Indications for Spinal Orthoses
Spinal orthoses are indicated for specific conditions, but evidence suggests they may not be necessary in all cases traditionally thought to benefit from bracing, particularly in neurologically intact patients with thoracolumbar burst fractures.
Thoracolumbar Fractures
Neurologically Intact Patients
- For neurologically intact patients with thoracic or lumbar burst fractures, management either with or without an external brace is equally effective 1
- High-quality evidence from randomized controlled trials shows no difference in final clinical and radiographic outcomes between patients treated with an external brace versus no brace 1
- Meta-analysis demonstrates that orthosis adds no benefit in conservative treatment of acute thoracolumbar fractures and actually increases hospital length of stay by approximately 3.5 days 2
Biomechanical Considerations
- For single-level injuries with up to 50% loss of segmental stiffness, orthoses can restore normal resistance to deformity 3
- For injuries with 50-85% loss of stiffness (severe two-column disruptions), orthoses may help only with restricted activity levels 3
- For injuries with greater than 85% loss of segmental stiffness (three-column injuries), orthoses alone are ineffective in preventing deformity progression 3
Osteoporotic Vertebral Fractures
- Spinal orthoses are indicated for elderly patients (≥60 years) with osteoporotic vertebral compression fractures 4
- Benefits include:
- Improved biomechanical vertebral stability
- Reduced kyphotic deformity
- Enhanced postural stability
- Greater muscular strength
- Superior functional outcomes 4
Low Back Pain Management
Acute/Subacute Low Back Pain
- Short-term use (1-3 weeks) of rigid lumbar support is indicated for low back pain of relatively short duration (<6 months) 1
- For patients with subacute pain (<6 months), lumbar supports can reduce pain scores, decrease medication usage, and improve functional disability at 30-90 days 1
Chronic Low Back Pain
- Not recommended for chronic low back pain (>6 months) due to lack of evidence for long-term benefit 1
Occupational Use
- Not recommended for primary prevention of low back pain in the general working population 1
- Recommended for secondary prevention in workers with a history of low back pain, as it reduces the number of days of self-reported low back pain and days lost to work 1
Post-Surgical Applications
- Not supported following instrumented posterolateral lumbar fusion for lumbar spondylosis due to equivalent outcomes with and without bracing 1
- Widespread use continues despite lack of consistent evidence to support or refute the practice 5, 6
Preoperative Evaluation
- Not recommended as a preoperative diagnostic tool to predict outcomes following lumbar fusion surgery 1
Common Pitfalls and Considerations
Overuse in neurologically intact fracture patients: Evidence clearly shows equivalent outcomes with or without bracing for neurologically intact thoracolumbar burst fractures 1
Prolonged use leading to muscle atrophy: Critics argue that braces may provide a false sense of support or allow muscles to atrophy, potentially increasing injury risk upon discontinuation 1
Limited efficacy in severe injuries: Orthoses alone are ineffective for three-column injuries with >85% loss of segmental stiffness 3
Compliance issues: Studies show compliance rates as low as 42% in some populations 1
Increased hospital stays: Meta-analysis shows orthosis use increases mean admission time by 3.47 days 2
The decision to use an external brace should be based on specific clinical scenarios, with recognition that in many cases traditionally treated with bracing, outcomes may be equivalent without the use of orthoses.