Spinal Orthotics

Dr. Aliaa Omar EL-HadyMD. Physical medicine, Rheum. & Rehabilitation

A spinal orthotic device is an external apparatus applied to the body to:1. Limit the motion.2. Correct deformity.3. Reduce axial loading.4. Improve the function

of a particular spinal segment of the body.

• Ancient Egyptians used 1st splints ~ 5.000 ys ago, not to stabilize joints or body parts.

• Middle Ages armorers manufactured splints that protected as well as stabilized the body.

• French surgeon, Ambroise Pare` developed metal corsets in the late 16th century

HISTORY

• Lorenz Heister is credited with developing 1st spinal orthosis in the late 17th century. It was quite similar to the modern day Halo brace.

• The basic principles of spinal immobilization have actually changed little in the past 300 years, however the materials used and combination of surgery and bracing has changed tremendously.

HISTORY

Spinal Orthotics• Outline of spinal biomechanics

• Motion of spine

• Clinical considerations of spinal

orthotics

SPINE BIOMECHANICS• Three flexible curves of

vertebral column (cervical, thoracic & lumbar)

• Transfers load from head & trunk to pelvis.

• Protects spinal cord.

• Permits motion in three planes.

• Vertebral bodies progressively larger in size caudally to sustain increasing superimposed weight.

• Intrinsic Stability: Intervertbral disc + surrounding ligaments.

• Extrinsic Stability: muscles

•Intervertbral discs bears & distributes loads & restrains excessive motion.•Intradiscal pressure is 1.5 times of external load in compression.

SPINAL MOTION

Characteristics of spinal orthosis: Weight of the orthosis Adjustability Functional use Cosmesis Cost Durability Material Ability to fit various sizes of patients Ease of putting on (donning) and

taking off (doffing) Access to tracheostomy site, peg

tube, or other drains Access to surgical sites for wound

care Aeration to avoid skin maceration

from moisture

Indications of spinal orthosis:Pain relief Mechanical unloading Scoliosis management Spinal immobilization after

surgery Spinal immobilization after

traumatic injury Compression fracture

management Kinesthetic reminder to avoid

certain movements

The biomechanical principles of orthotic design include : balance of horizontal forces. fluid compression. distraction. construction of a cage around the

patient. skeletal fixation.

In general, structural damage to posterior elements of the spine creates more instability with flexion, whereas damage to anterior elements creates more instability with extension.

Construction of a cage around the patient leads to: Balance of horizontal forces Increase intra-abdominal pressure Relieve load on vertebrae Prevention of certain movements Stability

Duration of use of spinal orthosis: Pain: 1-2 weeks. Instability: till the patient

can tolerate discomfort. Post surgical: after acute

fractures 6-12 weeks Gradual removal + static EX

Complications of spinal orthosis: Discomfort & local pain Osteopenia Skin breakdown Nerve compression Ingrown facial hair for men Muscle atrophy with prolonged use Decreased pulmonary capacity Increased energy expenditure with

ambulation Difficulty donning and doffing orthosis Difficulty with transfers Psychological and physical dependency Increased segmental motion at ends of

the orthosis Unsightly appearance Poor patient compliance

Success of spinal orthosis: Decreased pain Increased strength Improved function Increased proprioception Improved posture Correction of spinal curve deformity Protection against spinal instability Minimized complications Healing of ligaments and bones

CLASSIFICATION According To Region Crossed• Crevical (CO )• Head Cervical Orthoses (HCO)• Cervicothoracic Orthoses (CTO)• Halo Device• Thoracolumbar Orthoses (TLO) • Lumbosacral Orthoses (LSO)• Thoracolumbosacral orthosis

( TLSO)

CLASSIFICATIONAccording To Motion Restriction

• Flexion- Extension FE control• Flexion- Extension- Rotation FER

Control• Flexion- Extension- Lateral

bending-Rotation- FELR Control

CLASSIFICATIONAccording To Materials Used• Rigid• Flexible

Cervical Orthosis

Cervical Orthosis

F-E

• Soft (zimmer)• Hard (semi-rigid): moulded• a. Thomas• b. Philadelphia • c. Aspen• d. Miami• Collars for weak neck extensors: Head master &

Executive

F-E-R

•SOMI

F-E-L-R

• 1- Poster• 2- Custom• Minerva• Cuirass• 3- Yale• 4- Halo vest

CERVICAL ORTHOSES (COLLARS)

Flexible Soft Collar• Made from soft foam.• Provide mechanical restraint (5-15%)• Psychologic comfort.• Head support when acute neck pain

occurs.• Relief from minor muscle spasm.• Relief from cervical strain.

