Article at spineuniverse.com

Thomas A. Zdeblick, M.D.
Professor and Chairman Orthopaedic Surgery
University of Wisconsin
Madison, WI, USA

The purpose of the brace is two-fold. Bracing helps to reduce acute pain by immobilizing the fracture. It also helps to reduce the eventual loss in height and in angulation from the fracture. Compression fractures treated in a brace tend to have less deformity than those treated without a brace. Occasionally, bracing beyond twelve weeks is indicated in those patients with severe osteoporosis.

Surgery
Percutaneous Vertebroplasty is a new surgical procedure that may be used to treat compression fractures. In this procedure, the physician or surgeon advanced a catheter into the compressed vertebra under an anesthetic. This catheter is then used to inject the fractured vertebrae with bone cement. This bone cement hardens within the fractured vertebrae and gives the initial stability to the vertebral body. This procedure may be indicated in cases of severe osteoporosis, severe pain or failure to heal following initial bracing.

Spinal surgery is rarely indicated for patients with compression fracture. Indications would include severe fracture with neurologic injury, severe angulation, failure to heal with initial bracing, increased angulation despite bracing or late increasing neuologic deficit.

Recovery Most patients can expect to make a full recovery from their compression fracture. Typically, braces are worn for six to twelve weeks followed by three to six weeks of physical therapy and exercise. This is to help regain strength of the trunk muscles and to increase endurance of the trunk musculature. Overall strength, aerobic capacity and flexibility are also helped by physical therapy.

Article at www.nlm.nih.gov/medlineplus

Treatment

Most compression fractures are found in elderly patients with osteoporosis. These fractures generally do not cause injury to the spinal cord. Treatment includes treating the osteoporosis with prescription medications and supplemental calcium.

Otherwise, these fractures are treated symptomatically with pain medicines. Some practitioners employ back braces, but these may weaken the bones more and predispose the patients to more fractures in the future.

Compression fractures almost always affect the T12 and L1 vertebrae together, as in an injury that occurs after jumping or falling from a height. In a compression fracture of the spine, the bone tissue of the vertebral body collapses into itself.

Because most compression fractures heal within 6 to 8 weeks with rest and pain relief, nonoperative treatment has remained the standard for many years. Treatment depends on the type, location, and exact nature of the injury. Some options include:

• the use of a body cast, when the fracture is somewhat stable in relation to the spinal cord, but must be immobilized in order to promote successful healing
• the use of a custom orthosis (brace), to stabilize spine during healing
• non-steroidal anti-inflammatory medication (such as Motrin, Advil or Nuprin), often in time-released form
• your physician may prescribe stronger medication, though the use of narcotics is generally avoided
• a course of rehabilitation based on successful modes of treatment, such as traction, ultrasound, electrical muscle stimulation, whirlpool, and so on, proven beneficial to patients with spinal injuries

Where surgery is indicated, as in the case of compression on the nerve roots or spinal cord, the surgeon has the opportunity to correct any changes in position of the vertebrae due to the injury or other deformity. Various types of instruments, such as pedicle screws or steel rods, are used to hold the bones in place. Follow your surgeonÕs directions carefully before and after any surgical procedure, keeping in mind that recovery depends not on surgery alone but also on commitment to the recovery process.

A rehabilitation program needs to be designed that includes exercise as soon as possible. Back muscles are just like other muscles adjacent to a fracture--they become weak and need exercise to regain previous strength.Ê Walking should be encouraged. Once the fracture has healed, a more vigorous program can be initiated to strengthen, stretch, and support the muscles of the mid-body.

People who have experienced a break in one of the bones of their spine, whether treated conservatively or with surgery, are advised to become knowledgeable about caring for their backs.Ê It is important to use proper lifting techniques, to practice a specific set of stretching and strengthening exercises as advised by a physical therapist, and to modify exercise and activities to protect the backbone.Ê All of these measures may significantly reduce the chance of repeated injury to the spine.

Results: In compression fractures, the results were found to be statistically insignificant when angle of kyphosis, vertebral index and height loss percentages were compared (p>0.05). Differences in angle of scoliosis and wedding index were statistically significant (p<0.05). Pain score had an average value of 1.66 while functional score was found to be 1.03.

