TLSO Brace Candidacy for Thoracolumbar Spine Injuries
TLSO braces are indicated for neurologically intact patients with stable thoracolumbar burst fractures (T11-L3), though bracing is optional as outcomes are equivalent to no bracing, making the decision physician-dependent based on patient preference and clinical judgment. 1
Primary Indications
Stable Thoracolumbar Burst Fractures
- Neurologically intact patients with AO Type A3 burst fractures between T11-L3 are the classic candidates for TLSO consideration 1, 2
- Fractures must demonstrate intact posterior ligamentous complex (no posterior column disruption) 3
- Initial kyphotic deformity should be less than 35 degrees 2
- Patients should be skeletally mature and under 60 years of age 2
- Admission within 72 hours of injury is typical for conservative management protocols 2
Key Clinical Decision Point
The American Association of Neurological Surgeons provides a Grade B recommendation that management with or without external bracing produces equivalent outcomes—the decision is at the treating physician's discretion. 1, 4
Evidence Against Routine Bracing
Equivalent Outcomes Demonstrated
- Level I randomized controlled trial evidence shows no difference in pain, disability, or radiographic outcomes between braced and non-braced patients at 6 months 1, 5
- Meta-analysis confirms no significant differences in Roland Morris Disability Questionnaire scores, Oswestry Disability Index, SF-36 scores, pain levels, or kyphotic progression at both short-term and long-term (≥5 years) follow-up 6
- Hospital length of stay is significantly shorter in non-braced patients (mean 2.8 days vs 6.3 days with TLSO) 5
Fracture Stability Rationale
- Thoracolumbar burst fractures without posterior ligamentous complex injury are inherently stable and may not require external support 2
- CT follow-up demonstrates significant resorption of retropulsed bone occurs naturally without bracing 3
When TLSO Is Reasonable to Use
Patient-Specific Factors Favoring Bracing
- Patient anxiety or preference for external support during healing 1
- Concerns about maintaining spinal precautions without external reminder
- Concomitant lower extremity fractures that may complicate early mobilization (though these patients still achieve independent ambulation, just requiring more physical therapy sessions) 7
- Occupational demands requiring earlier return to modified activities
Bracing Protocol When Used
- Custom-molded TLSO typically arrives within 2 days of admission 7
- Patients begin weaning at 8 weeks over a 2-week period 2
- Early mobilization is encouraged even with brace, maintaining neutral spinal alignment 2
- Most patients achieve independent ambulation after 1-2 physical therapy sessions 7
Absolute Contraindications to Conservative Management (Requiring Surgery, Not TLSO)
Unstable Fracture Patterns
- Significant vertebral collapse, angulation, or canal compromise 1
- Any neurological deficit present 1, 2
- Posterior ligamentous complex disruption (posterior column injury) 3
- Fractures with TLICS score >4 suggesting instability 1
- Evidence of shear, rotation, or translational injury components 1
Common Pitfalls to Avoid
- Do not assume bracing is mandatory—high-quality evidence supports early mobilization without orthosis as equally effective 1, 6
- Do not prolong hospitalization solely for brace fitting—non-braced patients have shorter stays without worse outcomes 5
- Do not order TLSO for patients with neurological deficits—these require surgical evaluation 1
- Do not use bracing as substitute for proper patient selection—ensure posterior column integrity before any conservative approach 3
Practical Implementation
For Non-Braced Approach
- Educate patients on neutral spinal alignment maintenance for 8 weeks 2
- Initiate physical therapy within 4 days of admission 7
- Most patients discharge home the same day they clear PT for independent ambulation 7
- Follow-up radiographs at 6 weeks and cessation of activity restrictions 8