Soft cervical collar:Polyethylene or foam Least limitation of cervical motion. Increase resistance to extension or

hyperextension. Through feedback, it reminds the wearer to

limit neck movement. Retains heat; reduce muscle spasm and aid

in healing of soft tissues.

HEADMASTER COLLAR (ADJUSTABLE WIRE FRAME CERVICAL COLLAR) - FLEXIBLE

Lightweight, open, and is comfortable in warm climates. It is easily formed by hand to fit snuggly under the chin. It is made of a specially tempered wire frame which is

liberally padded with foam rubber covered in a soft, washable fabric and uses a Velcro closure strap attached to cushioned back piece.

Used with weak neck extensors to prevent the head from falling forward, however, if weakness is present in rotation and/or lateral flexion

EXECUTIVE COLLAR: Comfortable, lightweight Kydex frame, open neck

design. An occipital strap can be positioned to fit any neck

circumference. Useful with patients with weak neck extensors to

prevent the head from falling forward. However, if weakness is present in rotation and/or

lateral flexion (i.e. when shaking the head "no" or touching the ear to the shoulder), it will not be adequate and more support is needed.

SEMIRIGID COLLAR These types of collars are semirigid

types made of anterior and posterior pieces fastened together by Velcro.

They provide FE> R> L motion restriction.

All can be applied when lying down. The Phladilphia collar is washable while

the Aspen & Miami have washable padding.

The Phladilphia can be applied during showering while the second two had padding which can be washed and replaced when dry.

The three may have a tracheostomy opening

Made of firm plastic with superior and inferior paddings that wrap around the neck and is secured by velcro

It may be adjustable in height or may contain an adjustable chin piece

SEMI-RIGID THOMAS COLLAR:

SEMIRIGID COLLAR: PHILADELPHIA COLLARIndications: Anterior cervical fusion, Halo removal, Dens type I

cervical fracture of C2, Anterior diskectomy. Suspected cervical trauma in unconscious patients,

Tear-drop fracture of the vertebral body (Note: Some tear-drop fractures require anterior decompression and fusion.)

Cervical strain

thoracic extension can be added to increase motion restriction and treat

C6-T2 injuries.

Semirigid collar: Miami

MIAMI COLLAR Semirigid 2-piece

system made of polyethylene, with a soft, washable lining

same indications for use as those for the Philadelphia collar.

thoracic extension can be added to increase support and treat C6-T2 injuries.

Semirigid collar: Aspen

MALIBU COLLAR semi-rigid, 2-piece orthosis anterior opening for a

tracheostomy. indications similar to those

for the Miami J and Philadelphia collars.

comes in only one size adjustable in multiple

planes to ensure proper fit. Padding around the chin

can be trimmed to ensure proper fit

thoracic extension can be added to increase support and treat C6-T2 injuries.

Ambu collar

Semirigid and rigid plastics. Provide more rigid stabilization of the

cervical spine. Include Occiput & Chin to decrease

ROM.Used in stable spine conditions.Supported chin is a common place for

skin breakdown.Clavicle is area HCOs can cause skin

breakdown.Long-term use associated with

decreased muscle function and dependency.

INDICATIONS: ANTERIOR CERVICAL FUSION. HALO REMOVAL. DENS TYPE I  CERVICAL # OF C2. ANTERIOR DISKECTOMY. SUSPECTED CERVICAL TRAUMA IN

UNCONSCIOUS PATIENTS. MOST OF TEARDROP # OF

VERTEBRAL BODY. CERVICAL STRAIN.

G R E AT E R M O T I O N R E S T R I C T I O N I N T H E M I D D L E T O LO W E R C E R V I C A L S P I N E .

U P P E R C E R V I C A L S P I N E H A S L E SS M O T I O N R E S T R I C T I O N .

U S E D I N M I N I M A L LY U N S TA B L E F R A C T U R E S .

Cervico-thoracic orthoses (CTOs)

STERNAL-OCCIPITAL-MANDIBULAR IMMOBILIZER (SOMI)

CTO with anterior chest plate extending to the xiphoid process & metal or plastic bars curve over the shoulder.

