Bracing for Thoracolumbar Fractures
Traumatic fractures of the thoracolumbar spine are relatively common occurrences that can be a source of pain and disability. Similarly, osteoporotic vertebral fractures are also frequent events and represent a significant health issue specific to the elderly. Neurologically intact patients with traumatic thoracolumbar fractures can commonly be treated nonoperatively with bracing. Nonoperative treatment is not suitable for patients with neurological deficits or highly unstable fractures. The role of operative versus nonoperative treatment of burst fractures is controversial, with high-quality evidence supporting both options. Osteoporotic vertebral fractures can be managed with bracing or vertebral augmentation in most cases. There is, however, a lack of high-quality evidence comparing operative versus nonoperative fractures in this population. Bracing is a low-risk, cost-effective method to treat certain thoracolumbar fractures and offers efficacy equivalent to that of surgical management in many cases. The evidence for bracing of osteoporotic-type fractures is less clear, and further investigation will be necessary to delineate its optimal role.
Traumatic spinal fractures of the thoracolumbar area represent approximately 90% of all spinal fractures, with more than 160,000 of these fractures occurring annually in North America. These injuries can result in loss of neurological function, pain, disability, and deformity, and represent a great economic burden to society. Therefore, it is incumbent on the treating physician to be aware of the most efficacious treatment options when encountering this relatively common problem.
There are a number of classification systems that have been proposed for thoracolumbar fractures. The primary goal of classification systems is to establish a reliable and reproducible methodology for categorizing these injuries to guide therapy. The 3-column model described by Denis represents a biomechanical classification system to identify which fractures are potentially unstable and thus require some type of intervention. The Denis model was developed prior to the widespread use of CT and MRI, and many authors since have noted its relative lack of inclusivity and reproducibility for unusual fractures. Magerl and colleagues described a more complicated hierarchical classification system (the so-called AO system) based on pathomorphological criteria, which includes 3 broad categories: vertebral body compression as Type A, anterior and posterior element injury with distraction as Type B, and anterior and posterior element injury with rotation as Type C. Due to its complexity, this system can be fairly cumbersome and its practicality for daily clinical use has been questioned by some authors. In addition, this system was found to have only moderate reliability and reproducibility among different spine surgeons.
However, despite being imperfect systems, both the Denis model and AO classification system have been used in guiding treatment algorithms. In addition, evaluation of the literature on spinal fractures reveals that these older classification systems are very much part of the vernacular for many clinical studies, despite the advent of newer and more streamlined classification systems such as the Thoracolumbar Injury Classification and Severity Score introduced by Vaccaro et al.
The other common setting in which thoracolumbar fractures are encountered is in the elderly population. In particular, osteoporotic vertebral fractures (OVFs) in elderly patients represent a disease entity that differs from traumatic fractures. Given the increasingly aging US population, these fractures will become an even more widely encountered problem. Osteoporotic vertebral fractures can be a great source of pain and disability in elderly patients, as well as a significant societal burden. As with traumatic fractures, efficacious treatment of OVFs with appropriate intervention is critical.
In this review we examine the role of bracing for the treatment of traumatic thoracolumbar fractures as well as OVFs. Familiarity with the relevant literature can prove very useful to the treating physician and can enhance the decision-making algorithm for this patient population.
Abstract and Introduction
Abstract
Traumatic fractures of the thoracolumbar spine are relatively common occurrences that can be a source of pain and disability. Similarly, osteoporotic vertebral fractures are also frequent events and represent a significant health issue specific to the elderly. Neurologically intact patients with traumatic thoracolumbar fractures can commonly be treated nonoperatively with bracing. Nonoperative treatment is not suitable for patients with neurological deficits or highly unstable fractures. The role of operative versus nonoperative treatment of burst fractures is controversial, with high-quality evidence supporting both options. Osteoporotic vertebral fractures can be managed with bracing or vertebral augmentation in most cases. There is, however, a lack of high-quality evidence comparing operative versus nonoperative fractures in this population. Bracing is a low-risk, cost-effective method to treat certain thoracolumbar fractures and offers efficacy equivalent to that of surgical management in many cases. The evidence for bracing of osteoporotic-type fractures is less clear, and further investigation will be necessary to delineate its optimal role.
Introduction
Traumatic spinal fractures of the thoracolumbar area represent approximately 90% of all spinal fractures, with more than 160,000 of these fractures occurring annually in North America. These injuries can result in loss of neurological function, pain, disability, and deformity, and represent a great economic burden to society. Therefore, it is incumbent on the treating physician to be aware of the most efficacious treatment options when encountering this relatively common problem.
There are a number of classification systems that have been proposed for thoracolumbar fractures. The primary goal of classification systems is to establish a reliable and reproducible methodology for categorizing these injuries to guide therapy. The 3-column model described by Denis represents a biomechanical classification system to identify which fractures are potentially unstable and thus require some type of intervention. The Denis model was developed prior to the widespread use of CT and MRI, and many authors since have noted its relative lack of inclusivity and reproducibility for unusual fractures. Magerl and colleagues described a more complicated hierarchical classification system (the so-called AO system) based on pathomorphological criteria, which includes 3 broad categories: vertebral body compression as Type A, anterior and posterior element injury with distraction as Type B, and anterior and posterior element injury with rotation as Type C. Due to its complexity, this system can be fairly cumbersome and its practicality for daily clinical use has been questioned by some authors. In addition, this system was found to have only moderate reliability and reproducibility among different spine surgeons.
However, despite being imperfect systems, both the Denis model and AO classification system have been used in guiding treatment algorithms. In addition, evaluation of the literature on spinal fractures reveals that these older classification systems are very much part of the vernacular for many clinical studies, despite the advent of newer and more streamlined classification systems such as the Thoracolumbar Injury Classification and Severity Score introduced by Vaccaro et al.
The other common setting in which thoracolumbar fractures are encountered is in the elderly population. In particular, osteoporotic vertebral fractures (OVFs) in elderly patients represent a disease entity that differs from traumatic fractures. Given the increasingly aging US population, these fractures will become an even more widely encountered problem. Osteoporotic vertebral fractures can be a great source of pain and disability in elderly patients, as well as a significant societal burden. As with traumatic fractures, efficacious treatment of OVFs with appropriate intervention is critical.
In this review we examine the role of bracing for the treatment of traumatic thoracolumbar fractures as well as OVFs. Familiarity with the relevant literature can prove very useful to the treating physician and can enhance the decision-making algorithm for this patient population.
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