TREATMENT ALTERNATIVES
...
Mild injuries such as some single column compression fracture usually don't require any stability augmentation and is frequently treated with bedrest and a lumbosacral corset for pain control.

ORTHOTIC STABILIZATION
The most recent developments occurred in the 1960s and 1970s and replaced the former steel and leather designs with aluminum and various thermoplastics. Regardless of the materials used to construct spinal orthoses, the indications for and usage of spinal orthoses is unchanged. Orthoses for spinal injury are designed to protect the spinal column from loads and stresses that cause progression of the angular and translational deformity from the injury.Ê

Current usage of spinal orthoses for thoracolumbar injuries depend on the amount of support or stabilization required and vary with injury. Mild injuries are at low risk of progression of injury and require minimally immobilizing orthoses only while the more severe injuries that have marginal stability yet do not require surgery, need orthoses that offer maximum stabilization and resistance to further progression of the deformity.Ê

BIOMECHANICS

Orthoses primarily function to augment biomechanical stability of a disrupted vertebral segment or segments. The most minimal of these functions is that of a limiter of gross trunk motion. Gross trunk motion is the movement and sway of the vertebral column during activities of normal daily living. Orthoses that primarily restrict gross trunk motion do not necessarily limit segmental motion but will minimally augment stability to the vertebral column by reducing overall bending moments on the lower spine by restricting bending and slouching. The next mechanism of orthotic stabilization is the reduction of inter-segmental motion. Inter-segmental motion is the motion that one vertebra exhibits that is relative to the vertebra that is just above and the vertebra just below. Orthoses that reduce segmental motion may be assumed to also reduce overall gross spinal motion. The third mechanism is that of `three-point' sagittal (side view) hyperextension. Biomechanical studies have defined the ability of various orthoses to limit overall gross and segmental motion of the spine.Ê

Stable thoracolumbar fractures without signs of neurologic compromise are usually treated nonoperatively with an orthosis that provides maximum sagittal hyperextension, while surgery is indicated in those fractures that are considered highly unstable. However, there appears to be considerable controversy in deciding which fractures have enough stability to be treated in an orthosis only and which need surgical stabilization.Ê

CLINICAL STUDIES
... White and Panjabi (1988) suggest reduction in a hyperextension cast for treatment of moderate to severe wedge compression fractures. These clinical studies of nonoperative treatment of thoracolumbar injuries are supported by the analytical work of Patwardhan et al (1990). The majority of single and two column Thoracolumbar spinal fractures without neurolgic deficit can be treated in a brace with good result. The brace must be fabricated and fitted properly thus providing measurable hyperextension and immobilize the spine three-dimensionally.

MECHANISM OF ORTHOTIC TREATMENT

White and Panjabi (1990) reported that single column compression fractures with loss of one-third or less anterior height can be treated with active exercise and mobilization after a period of bed rest to allow acute symptoms to subside and to permit any slow elastic recoil. These fractures are usually stable and do not require an orthosis to improve stability, however a lumbosacral corset (Figure 1A) may be worn to reduce gross trunk motion for pain management. For nonoperative management of the more severe compression fracture, an orthosis must not only reduce gross trunk motion but also must reduce segmental motion at the injured segment and provide sagittal plane hyperextension. The Jewett hyperextension orthosis (Figure 1B) has long been the standard orthosis for this treatment although in recent years the Cash orthosis (Figure 1C) has been an acceptable alternative. Whereas the Jewett and Cash orthosis function well on the sagittal plane, they both lack the ability to decrease motion on the coronal and transverse planes. To treat the severe compression fracture that is at the uppermost limit of nonoperative treatment, the orthosis must provide sagittal three point hyperextension, as well as reduce gross trunk and segmental motion on all three planes. This is best accomplished with a custom molded TLSO (Thoraco-lumbar Sacral Orthosis) , fitted in hyperextension (Figure 1D). For nonoperative stabilization of compression fractures the optimal orthosis will provide measurable extension at the injured segment on the lateral radiograph as shown in Figures 2A&B. Patient restriction is suggested to be orthosis wear during waking hours, minimal lifting, no running and no sports while the injury restores itself to normal strength.