Straps from the bars over the shoulder & cross to opposite side of the anterior plate for fixation.

2-poster CTOs start from the chest plate and attach to the occipital component.

SOMI is ideal for bedridden patients because it has no posterior rods.

removable chin piece with an optional headpiece can be used if chin piece is removed for eating.

Comfortable. Proper adjustment is crucial for motion

restriction.

INDICATION: S O M I C O N T R O L S F L E X I O N I N C 1 - C 3

S E G M E N T S B E T T E R T H A N C E R V I C O T H O R A C I C B R A C E .

AT L A N T OA X I A L I N S TA B I L I T Y ( R A ) . N E U R A L A R C H F R A C T U R E S O F C 2 ( F L E X I O N

C AU S E S I N S TA B I L I T Y ) .

(F-E-R )SOMI COLLARF-E-R control orthosis (sterno-occipital mandibular immobilizer): The mandibular support can be removed and the patient can eat, wash, or shave while supine

MOTION RESTRICTIONS ASSOCIATED WITH THE SOMI INCLUDE Cervical flexion and extension are

limited by 70%-75% Lateral bending is limited by 35% Rotation is limited by 60-65%

CERVICAL FELR CONTROL ORTHOSIS Four Posters Cuirass Yale Minerva Halo

Four-Poster The four-poster is a rigid cervical orthosis

with anterior and posterior sections consisting of pads that lie on the chest and are connected by leather straps.

4 POSTERS CERVICAL ORTHOSIS

Mandibular support Occipital support

Double anterior uprights

Double posterior uprights

Sternal Plate Interscapular Plate

MOTION RESTRICTIONS ASSOCIATED WITH THE 4-POSTER ORTHOSIS

Flexion and extension are limited by 80%.

Lateral bending is limited by 55%-80%.

Rotation is limited by 70%.

Yale The Yale orthosis consists of chin and occipital

pieces that extend higher on the skull in the posterior region; this increases comfort.

The Yale orthosis is a modified Philadelphia collar with a thoracic extension.

The extension consists of fiberglass that extends both anteriorly and posteriorly, and has thoracic straps that hold the sections together.

The thoracic extension to the orthosis helps to stabilize injuries at the vertebral levels of C6-T2

Cuirass Orthosis

Minerva Brace (custom moulded)

The Minerva collar has head straps to provide additional support and to keep head immobilized throughout ttt.

Halo device

• The halo orthosis provides flexion, extension, and rotational control of the cervical region.

• Pressure systems are used for control of motion, as well as to provide slight distraction for immobilization of the cervical spine.

• This orthosis provides maximum restriction in motion of all the cervical orthoses. It is the most stable orthosis, especially in the superior cervical spine segment.

• A halo is used for approximately 3 months (10 to 12 weeks) to ensure healing of a fracture or of a spinal fusion.

• Usually a cervical collar is indicated after the halo is removed, because the muscles and ligaments supporting the head become weak after disuse.

• All pins on the halo ring should be checked to ensure tightness 24 to 48 hours after application.

Indications• Dens type I, II, or III fractures of C2 .• C1 fractures with rupture of the transverse ligament• Atlantoaxial instability from RA, with ligamentous

disruption and erosion of the dens.• C2 neural arch fractures and disc disruption between

C2 and C3. Bony, single-column cervical fractures• Cervical arthrodesis - Postoperative• Cervical tumor resection in an unstable spine -

Postoperative• Debridement and drainage of infection in an unstable

spine - Postoperative• Spinal cord injury (SCI)

Contraindications• Concomitant skull fracture with cervical

injury• Damaged or infected skin over pin insertion

sitesRelative contraindications• Cervical instability with ligamentous

disruption• Cervical instability with 2- or 3-column injury• Cervical instability with rotational injury

involving facet joints

Complications• Neck pain or stiffness - 80%• Pin loosening - 60%• Pin site infection - 22%• Scarring - 30%• Pain at pin sites - 18%• Pressure sores - 11%• Redislocation - 10%• Restricted ventilation - 8%• Dysphagia - 2%• Nerve injury - 2%• Dural puncture - 1%• Neurological deterioration - 1%• Avascular necrosis of the dens• Ring migration• Inadequate bony healing• Inadequate ligamentous healing

Complications of cervical orthosis:extremely mobile joint complex with

multiple planes little body surface available for contacthigh incidence of skin breakdown (occiput,

chin)pressure-related pain common (clavicles,

chin)hygiene issues limit comfort (shaving)The soft-tissue structures around the neck

(eg, blood vessels, esophagus, trachea) limit the application of aggressive external force.

