Thoracolumbosacral Orthosis Research Articles

Effect of upper back brace with auditory feedback for forward head rounded shoulder posture among office workers with chronic neck pain – A pre-post single group study

Background: Forward head and rounded shoulder posture (FHRSP) is a poor habitual neck posture among office workers. The posture results in muscle tension and pain around the neck and shoulders and nerve root symptoms in the upper extremities. Objectives: The aim of this study was to investigate the effect of upper back brace with auditory feedback on posture among office workers with neck pain and forward head posture. Study Design: The study design involves prospective, experimental, pre–post single group. Methods: The office workers (males and females aged 25–60 years) were screened on shoulder girdle flexibility test (fingertips > 2 inches [5 cm] apart). Ten subjects (out of 50 screened subjects) meeting the eligibility criteria were selected for the study. The subjects wore the upper back brace with auditory feedback for 6 h in a day (minimum 30 min in continuation) for 2 weeks. Pre- and post-assessments of the neck disability index (NDI), visual analog scale (VAS), craniovertebral angle (CVA), and scapular index (SI) were carried out at the baseline and after 2 weeks, respectively. Results: Postintervention, significant reduction was found in NDI score (P < 0.05, 95% confidence interval (CI) of mean difference (CI): 2.33–8.72 and VAS score (P < 0.05, 95% CI: 0.70–2.89) and significant improvement was found in CVA score (P < 0.05, 95% CI: 0.60–6.59) and SI score (P < 0.05, 95% CI: 0.70–10.01). Conclusion: The results indicate that the upper back brace with auditory feedback improves the FHRSP and reduces neck pain and related disability among office workers.

Investigation of Future 3D Printed Brace Design Parameters: Evaluation of Mechanical Properties and Prototype Outcomes

Aim: Spinal brace wear time affects treatment effectiveness of adolescent idiopathic scoliosis but remains challenging with the brace’s bulkiness. This study aims to determine the appropriate material and thickness to improve wear comfort. Materials &amp; methods: Thirty-one specimens were tested with 13 ULTEM1010 and 13 Nylon12 potential materials and 5 standard polypropylene material in 2.5, 3.25 and 4 mm thicknesses to evaluate mechanical properties. Donning tests of ULTEM1010 and Nylon12 printed braces were conducted. Results: Nylon12 with 2.5–3.25 mm thickness had higher flexibility and the closest mechanical characteristics as 4-mm thick polypropylene. ULTEM1010 brace fractured after 615-times and Nylon12 brace handled 2920-times of opening and closing. Conclusion: Nylon12, 2.5–3.25 mm are appropriate design parameters. Further clinical study can validate long term brace effectiveness.

Colonoscopy using back brace support belt: A randomized, prospective trial.

Background and AimLooping is a major problem in colonoscopy, and it prolongs procedure time. We evaluated the efficacy and safety of an external abdominal compression device (back brace support belt; Maxbelt) with respect to cecal insertion time and other outcomes.MethodsWe performed a prospective study on outpatients undergoing elective colonoscopy in Toyoshima Endoscopy Clinic. Subjects were randomly assigned to groups and were subjected to either Maxbelt (n = 39) or no device (control, n = 38) during colonoscopy. The colonoscopist was blinded to the study. The primary outcome that was observed was insertion time.ResultsThe intubation time of the Maxbelt group was shorter than that of the no device group, but the difference was not significant (3.29 vs 4.49 min, P = 0.069). After stratifying by age, the use of Maxbelt significantly decreased cecal intubation time in elderly participants (age ≥ 45) compared to no device group (3.27 vs 5.00 min, P = 0.032). The use of the Maxbelt significantly decreased insertion difficulty encountered by the colonoscopist (P = 0.01). There was no difference in adenoma detection rate, manual pressure, position change, and adverse event.ConclusionsThe use of a back brace support belt could be a viable approach for colonoscopy in elderly patients. (University Hospital Medical Information Network: UMIN000029361).

Stress Analysis of Thoracolumbosacral Orthosis (TLSO) for Scoliosis deformity and its Effects on Gait Cycle

This work involved two major parts: the first one is the experimental part which included treatment of scoliosis deformity by manufacturing thoracolumbosacral orthosis, measuring the cobb angle of deformity, measuring the gait cycle data and walk path for both legs and suggesting a composite material to improve the mechanical properties of the orthosis and finally the interface pressure between trunk and orthosis is measured for twelve points covering of the total TLSO surface area by using f-socket devise. The second part of this study is the numerical simulation part during which the stresses are calculated using Ansys software for calculating stresses due to interface pressure loading boundary condition. The result shows no deference in gait cycle phases but the clear difference noted in walking path due to deviate center of mass, maximum pressure recorded left thoracic region with 900KPa due to correct spinal deformity while the minimum pressure recorded at right chest with l40KPa because of it is tissue region and Maximum value of stress was recorded at the left thoracic region with 2.81MPa due to Maximum interface pressure at this point.

Thoracolumbar Evaluation in the Low-Risk Trauma Patient: A Pilot Study Towards Development of a Clinical Decision Rule to Avoid Unnecessary Imaging in the Emergency Department.

