduction, and a halo vest for a total of 3 months.
Operative Treatment With a Postoperative Orthotic
For unstable fractures with a C1–2 subluxation of more than 5 mm, a C1–3 fusion should be considered. There is no current guideline regarding postoperative orthotics.
Considerations
After bony healing occurs, late subluxation of C1 may occur and should be monitored.
Hangman Fracture
A hangman fracture is a bilateral fracture through the pedicles of C2 that separates the posterior neural arch from the vertebral body. The typical mechanism of injury, which consists of hyperextension followed by distraction, is called traumatic spondylolisthesis. The spinal cord may be compressed with possible transient neurologic findings.
Levine Classification
For an image of the Levine Classification, Please see Kalantar, S., Babak, Md. Seminars in Spine Surgery . Published March 1, 2013. Volume 25, Issue 1. Pages 23-35. Fig. 15. © 2013.
Type I
Fracture of the bilateral pars interarticularis with less than 3 mm of translation and no angulation is classified as type I. This is considered a stable fracture.
Type IA
A type IA fracture extends through the foramen transversum, which may injure the vertebral artery.
Recommended orthotic
A cervicothoracic brace is recommended to limit neck flexion.
Type II
A type II fracture is fracture of the bilateral pars interarticularis with more than 3 mm of translation and more than 10 degrees of angulation. Also seen is anterior displacement of the C2 body with disruption and asymmetric widening of the C2–3 disc space. The posterior longitudinal ligament is disrupted, whereas the anterior longitudinal ligament usually remains intact. This is considered unstable.
Type IIA
Additional widening of the posterior C2–3 disk space occurs in a type IIA fracture.
Recommended orthotic
A halo vest should be worn for 3 months. Overdistraction must be avoided with type IIA fractures.
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