Cervical orthosis offer no control for the head or thorax; therefore, motion restriction is minimal. (Cervical orthosis serve as a kinesthetic reminder to limit neck movement.)

All orthotics tend to control flexion better than extension

Limitation of flexion at C1-C3 Halo > 4-poster > CTO CTO are best at controlling flexion and

extension at C3-T1 SOMI brace is best at controlling flexion

from C1-C5 SOMI is less effective in controlling

extension Limitation of rotation and lateral bending

C1-C3 Halo > cervico-thoracic brace

Cervical Immobilization Pearls

Thoraco-Lumbo-sacral (TLS) Orthoses

Rigid TLS Spinal Orthosis

Extends from sacrum to above the inferior angle of scapula

Contain thoracic and pelvic bands Used to support and stabilize the trunk Used in cases of truncal paralysis, post-spinal

fusion, post-scoliotic surgery To prevent mild scoliosis 20-45º Work through increase intra-abdominal pressure

and reduce weight on vertebral body Used in intervertebral disc diseases

TLS Orthoses

a.The TLS F-E control orthosis (Taylor brace)b.The TLS F-E-L control (Knight Taylor brace)c.The TLS F-E-R control orthosis (Cowhorn brace)d.The TLS flexion (F) control orthosis Jewett or Becher TLSO Cruciform anterior spinal hyper- extension

(CASH) TLSOe. The TLS F-E-L-R control (TLS jacket)f. Boston TLSO

Extends from sacrum to above the inferior angle of scapula

Taylor & Knight-Taylor brace

Knight-Taylor brace Has two lateral and two posterior uprights and

shoulder straps. Reduce lateral bending, flexion, and extension. The brace can be prefabricated and made with

polyvinyl chloride or aluminum. The posterior portion of the brace has added cross

supports below the inferior angle of the scapula and a pelvic band fitted at the sacrococcygeal junction.

The anterior corset is made of canvas and provides intracavitary pressure.

The anterior corset is laced to the lateral uprights.

Indication: To provide flexion immobilization to treat

thoracic and lumbar vertebral body fractures. Post-surgical support (for years) of traumatic

fractures, spondylolisthesis, scoliosis, spinal stenosis, herniated disks, and disk infections.

However, clinicians typically now prefer the custom-molded TLSO body jackets, because better control of position is obtained

Motion restrictions:control of flexion, extension, and a minimal axial rotation via the three-point pressure systems for each direction of motion. For e.g, flexion is controlled by: the posteriorly directed forces applied through the axillary straps and the abdominal apron, and an anteriorly directed force through the paraspinal uprights.

Knight-Taylor has an additional thoracic band that extends from the uprights just below the inferior angle of the scapula to the midsagittal plane, and a lateral upright on each side that connects the pelvic band and the thoracic band.

These bands provide additional lateral support and motion control to the trunk.

Jewett hyperextension brace

uses a 3-point pressure system with 1 posterior and 2 anterior pads.

The anterior pads place pressure over the sternum and pubic symphysis.

The posterior pad places opposing pressure in the mid-thoracic region.

The posterior pad keeps the spine in an extended position

Lightweight design that is more comfortable than the CASH brace.

Pelvic and sternal pads can be adjusted from the lateral axillary bar where they attach.

No abdominal support is provided with this device. When the patient is seated, the sternal pad should be

half an inch inferior to the sternal notch, and the pubic pad should be half an inch superior to the pubic symphysis.

Indication Symptomatic relief of stable spinal fractures T6

to L1 not due to osteoporosis Immobilization after surgical stabilization of

thoraco-lumbar fractures Postural Kyphosis.Advantage Prevents flexion & limits extension of spine Controls thoracic spine Does not prevent extension More comfortable on women Velcro closure

Contraindication: Three column spine fractures involving

anterior, middle, and posterior spinal structures

Compression fractures above T6 since segmental motion increases above the sternal pad

Compression fractures due to osteoporosis

More effective than the CASH brace.

