SPINAL ORTHOTICS

SPINAL ORTHOTICS Allen S. Edmonson, M.D. T h e r e a r e a t least t w o pertinent q u e s t i o n s w h i c h c a n s e r v e a s a n i n t r o d u c t i o n to this topic. First, is it p o s s i b l e to a c t u a l l y i m m o b i ­ lize the s p i n e with a n o r t h o s i s that the p a ­ tient c a n t o l e r a t e ? S e c o n d , in a t t e m p t i n g t o i m m o b i l i z e the s p i n e with a n o r t h o t i c d e v i c e , c a n the n o r m a l differences in p o s t u r e of the s p i n e f r o m s t a n d i n g to sitting b e a c c o m o d a t ­ e d in the fit? W e s h o u l d c o n t i n u e to a s k m o r e q u e s t i o n s t h a n w e a n s w e r , c h o o s e s o m e of the better o n e s a n d get o n w i t h it. K e e p i n g these q u e s t i o n s in m i n d , w e will l o o k at s p i n a l o r t h o s e s of t w o b a s i c t y p e s : 1) t h o s e for general i m m o b i l i z a t i o n of the s p i n e a n d 2) those w h i c h h a v e s p e c i a l i z e d g o a l s . By g e n e r a l i m m o b i l i z a t i o n , I m e a n the or­ t h o s e s for p a i n f u l b a c k s , p o s t o p e r a t i v e or­ thoses a n d postinjury orthoses. Under ortho­ ses for s p e c i a l i z e d g o a l s , w e will d i s c u s s t h o s e c o n c e r n e d with specific p r o b l e m s s u c h a s s c o l i o s i s , k y p h o s i s a n d s p i n a l c o r d injur­ ies.

Fig.

1A:

S p i n a l o r t h o s e s g e n e r a l l y a r e classified a c ­ c o r d i n g to the a n a t o m i c a l a r e a s to w h i c h they a r e a p p l i e d . W e will d i s c u s s them u n d e r cervical, t h o r a c i c , t h o r a c o l u m b a r a n d l u m ­ b o s a c r a l ( a n d I a m a w a r e of C T L S O ) . T h e p r e s e n t a t i o n of e a c h a r e a will b e b r o k e n d o w n into o r t h o s e s w h i c h a r e n o w a v a i l a b l e a n d o r t h o s e s for f u t u r e n e e d s . F o r t h o s e n o w a v a i l a b l e , w e will a s k w h a t they a c t u a l l y a c ­ c o m p l i s h a n d if there a r e deficiencies.

ORTHOSES N O W AVAILABLE FOR THE CERVICAL SPINE B e g i n n i n g at the t o p with cervical o r t h o ­ ses, t h o s e w h i c h a r e n o w a v a i l a b l e a r e of s e v e r a l t y p e s : the v a r i o u s t y p e s of c o l l a r s i n c l u d i n g the f u l l - m o l d e d p l a s t i c c o l l a r s , the f o u r - p o s t e r s , the t w o - p o s t e r s , the S O M I ' s a n d , b y e x t e n d i n g the definition of o r t h o s e s , the h a l o j a c k e t a n d h a l o c a s t . C o l l a r s (Figs. 1 A - B ) h a v e b e e n u s e d for a long time a n d can be r e a s o n a b l y comfort-

Soft collar (foam) a n d B: H a r d collar (polyethylene). (From

A c a d e m y of O r t h o p a e d i c S u r g e o n s : Atlas of Orthotics: Biomechanical and Application, S t . L o u i s : T h e C . V . M o s b y C o . , 1 9 7 5 , p . 3 6 1 . )

American

Principles

Fig. 2: Four-poster orthosis in A: flexion and B: extension. (From American Academy of Orthopaedic Surgeons: Atlas of Orthotics: Biomechanical Principles and Applica­ tion, St. Louis: The C . v. M o s b y C o . , 1975, p. 362.)