See: Journal of Rehabilitation Research and Development Plattner Orthopedic Co TLSO (http://www.plattners.com/tlso.htm)

... When using an orthosis for nonoperative treatment of spinal injury the criteria for orthosis selection should be based on biomechanical deficit and the vulnerability of deformity progression. If at anytime during the nonoperative treatment the deformity shows progression, the decision to proceed with this modality should be reevaluated so the patient is not put at risk of neurologic deficit. The most ideal orthosis will not function well if it is not worn properly or at all. Patient compliance is essential for the success of this treatment.Ê

Proper decision making for the selection of a spinal orthosis for thoracolumbar injury treatment is a combination of sound biomechanical mechanism of action, clinical intuition and patient subjectivity. Over treating or under treating an injury with an orthosis can lead to detrimental results. Following established criteria for selection of an orthosis and informing the patient as to the consequences of non compliance will more frequently than not yield the best result. If there is any question of spinal injury, consult your physician immediately.Ê

SUGGESTED REFERENCES

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Discussion
Thoraco-lumbar fractures are a major cause of disability (1). Ninety percent of all spinal fractures are in the thoraco-lumbar region. Fractures at the thoraco-lumbar junction have a significant incidence of neurologic deficit of up to 40% in one series (2). Several factors contribute to thoraco-lumbar vulnerability.
a. In the lumbar spine , there are no ribs to provide additional stability as in the thoracic region (3).
b. The alignment of the spine changes from a kyphotic curvature in the thorax to a lordotic alignment in the lumbar spine (4).
c. Lumbar spinal segments are more mobile than thoracic segments. The mobility is due in part to the changing orientation of the facet joints. The coronal orientation of the facets in thoracic region is more stable then the oblique orientation of the lumbar region.

The Three Column Concept
The management and outcome of lumbosacral spine injuries largely depend upon the stability of the spinal column. There are different models to describe the stability following an injury. The three-column concept described by Denis (5,6) in 1983 is the most accepted.

Fig. 1

1. The anterior column consists of the anterior longitudinal ligament and the anterior part of the vertebral body.
2. The middle column extends from the middle portion of the vertebral body to the posterior aspect of the vertebral body and includes the posterior longitudinal ligament.
3. The posterior column includes all bony and ligamentous structures posterior to the posterior longitudinal ligament and includes the pedicles, facets, spinous processes and all associated ligaments.

Types of Thoraco-lumbar Fractures Thoraco-lumbar fractures and dislocations have been classified by different investigators (1,4). However, no one classification system is inclusive of all injury patterns. Currently the classification described by McAfee, et al. (7), is the most widely recognized. Their TLS injury scheme consists of five distinctive injury patterns: wedge compression fractures, burst fractures, Chance fractures, flexion-distraction injuries and translational injuries (see Fig 2). In recent years, the increased use of magnetic resonance imaging (MRI) and helical CT scanning has led to improvements in classifying TLS injuries.

View TLS injury types: Fig2

1. Wedge compression fractures are the most common type of lumbar fracture (4). They occur during hyperflexion and axial loading (as was likely in our case). The vertebral body fails under a compressive load and its anterior portion becomes compressed while the middle column remains intact. This fracture is rarely associated with neural injury unless multiple adjacent vertebral bodies are compressed. Radiographically, the wedge deformity is best appreciated on the lateral view. A CT scan is used to confirm that the posterior vertebral body, pedicles and lamina are intact.

2. A burst fracture ...

3. A Chance fracture is commonly associated with lap seat belt use in high-speed motor vehicle crashes. ...

4. A flexion distraction injury is one in which the axis of flexion is posterior to the anterior spinal longitudinal ligament. ...Typically, these injuries involve both ligamentous and bony structures and can extend over more than one vertebral level. These injuries are considered unstable because the middle column and often the posterior column are disrupted.

5. Translational injuries are associated with shearing forces that disrupt all three columns.

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