The TLS flextion (F) control orthosis Cruciform anterior spinal hyperextension brace with round anterior chest pads. (CASH)

Indication Immobilization of

compression fracture of vertebral bodies from T6 to L1

Reduction of kyphosis not in patients with osteoporosis

Advantage Prevents flexion of spine Controls thoracic spine Does not prevent extension More comfortable on women Velcro closure

CASH Orthosis

Motion restrictions : Limits flexion from T6-L1

Contraindications : Three-column spine fractures involving

anterior, middle, and posterior spinal structures .

Compression fractures due to osteoporosis

Custom-molded plastic body jacket (calmshell)

PLASTIC BODY JACKET•Fabricated with high-temperature co-polymer plastics.• Well-fitted body jacket restrict motion in all planes. •Anterior and lateral trunk containment elevate intracavitary pressure.•Decrease demands on the vertebral discs.• Body jackets are frequently used post surgically or during an acute trauma.

(flexion-extension-lateral –rotary control)

Lightweight design and is easy to don and doff. Material is easy to clean and comfortable to wear. The TLSO provides efficient force transmission as

pressure is distributed over wide surface area, which is ideal for use in patients with neurologic injuries.

Use it with an undershirt to absorb perspiration and protect the skin.

Frequent checks to ensure proper fit help prevent pressure ulcers.

Velcro straps are used to tighten the brace.

Indications Immobilization for compression fractures

from osteoporosis Immobilization after surgical stabilization

for spinal fractures Bracing for idiopathic scoliosis Immobilization for unstable spinal

disorders for T3 to L3

Motion restrictions custom-molded TLSO Limits side-bending , flexion ,extension and rotation to some extent

It is more effective in preventing idiopathic scoliosis curve progression than the Milwaukee and Charleston braces.

The mean curve progression with TLSO is less than 2° while the Charleston and Milwaukee braces have a curve progression greater than 6°.

Fewer than 18% of patients treated with TLSO brace required surgery for scoliosis compared to 23% for patients treated with a Milwaukee brace.

Plastic TLS jacket that extend upward to the mandible and mastoid.

The Milwaukee brace, (CTLSO) used for scoliosis has a rigid plastic pelvic girdle connected to a neck ring over the upper thorax by one anterior and two posterior uprights.

Pads strapped to the uprights apply forces to correct the scoliotic curve.

It is used for curves at or below T6

Cow horn spinal orthosis

Lumbosacral Orthoses

Extend from sacrum to the inferior scapular anglea.The LSO (F-E) control orthosis (Chairback orthosis)b.The LSO (F-E-L) control othosis (Knight spinal)c.The LSO (E-L) contorl orthosis (Williams brace)d.The LSO with hip spica or thigh cuffe.The LS jacket (Boston overlap brace)

Rigid short LSO with 2 posterior uprights with thoracic and pelvic bands.

The abdominal apron has straps in front for adjustment to increase intra-cavitary pressure.

The thoracic band is located 1 inch below the inferior angle of scapula.

Chairback brace

The thoracic band extends laterally to the mid-axillary line, and the pelvic band extends laterally to the mid-trochanteric line.

Position the posterior uprights over the paraspinal muscles.

Uprights can be made from metal or plastic. The brace uses a 3-point pressure system

and can be custom molded to improve the fit for each individual patient.

Indications : Unloading of the intervertebral discs and

transmit pressure to soft tissue areas Relief for LBP Immobilization after lumbar laminectomy Kinesthetic reminder to patient following

surgery

Motion restrictions : Limits flexion and extension at the L1-L4 level Limits rotation minimally Limits lateral bending by 45% in the

thoracolumbar spine

Chairback Ortho-Mold brace Similar to the chairback brace, but it has

a rigid plastic back piece custom molded to the patient.

The plastic back can be inserted into the canvas and elastic corset.

Indications for use are the same as the chairback brace.

Williams brace Short LSO with an anterior elastic apron to allow for

forward flexion. Lateral uprights attach to the thoracic band, and

oblique bars are used to connect the pelvic band to the lateral uprights.

The abdominal apron is laced to the lateral uprights. The brace limits extension and lateral trunk movement

but allows forward flexion. The brace is indicated to provide motion restriction

during extension to treat spondylolysis and spondylolisthesis.