Fig. 3: Custom-molded orthosis. (From American Academy of Orthopaedic Surgeons: Atlas of Or­ thotics: Biomechanical Principles and Applica­ tion, St. Louis: The C . V . Mosby C o . , 1975, p. 363.)

a b l e . T h e y limit either flexion or e x t e n s i o n a n d c a n b e d e s i g n e d o r a d j u s t e d to d o o n e or b o t h , b u t they don't i m m o b i l i z e . T h e y d o v e r y little to limit r o t a t i o n . T h e y a r e r e m o v ­ a b l e b y the p a t i e n t for c o m f o r t a n d for hy­ giene. T h e f o u r - p o s t e r b r a c e (Fig. 2 ) , a n d s o m e better t w o - p o s t e r b r a c e s , a r e m o r e c o m p l i ­ c a t e d d e v i c e s w h i c h g e n e r a l l y g i v e better c o n t r o l of the h e a d w i t h l i m i t a t i o n of r o t a ­ tion. W h e n fitted tightly a g a i n s t the chin a n d o c c i p u t , they a r e relatively u n c o m f o r t a b l e for the p a t i e n t a n d m a n y r e q u i r e f r e q u e n t re­ alignment. T h e S O M I brace also accom­ plishes the s a m e function a n d is p o s s i b l y a little m o r e c o m f o r t a b l e , b u t like the o t h e r s is r e m o v a b l e b y the p a t i e n t . In g e n e r a l , the ef­ ficiency of this g r o u p of b r a c e s is directly re­ l a t e d to the a m o u n t of c h i n - o c c i p u t p r e s s u r e for w h i c h they a r e fitted. O f the r e m o v a b l e c o l l a r s , the P h i l a d e l p h i a or m o l d e d o r t h o s i s (Fig. 3) w h i c h e n c l o s e s the neck, chin, o c c i p u t a n d b a s e of the n e c k is p r o b a b l y the m o s t efficient. It g i v e s better l i m i t a t i o n of r o t a t i o n c o m b i n e d with limita­ tion of flexion a n d e x t e n s i o n than the o r d i ­ n a r y c o l l a r s . It c a n b e m a d e r e a s o n a b l y c o m ­ fortable.

Fig. 4: Halo cast.

T h e o n l y o r t h o s i s , if I m a y call it that, w h i c h c o m e s c l o s e to the theoretical "total i m m o b i l i z a t i o n " is the h a l o c a s t (Fig. 4 ) . T h e h e a d is rigidly held b y the h a l o w h i c h is a t ­ t a c h e d t o a s n u g c a s t o n the t o r s o . It o b v i ­ o u s l y d o e s n o t "totally i m m o b i l i z e " the cer­ v i c a l s p i n e , b u t is v e r y efficient. T h e r e m o v a b l e h a l o j a c k e t (Fig. 5) w h i c h is b e i n g m a r k e t e d , a n d w i t h w h i c h I h a v e h a d n o first h a n d e x p e r i e n c e , at least p o t e n ­ tially c a n b e h a r m f u l . If b y a p p l y i n g a h a l o to the s k u l l , y o u i m p l y that the i n s t a b i l i t y of the c e r v i c a l s p i n e is s i g n i f i c a n t , then a n effi­ cient i m m o b i l i z a t i o n d e v i c e is n e e d e d . T h e h a l o j a c k e t s y s t e m a l l o w s the p o s s i b i l i t y of l o o s e n i n g o r p a r t i a l r e m o v a l of the j a c k e t b y the p a t i e n t a n d d a n g e r o u s a l t e r a t i o n of p o s i ­ tion of the h e a d . T h e l o n g lever a r m a t t a c h e d r i g i d l y t o the h e a d j u s t a b o v e the s p i n a l in-

Fig. 5: Halo-vest assembly (halo jacket). (From brochure on "Halo Traction Equipment," Ace Orthopedic C o . , Hawthorne, California.)

s t a b i l i t y , w o u l d s e e m to a n d s t r e s s to the u n s t a b l e an empiric concern, and I w h e t h e r it h a s p r o v e n to s o m e of the p a r t i c i p a n t s c a n s h e d light o n this.

m a g n i f y the risk s e g m e n t s . T h i s is don't r e a l l y k n o w be real. Perhaps, of this w o r k s h o p

F u t u r e N e e d s in the C e r v i c a l A r e a F r o m the p h y s i c i a n ' s s t a n d p o i n t , I w o u l d like to s e e a m e t h o d of i m m o b i l i z a t i o n of flexion, e x t e n s i o n a n d r o t a t i o n w i t h o u t s k u l l p e n e t r a t i o n . F r o m the p a t i e n t ' s s t a n d p o i n t , three q u a l i f i c a t i o n s s h o u l d b e met: 1) the o r ­ t h o s i s s h o u l d b e r e a s o n a b l y c o m f o r t a b l e , 2) the p a t i e n t s h o u l d h a v e the a b i l i t y to conti­ n u e his o c c u p a t i o n , a n d 3) the p a t i e n t s h o u l d have reasonable ability to remain clean.

