Is a Back Brace Really Needed for a Burst Fracture of the Spine?
In this study, the use of a brace for thoracolumbar burst fractures is investigated. Do patients really need a back brace for this condition? If they do, what kind of brace works best? How long should they wear it? The first step in answering questions like these is to find out if patients wearing the brace have any better results than those who don't wear a brace.
Thoracolumbar burst fractures occur in the spine where the end of the 12 thoracic vertebrae meet the start of the five lumbar vertebrae. A high-energy load through the spine causes the vertebra to break or shatter into many tiny pieces. That's why they call them burst fractures.
Burst fractures are most often caused by car accidents or by falls. The danger of these fractures is that the bone fragments can shift and press into the spinal cord or spinal nerve roots causing temporary and even permanent neurologic damage. Bracing might help keep the spine stable while the bone heals and prevent neurologic damage of this type.
Everyone in the study had a Type A3 burst fracture between the 11th thoracic vertebra (T11) and the third lumbar vertebra (L3). Type A3 is a classification made by the radiologist at the time X-rays are taken. It is a specific designation letting the medical doctor know that the patient has a burst fracture as opposed to some other type of fracture (e.g., Type A1 is a wedge compression fracture, Type A2 is a coronal split fracture). Only adults under the age of 60 were included. They were seen within 72 hours of the injury and did not have any apparent nerve damage or neurologic injury.
Past studies with a small number of patients have shown that it didn't seem to matter whether patients wore a brace or not. And different types of specific braces seemed to yield the same results. There hasn't been one individual brace to rise above all others as giving the best results. The authors of this study thought it was more likely that the type of fracture treated was stable and didn't need brace stabilization. In the case of a thoracolumbar burst fracture, if the posterior ligaments aren't damaged, the burst fracture is stable (not likely to shift or move out of place).
To test this theory, they compared 72 patients with thoracolumbar burst fractures. The patients were randomly assigned to one of two groups. One group of 36 patients was given a thoracolumbrosacral orthosis (TLSO). This type of rigid support encompasses the trunk including the thoracic and lumbar spine and sacrum. Patients in this group were kept on bed rest until the brace was in place. They just used an off-the-shelf (prefabricated) TLSO, rather than one that was specifically designed for each individual person. The brace was worn all the time for eight weeks unless the patient was lying flat in bed.
An equal number of patients in the second group (36) did not get a brace. They were allowed to get up and walk unassisted right away. Patients in both groups were seen by a physical therapist who explained which movements to avoid during the eight-week healing process. Once the patients in group one had a brace, they were allowed to get up and walk around as much as they felt comfortable. They were told not to bend the hips past 90-degrees of flexion. Patients without the brace were told not to bend or twist the trunk and not to flex the hips past 90-degrees. Restrictions for both groups were in place for eight weeks.
For three months, patients in both groups participated in a rehab program supervised by a physical therapist. An exercise program of spinal stabilization exercises was started at four weeks and progressed from isometric (muscle contraction without movement) to isotonic (muscle contraction with movement) exercises. When the patient was ready, the program was advanced to specific activities to prepare them for return-to-work. The brace group slowly stopped wearing the brace at the end of the first eight weeks.
Results were compared after three months by measuring differences in pain, function, health-related quality of life, spinal alignment, number of days in the hospital, and any complications that occurred. The Roland-Morris Disability Questionnaire was used to assess pain, function, and quality of life. X-rays and CT scans showed before and after spinal alignment.
Some of the patients in both groups ended up having surgery before they even left the hospital. There were a few reports in both groups of radicular pain (pain from the back down the leg). In those cases, surgery was needed to remove bone fragments from impinging or pressing on a spinal nerve. A couple of other patients were unable to get up and walk without severe pain, so they also had surgery to stabilize the spine (even though the X-rays showed a stable fracture).
For the rest of the patients, comparisons of variables measured showed no difference in results with or without bracing. And patients were equally satisfied with their treatment no matter which group they were in. Not only that, but there were no major differences in before and after results as seen on imaging studies. Spinal healing was just as good in one group as it was in the other. Spinal alignment and posture was also comparable. The authors intend to follow these patients for a full two-years to see if there are any long-term differences.
The only possible reason to use a brace might be for pain control in the first two-week period of time. The test scores for pain showed a slight increase in pain control for patients wearing a brace early on. The difference was only slight and by the end of six weeks, there was no difference at all. The amount of additional pain control experienced by some of the patients in the brace group might not be warranted by the price of the brace since the results will be the same in just a few short weeks. This can be decided on a case-by-case basis.
When it was all said and done, the authors concluded that for stable burst fractures, immobilization in a cast or brace just isn't necessary. Keeping good posture and avoiding extremes of spinal movement can save these patients the financial cost of the brace as well as the physical cost of wearing an uncomfortable suit of body armor (as patients sometimes refer to this type of brace). Long-term studies are needed to confirm that the results will continue over the next year's worth of time. Therefore, these results and recommendations are considered preliminary by the authors until they complete the full two-years of the study.
Christopher S. Bailey, MD, MSc(Surg), FRCSC, et al. Comparison of Thoracolumbosacral Orthosis and No Orthosis for the Treatment of Thoracolumbar Burst Fractures: Interim Analysis of a Multicenter Randomized Clinical Equivalence Trial. In Journal of Neurosurgery: Spine. September 2009. Vol. 11. No. 3. Pp. 295-303.
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