Contraindication : in spinal compression fractures. Motion restrictions of the Williams brace include the following: Limits extension Limits side bending at terminal ends only

A custom-made orthosis molded over the iliac crest for improved fit.

Plastic anterior and posterior shells overlap for a tight fit.

Velcro closure in the front is designed for easy donning and doffing.

Multiple holes can be made for aeration to help decrease moisture and limit skin maceration.

The rigid LSO can be trimmed easily to make adjustments for patient comfort and may be used in the shower if needed.

Rigid LSO

Indications: Post-surgical lumbar immobilization. Treatment of lumbar compression

#. Motion restrictions: Limits flexion and extension Limits some rotation and side

bending

uses a thigh piece on the symptomatic side and extends to 5 cm above the patella.

The hip is held in 20° of flexion to allow sitting and walking.

Some patients require a cane for ambulation after application.

Indications Immobilization to treat lumbar instability from

L3-S1 Immobilization after LS fusion with anchoring to the

sacrum Motion restrictions Limits flexion and extension Limits some rotation and side bending

Rigid LSO with hip spica

Corsets (Flexible Spinal Orthoses) Made of fabric with pouches for vertical stays No thoracic or pelvic bands The vertical stays are made of plastic or rigid

steel Create similar forces as rigid SO Do NOT restrict movement or spinal re-alignment Increase intra-abdominal pressure more than

rigid SO Used in direct contact with skin

Has metal bars within the cloth material posteriorly that can be removed and adjusted to fit the patient.

The anterior abdominal apron has pull-up laces from the back to tighten. The abdominal apron can come with Velcro closure for easy donning and doffing.

It has a lightweight design and is comfortable to wear. The corset increases intracavitary pressure. Anteriorly,

the brace covers the area between the xiphoid process and pubic symphysis.

Posteriorly, the brace covers the area between the lower scapula and gluteal fold.

The Standard LSO corset

Indications: Treatment of LBP Immobilization after lumbar laminectomy

Motion restrictions: limitation of F-E.

The TLS corset: Restrict spinal motion at thoracic and lumber spine Increase intra-abdominal pressure to remove load from

vertebrae Remind the wearer to avoid abrupt trunk motion and to

lift properly

The LS corset (Richard’s corset) It extends to below the inferior angles of the scapulae

instead of the midscapular level Same function as TLS corset but does not restrict

thoracic spinal motion

Sacroiliac Orthoses

Sacroiliac (SI) Corsetsa.Sacroiliac corset : from illiac crest to symphysis pubis Used in low back pain and stabilization of sacroilliac joint

b. Sacroiliac belt : Encircle the pelvis between the illiac crests The belt passes below the anterior superior pelvic spine Used in post surgical conditions of pelvis

c.Elastic sacroiliac corset (binder) with plastic insert: Similar to the corset Mainly used to correct back posture and low back pain

Bracing For Scoliosis

The main goal: prevent further deformity Prevent or delay need for surgery. If surgery is needed, delaying the procedure as long

as possible helps optimize spinal height and avoid stunting of truncal growth.

Assessing the degree of skeletal maturity in a child with scoliosis is important because with more advanced skeletal maturity, you expect less further skeletal growth and thus less progression of the scoliosis.

This has obvious implications when forming a treatment plan.

Risser classification of ossification of the iliac epiphysis:Used to evaluate skeletal immaturity. • Ossification of the iliac crest occurs from ASIS to PSIS. • When ossification is complete, fusion of the epiphysis occurs to the iliac

crest.• Risser staging is based on using radiographs to determine what % of the

excursion (along the length of the iliac epiphysis) has ossified. • Risser score of 0-I with a curve of 20-30° indicates nearly 70% chance of

progression.

Risser stages are defined as follows: Stage 0 = 0% excursion Stage I = 25% excursion Stage II = 50% excursion Stage III = 75% excursion Stage IV = 100% excursion and correlates with end of spinal growth Stage V = fusion to ilium, indicating cessation of vertical height growth

The younger the age, the larger the curve, the shorter the duration of curve progress and the more the liability to surgery.

The most common time to lose control of idiopathic curves is at puberty.

Boys tend to show less curve progression than girls, and tend to have later onset of curve progression between 15-18 years.

Younger patients show greater initial in-brace correction.

Curve correction with bracing >50 degrees is expected to have final net correction, whereas curve correction < 50 is expected to have limited progression.