Fig. 6A: Jewett Brace—front.

Fig. 6B: Jewett Brace—side.

ORTHOSES NOW AVAILABLE FOR THE THORACIC AND THORACOLUMBAR SPINE

Fig. 6C: Jewett Brace—rear.

I will d i s c u s s these together. W e h a v e three b a s i c t y p e s : 1) the Jewett (Figs. 6 A - C ) , w h i c h p r e v e n t s flexion p r i m a r i l y in the tho­ r a c o l u m b a r a r e a , 2) the l o n g T a y l o r (Figs. 7 A - C ) , w h i c h is r e a s o n a b l y efficient in p r e ­ v e n t i n g flexion, e x t e n s i o n a n d lateral m o ­ tion, a n d 3) the c o w - h o r n b r a c e , w h i c h a c ­ c o m p l i s h e s m u c h the s a m e . T h e r e a r e b a s i c deficiencies in o r t h o s e s for the t h o r a c i c s p i n e in that u n l e s s a cervical o r t h o s i s is a t t a c h e d rigidly, there is little s u p p o r t or i m m o b i l i z a ­ tion a b o v e 1-7 or T - 8 . T h e o r t h o s e s w h i c h a r e d e s i g n e d to limit flexion a r e r e a s o n a b l y efficient w h e n p r o p e r l y fitted. L o n g T a y l o r o r t h o s e s c a n s u p p o r t the s p i n e in e x t e n s i o n a l s o but a r e efficient o n l y w h e n v e r y tightly a p p l i e d a r o u n d the s h o u l d e r s a n d the a x i l l a e .

Fig. 7A: Long Taylor Brace—front.

Fig. 7B: Long Taylor Brace—side.

F u t u r e N e e d s in the T h o r a c i c a n d Thoracolumbar Area F u t u r e n e e d s for the p h y s i c i a n a r e : 1) bet­ ter m e t h o d s of i m m o b i l i z a t i o n of the u p p e r half of the t h o r a c i c s p i n e , a n d 2) s o m e m e a n s of m a i n t a i n i n g i m m o b i l i z a t i o n a n d s u p p o r t w h i l e a l l o w i n g c h a n g e s in p o s t u r e f r o m s t a n d i n g to sitting. A g a i n , the p a t i e n t is l o o k i n g for r e a s o n a b l e c o m f o r t , the a b i l i t y to c o n t i n u e his w o r k a n d r e a s o n a b l e m e a n s of m a i n t a i n i n g g o o d h y g i e n e .

LUMBOSACRAL ORTHOSES PRESENTLY AVAILABLE

Fig. 7C: Long Taylor Brace—rear.

I h a v e g r o u p e d these since a g o o d o r t h o s i s for the l u m b a r s p i n e w h i c h d o e s not i n c l u d e the p e l v i s p r o b a b l y doesn't exist. T h e r e a r e at least three g e n e r a l t y p e s : 1) the K n i g h t , c h a i r b a c k o r l o w T a y l o r t y p e , 2) the Wil­ liam's flexion b r a c e a n d 3) the rigid m o l d e d p l a s t i c j a c k e t s , m a n y of w h i c h a r e flexion jackets. T h e Knight (Figs. 8 A - C ) , chairback o r l o w T a y l o r b r a c e d o e s a r e a s o n a b l e j o b of

Fig. 8A: Knight Brace—front.

Fig. 8B: Knight Brace—side.

Fig. 8C: Knight Brace—rear.

Fig. 9A: Williams Brace—front.

Fig. 9B: Williams Brace—side.

