Back Brace for Compression Fracture
Direct Recommendation
For thoracolumbar compression fractures in neurologically intact patients, bracing with a TLSO is optional—high-quality evidence demonstrates that braced and non-braced management produce equivalent long-term outcomes, making the decision physician discretion based on patient comfort and early pain control needs. 1
Evidence-Based Decision Algorithm
Step 1: Determine Fracture Stability and Neurological Status
Absolute contraindications to conservative management (brace or no brace):
- Any neurological deficit present 1
- Significant vertebral collapse, angulation, or canal compromise 1
- TLICS score >4 suggesting instability 1
- Evidence of shear, rotation, or translational injury components 1
These patients require surgical evaluation, not bracing.
Step 2: For Stable Fractures Without Neurological Deficit
The American Association of Neurological Surgeons provides Grade B recommendation that management with or without external bracing produces equivalent outcomes. 1 This is supported by Level I randomized controlled trial evidence showing no difference in pain, disability, or radiographic outcomes between braced and non-braced patients at 6 months. 1
Step 3: If Choosing to Brace
Rigid bracing (TLSO) provides short-term pain reduction:
- Moderate quality evidence shows rigid bracing decreases pain up to 3-6 months post-injury compared to no brace (SMD = -1.32,95% CI: -1.89 to -0.76, P<0.05) 2
- This pain benefit diminishes at long-term follow-up (48 weeks) 2
- No difference exists in radiographic kyphosis progression, opioid use, function, or quality of life at any timepoint 2
Soft bracing is an adequate alternative:
- No significant difference found between rigid and soft bracing outcomes 2
- Soft braces are more comfortable and have fewer complications than rigid structures 3
Step 4: Duration of Bracing
Recommended bracing duration: 6-8 weeks maximum for continuous use 3
- Must be removed overnight 3
- Beyond 8 weeks, there is increased risk of trunk muscle atrophy and weakness 4, 3
- Situational use (during prolonged standing, walking, or physical activity) is acceptable beyond this period 3
Key Clinical Considerations
For osteoporotic compression fractures specifically:
- Bracing assists in reducing acute pain, stabilizing the spine, and increasing early motor activity 3
- Semi-rigid and elastic corsets are preferable to rigid structures due to better tolerability 3
- Bracing enables earlier participation in exercise therapy, which is the mainstay of osteoporotic fracture management 3
Pediatric thoracolumbar impaction fractures:
- Significant remodeling capacity occurs regardless of bracing 5
- Bracing does not influence long-term remodeling or outcomes in children 5
Common Pitfalls to Avoid
Do not assume bracing is mandatory—high-quality evidence supports early mobilization without orthosis as equally effective for stable fractures. 1
Do not order TLSO for patients with neurological deficits—these require immediate surgical evaluation, not conservative management. 1
Do not continue rigid bracing beyond 8 weeks continuously—this leads to trunk muscle weakening and learned non-use, potentially worsening functional outcomes. 4, 3
Do not use bracing as a predictor of surgical fusion outcomes—preoperative brace therapy has poor predictive value (sensitivity 61%, specificity 35%) and is not recommended for this purpose. 6
Practical Application
If you choose to brace: Use a TLSO or soft brace for 6-8 weeks to facilitate early pain control and mobilization, then transition to situational use only. 3
If you choose not to brace: Implement early mobilization protocols with appropriate analgesia—outcomes are equivalent to bracing at 6 months and beyond. 1, 2
Both approaches should incorporate: Pain management, early physical therapy when tolerated, and osteoporosis treatment if applicable. 3, 7