Generally, curves between T8-L2 have the best correction.

Young patients with large curves usually fail treatment with a brace.

Milwaukee CTLSO

Biomechanics:• It is used for scoliosis management.• It provides control of flexion, extension, and lateral bending of

the cervical, thoracic, and lumber spine. • It also provides some rotational control of thoracic & lumbar

spine.• Pressure systems are used for control of motion, as well as to

provide correction for the spine.• It is a good choice for patients who need correction in the

higher thoracic region of the spine.

Design and Fabrication:The Milwaukee is custom made, consisting of a cervical portion with the option of a removable cervical ring.Also used is the thoracolumbar section of the orthosis in which the correction of the lower thoracic and lumbar spines is achieved.

Uprights have localized pads to apply transverse force, which is effective for small curves.

The main corrective force is the thoracic pad, which attaches to the 2 posterior uprights and 1 anterior upright. The lumbar pads play a passive role compared to the thoracic pads.

The uprights are perpendicular to the pelvic section Any leg-length discrepancy should be corrected. The neck ring is another corrective force and is designed to give

longitudinal traction. Jaw deformity is a potential complication of the neck ring. The

throat mold, instead of a mandibular mold, allows use of distractive force without jaw deformity.

During the child's growth, brace length can be adjusted. Pads also can be changed to compensate for spinal growth. The brace needs to be changed if pelvic size increases.

Indications• Patients with a Risser score of I-II, as well as a curve >

20-30° and that progresses by 5° over 1 year• Curves of 30-40°, but not curves  < 20°.• Curves of 20-30°, with no year-over-year progression,

require observation every 4-6 months. • The Milwaukee brace is used for curves with apex above

T7.

The Milwaukee brace's duration of use:• Daily use ranges from 16-23 hr/ day.• Treatment should continue until the

patient is at Risser stage IV or V.• If the curve is > 30°, consider continued

use of the brace for 1-2 years after maturity, because a curve of this magnitude is at risk of progression.

Advantages• It may remove for activities

of daily living.• Because its open design,

there is minimal restriction of respiration.

• It allows good air circulation to minimize skin problems.

• It is adjustable to growth and curve changes.

• Because it has cervical ring we could use it for high level curve deformity.

Problems associated with the use of a Milwaukee brace:• Jaw deformity• Pain• Skin breakdown• Unsightly appearance• Difficulty with mobility• Difficulty with transfers• Increased energy expenditure with ambulation

BOSTON BRACE

Is a prefabricated symmetric thoracolumbar-pelvic mold with built-in lumbar flexion that can be worn under clothes.

Lumbar flexion is achieved through posterior flattening of the brace and extending of the mold distally to the buttock.

Braces with superstructures have a curve apex above T7.

Curves with an apex at or below T7 do not require superstructures to immobilize cervical spine movement.

Unlike the Milwaukee brace, cannot be adjusted if the patient grows in height.

Indications for the use of a Boston brace

• A curve of 20-25° with 10° progression over 1 year

• A curve of 25-30° with 5° progression over 1 year

• Skeletally immature patients with a curve of  ≥ 30°.

ADVANTAGES• The Boston brace, in contrast to the Milwaukee

brace are low profile (underarm) an can be worn under clothing.

• The Boston brace fabrication is quicker than Milwaukee brace.

• Three-point pressure application in The Boston brace.

Problems that are associated with the use of a Boston brace

• Local discomfort• Hip flexion contracture• Trunk weakness• Increased abdominal pressure• Skin breakdown• Accentuation of hypokyphosis in the

thoracic spine, above the brace (contraindication).

Duration of Boston brace use is determined by several factors:

Daily use ranges from 16-23 hours per day. Treatment should continue until the patient is at Risser

stage IV or V. If the curve is greater than 30°, consider continued use for

1-2 years after maturity since these curves are at risk for progression.

The Boston brace with and without superstructure is equally effective in treating curves below T7.

CHARLESTON BENDING BRACEIs a nocturnal only treatment.

CHARLESTON BENDING BRACE (1979)

It is worn only at night, which is why it's also known as a "part-time" brace

The Charleston Bending Brace is molded while he or she is bent towards the convexity—or outward bulge—of the curve, the concept behind this design being that it "over-corrects" the curve during the eight hours the brace is worn.

For 20-35 degrees & apex of the curve below the level of the shoulder blade.