Fig. 9C: Williams Brace—rear.

limiting flexion a n d e x t e n s i o n a s well a s lat­ eral b e n d i n g . T h e W i l l i a m s ( F i g s . 9 A - C ) flex­ i o n b r a c e limits e x t e n s i o n a n d t e n d s to m a i n ­ tain a p o s t u r e of slight flexion. T h e rigid molded plastic orthoses (Figs. 1 0 A - D ) , espe­ cially t h o s e with i n f l a t a b l e p a d s a n d t h o s e with a c o m p r e s s i b l e lining p r o b a b l y a r e the m o s t efficient t o w a r d a g o a l of i m m o b i l i z i n g the l u m b a r a n d l u m b o s a c r a l s p i n e in all p l a n e s . A b d o m i n a l p r e s s u r e t e n d s to u n l o a d the s p i n e a n d , a p p a r e n t l y , is a significant p a r t in the i n c r e a s e d efficiency o f this t y p e o f o r t h o s i s . Its chief d r a w b a c k is that these rigid orthoses are frequently uncomfortable w h e n fitted l o w e n o u g h a r o u n d the p e l v i s a n d t r o c h a n t e r s a n d high e n o u g h a r o u n d the r i b s . M a n y a d u l t s c a n n o t t o l e r a t e this f o r a significant p e r i o d of a c t i v i t y . F o r m o s t effi­ cient w e a r i n g , a c u s t o m - m a d e a p p l i a n c e is p r o b a b l y necessary. There should be s o m e d e b a t e o n this p o i n t .

sis to a c c o m p l i s h the efficient i m m o b i l i z a ­ tion of the r i g i d j a c k e t w i t h the a b d o m i n a l p r e s s u r e to u n l o a d the s p i n e a n d p r o d u c e m i n i m a l d i s c o m f o r t s o that the o r t h o s i s c a n b e w o r n d u r i n g the e n t i r e w o r k i n g p e r i o d .

F u t u r e N e e d s in the L u m b o s a c r a l A r e a A s f o r the f u t u r e , I'd like to h a v e a n o r t h o -

ORTHOSES FOR SPECIAL G O A L S W e n o w m o v e o n to o r t h o s e s f o r these s p e c i a l g o a l s : t r e a t m e n t of s c o l i o s i s , k y p h o ­ sis a n d s p i n a l c o r d i n j u r y .

ORTHOSES FOR SCOLIOSIS T h e orthoses n o w a v a i l a b l e for scoliosis i n c l u d e the s t a n d a r d M i l w a u k e e b r a c e a n d a n u m b e r of " u n d e r a r m " o r t h o s e s a n d rigid j a c k e t s f o r the t r u n k . T h e s e u n d e r a r m j a c k ­ ets a n d b r a c e s i n c l u d e the rigid L e x a n j a c k e t f r o m P a s a d e n a , the o r t h o p l a s t j a c k e t f r o m the d u P o n t Institute in W i l m i n g t o n a n d the B o s t o n p r e f a b r i c a t e d s y s t e m . All a r e d e ­ s i g n e d to treat a l a t e r a l d e f o r m i t y of the s p i n e in g r o w i n g c h i l d r e n .

Fig. 10A: R i g i d m o l d e d p l a s t i c o r t h o s i s w i t h in­ flatable pads—front.

F i g . 10B: R i g i d m o l d e d p l a s t i c o r t h o s i s w i t h flatable p a d s — s i d e .

F i g . 10C: R i g i d m o l d e d p l a s t i c o r t h o s i s w i t h in­ flatable p a d s — r e a r .

F i g . 10D: I n t e r i o r v i e w s h o w i n g i n f l a t a b l e p a d s .

in­

Fig. 11A: Underarm prefabricated orthoses for scoliosis. Lumbar lordosis is also controlled— front.

Fig. 11B: Underarm prefabricated orthoses for scoliosis. Lumbar lordosis is also controlled— side.

The Milwaukee brace, which produced i m p r o v e m e n t b e l i e v e d to b e p e r m a n e n t in the l u m b a r , t h o r a c o l u m b a r a n d t h o r a c i c c u r v e s b u t not in u p p e r t h o r a c i c c u r v e s , is n o w b e i n g seen in a little different light. S e r ­ ies of p a r e n t s f r o m b o t h M i n n e a p o l i s a n d f r o m M i l w a u k e e i n d i c a t e that m o s t of the " p e r m a n e n t " c o r r e c t i o n is e v e n t u a l l y lost ev­ en t h o u g h there a r e o b v i o u s s p e c t a c u l a r ex­ ceptions. The Lexan jacket from P a s a d e n a a n d the o r t h o p l a s t j a c k e t f r o m W i l m i n g t o n a l s o s e e m to b e " h o l d i n g devices" for s t o p ­ p i n g p r o g r e s s i o n of s c o l i o t i c c u r v e s in g r o w ­ ing children a n d s e e m to offer little h o p e for a c t u a l i m p r o v e m e n t of the s c o l i o s i s . T h e verdict is not yet in o n the B o s t o n or­ thosis (F igs . 1 1 A - B a n d 1 2 A - C ) a s for a s " p e r m a n e n t i m p r o v e m e n t " is c o n c e r n e d . A f t e r o n l y a few y e a r s of u s a g e , it s e e m s to b e v e r y efficient in treating l u m b a r a n d t h o r a c o l u m ­ b a r c u r v e s a n d m a y p r o v e s a t i s f a c t o r y in t h o r a c i c c u r v e s a l t h o u g h this is still not yet d e t e r m i n e d . T h i s o r t h o s i s p r o v i d e s v e r y rig­ id i m m o b i l i z a t i o n of the l u m b a r a n d t h o r a ­ c o l u m b a r s p i n e , b u t a s I see it, d o e s not al-

Fig. 12A: Nine-year-old male with left lumbar curve of 32 degrees.

Fig. 12B: With plastic orthosis applied, curve measures 7 degrees.

Fig. 12C: Lateral view shows almost complete flattening of the lumbar lordosis.

l o w the s a m e f r e e d o m of a c t i v i t y of the t r u n k a s the s t a n d a r d M i l w a u k e e . W h e t h e r o r n o t this will m a k e a difference in the l o n g t e r m r e s u l t s will n o t b e d e t e r m i n e d f o r a n ­ other 1 0 to 1 5 y e a r s . P r e f a b r i c a t e d p l a s t i c g i r d l e s (Fig. 1 3 A ) of s e v e r a l t y p e s a r e a v a i l ­ a b l e . In the B o s t o n s y s t e m (Figs. 1 4 A - C ) , the b l a n k f o r the g i r d l e is c o n s t r u c t e d s o that the m a j o r p o r t i o n of the u n d e r a r m o r t h o s i s is also prefabricated. A s f o r the f u t u r e n e e d s f o r o r t h o s e s for s c o l i o s i s , w e a r e still l o o k i n g for p r o d u c t i o n of p e r m a n e n t i m p r o v e m e n t in the s c o l i o s i s a n d p e r m a n e n t i m p r o v e m e n t w i t h the least restriction of t r u n k a n d total b o d y a c t i v i t y . R e m o v a l f o r t r u n k e x e r c i s e s s e e m s to b e im­ p o r t a n t . T h e p a t i e n t a g a i n is l o o k i n g f o r c o s ­ metic acceptance, g o o d hygiene a n d minimal restriction in a c t i v i t y . T h e c o s m e t i c a d v a n ­ t a g e s of the u n d e r a r m b r a c e a r e o b v i o u s to e v e r y o n e . If t h e y l i v e u p to their p r o m i s e , they m a y well b e a g r e a t s t e p f o r w a r d in or­ thoses for scoliosis. Wally Blount has p o i n t e d o u t r e p e a t e d l y f o r m a n y y e a r s that u n d e r a r m b r a c e s w e r e n o t effective in c o n ­ trolling o r i m p r o v i n g s c o l i o s i s .

Fig. 13A: Milwaukee brace with prefabricated plastic girdle.

Fig. 13B: "Fixed" l u m b a r pad.

Fig. 14B. B l a n k s for prefabricated plastic girdles.

Fig- 14A: B l a n k s for prefabricated plastic girdles.

Fig. 14C: A n o t h e r b l a n k for a prefabricated plas­ tic girdle.

Fig. 15: Milwaukee brace principle for kyphosis bracing. (From Blount, Walter P., and Moe, John H.: The Milwaukee Brace. Baltimore: The Williams and Wilkins C o . , 1973, p. 74.) ORTHOSES FORKYPHOSIS M o v i n g o n to k y p h o s i s b r a c e s , the o n e s n o w a v a i l a v l e a r e t w o t y p e s : 1) the s t a n d a r d M i l w a u k e e b r a c e a n d 2) the u n d e r a r m b r a c e s e m p l o y i n g the flexion o r a n t i g r a v i t y princi­ ple. T h e r e is n o q u e s t i o n b u t that the full M i l w a u k e e b r a c e (Fig. 15) with c o n t r o l of the h e a d a n d n e c k a n d the u p p e r p o r t i o n of the t h o r a c i c s p i n e is far m o r e efficient than a n y of the u n d e r a r m or a n t i g r a v i t y t y p e b r a c e s . T h e m o l d e d p r e f a b r i c a t e d p e l v i c gir­ d l e w h i c h is v e r y efficient in flattening the l u m b a r l o r d o s i s , a d d e d to the r e g u l a r Mil­ w a u k e e s u p e r s t r u c t u r e b e c o m e s the m o s t ef­ ficient o r t h o s i s for k y p h o s i s to m y k n o w l ­ e d g e . A g a i n , a s for s c o l i o s i s , for the future w e n e e d a n o r t h o s i s to p r o d u c e p e r m a n e n t i m p r o v e m e n t a n d restrict the a c t i v i t y of the t r u n k a n d the p a t i e n t a s little a s p o s s i b l e . In addition, we must have cosmetic appear­ a n c e . A g a i n a l s o , the g r e a t e r c o s m e t i c a c ­ c e p t a n c e of the u n d e r a r m b r a c e s is o b v i o u s a n d w o u l d s e e m to b e the d i r e c t i o n for f u t u r e development.

O R T H O S E S FOR S P I N A L C O R D INJURY T h e last a r e a to b e c o v e r e d is that of or­ t h o s e s for a d u l t s with spinal c o r d i n j u r y . I k n o w of n o s u i t a b l e o r t h o s i s for the q u a d r i ­ plegic w h i c h c a n be u s e d for o t h e r than v e r y

s h o r t p e r i o d s of time. T h i s includes o r t h o s e s s i m i l a r to l o n g T a y l o r s , m o l d e d p l a s t i c jack­ ets a n d s o o n . T h e c o m b i n a t i o n of a c o l l a p s ­ ing p a r a l y t i c s p i n e a n d insensitive skin is for­ m i d a b l e . F o r a p a r a p l e g i c w i t h l o w level a n d p r o t e c t i v e s e n s a t i o n o v e r the l o w e r a b d o ­ m e n , a n d in the f o r t u n a t e patient w i t h s e n s a ­ tion a r o u n d the iliac crest, m o s t of the t h o r a ­ c o l u m b a r or l u m b o s a c r a l o r t h o s e s c a n b e u s e d . P r o b a b l y the m o s t f r e q u e n t l y u s e d is the Jewett t y p e of e x t e n s i o n o r t h o s i s w h i c h d o e s not d e p e n d o n p r e s s u r e a r o u n d the crest of the ilium or o v e r the s a c r u m . W h i l e it is certainly true that a l o n g s p i n e f u s i o n w i t h internal fixation will p r o v i d e the best p e r m a n e n t s t a b i l i t y for the s p i n e of a s p i n a l c o r d i n j u r y p a t i e n t , a d r e a m for the f u t u r e in o r t h o t i c s is a spinal o r t h o s i s with a p r e s s u r e fit a r o u n d the p e l v i s a n d the t h o r a x sufficient to s u p p o r t the s p i n e w i t h o u t p r o ­ d u c i n g skin n e c r o s i s . I n c l u d e d in this m u s t b e a fit a r o u n d the a b d o m e n w h i c h d o e s not inhibit or restrict r e s p i r a t i o n to a n y signifi­ c a n t d e g r e e . F o r p a t i e n t s w i t h high level spi­ nal c o r d i n j u r y , a shell t y p e m o d i f i c a t i o n of the s e a t i n g d e v i c e m a y b e the o n l y r e a s o n ­ able answer. T h e s e c o m m e n t s s h o u l d s e r v e a s a n intro­ d u c t i o n a n d w i t h o u t q u e s t i o n a r e not all in­ c l u s i v e . T h e "big picture" a s I h a v e p r e s e n t e d it will u n d o u b t e d l y l o o k different to m a n y of y o u . P e r h a p s , the w o r k s h o p will get us into the p l a n n i n g or p o s s i b l y s k e t c h i n g s t a g e of a new big picture.