Thoracolumbar (TL) injury is a common finding in the severely injured multi-trauma patient. However, the incidence and pattern of TL injury in patients with milder trauma is unclear. The aim of this study was to collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases. Adult patients with blunt trauma who presented to a major academic center (May 2016 to October 2017) and received dedicated imaging of the TL spine were included. Exclusion criteria consisted of any coexisting condition preventing the acquisition of history or examination. The primary endpoint is TL spine injury requiring orthopedic evaluation, bracing/orthosis, or surgery. Preliminary CDR derivation was performed with recursive partitioning. Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65years. No patients in this cohort with these four findings had a TL spine injury. In certain lower-risk blunt trauma patients < 65years of age, focused examination combined with mechanism of injury may be highly sensitive (100%) to rule out TL injury without the need for dedicated imaging. However, validation is necessary, given multiple study limitations. Potential instrument to screen for TL injury in minor trauma: TL injury is unlikely if all four of the following are present: 1) no midline back tenderness or deformity, 2) no focal neurologic signs or symptoms or altered mentation, 3) age < 65years; and 4) lack of severe mechanism of injury, for example, fall greater than standing, motor-vehicle collision with rollover/ejection/pedestrian or unenclosed vehicle, and assault with a weapon.

Percutaneous Vertebral Body Augmentations: The State of Art.

Osteoporotic compression fractures of the vertebral body can result in pain and long-term morbidity, including spinal deformity, with increased risk of mortality resulting from associated complications. Conservative management includes opioids and other analgesics, bed rest, and a back brace. For patients with severe and disabling pain, vertebral augmentation (vertebroplasty and kyphoplasty) is often considered, with these procedures endorsed by multiple professional societies, and provides immediate structural support, and stabilizes and reinforces the weakened bone structure. The purpose of this article is to review the vertebral biomechanics, indications and contraindications, and techniques of performing successful vertebral augmentation.

Experimental platform to facilitate novel back brace development for the improvement of spine stability

The spine or ‘back’ has many functions including supporting our body frame whilst facilitating movement, protecting the spinal cord and nerves and acting as a shock absorber. In certain instances, individuals may develop conditions that not only cause back pain but also may require additional support for the spine. Common movements such as twisting, standing and bending motions could exacerbate these conditions and intensify this pain. Back braces can be used in certain instances to constrain such motion as part of an individual’s therapy and have existed as both medical and retail products for a number of decades. Arguably, back brace designs have lacked the innovation expected in this time. Existing designs are often found to be heavy, overly rigid, indiscrete and largely uncomfortable. In order to facilitate the development of new designs of back braces capable of being optimised to constrain particular motions for specific therapies, a numerical and experimental design strategy has been devised, tested and proven for the first time. The strategy makes use of an experimental test rig in conjunction with finite element analysis simulations to investigate and quantify the effects of back braces on flexion, extension, lateral bending and torsional motions as experienced by the human trunk. This paper describes this strategy and demonstrates its effectiveness through the proposal and comparison of two novel back brace designs.

Concept and treatment outcomes of dynamic spinal brace for scoliosis in cerebral palsy.

We developed a novel device, dynamic spinal brace (DSB), with the basic concept of automatic correction by maximizing posture control. Herein, we report the structure of the DSB and preliminary treatment outcomes for scoliosis in patients with cerebral palsy. The study cohort comprised 219 patients with cerebral palsy treated for scoliosis with Cobb angle of at least 20° and follow-up of more than 3 years under the DSB. Cobb angle, trunk shift, and pelvic obliquity were assessed by semi-sitting radiography, and a questionnaire on daily lifestyle was collected. The immediate correction of these parameters by wearing DSB was demonstrated. In those who aged older than 15 years, the annual progression was 1.0°, and trunk shift was not deteriorated statistically. The questionnaire survey indicated that the DSB led to improvements in QOL and caregiving, and only 3.5% of the patients discontinued DSB because of intolerance. However, we could not find clear evidence that DSB affects the natural history of scoliosis in children with cerebral palsy.

Can I Stop Bracing Now? Utilizing Hand X-rays as Standalone Criterion for Discontinuation of Bracing in Adolescent Idiopathic Scoliosis

Category/Date Emerging Knowledge for Clinical Practice Podium Presentations focusing on the Research Agenda Priority of Pediatric Research: Chronic Illness, Presented at NAPNAP's 40th National Conference on Pediatric Health Care, March 8, 2019, New Orleans, LA. Purpose The purpose of this study is to determine if Sanders maturation stage 7 can be utilized as a stand-alone criteria for discontinuation of a thoracolumbosacral orthosis (TLSO) in adolescent idiopathic scoliosis (AIS). Background TLSO, or “bracing,” is a common treatment modality offered to skeletally immature patients with AIS. Maturation markers such as Risser sign on pelvis x-ray, growth velocity, time from first menses and curve stability are common factors utilized to determine end of brace treatment. However, these methods can be fraught with variability. The Sanders classification is a simplified, reliable bone age classification system that correlates strongly with the behavior of idiopathic scoliosis. Methods Inclusion criteria consisted of brace treatment in AIS measuring between 25 and 40 degrees, main cobb curve remaining Results Seventy-five patients (71 female [94.7%]; mean age 12.72 years) met the criteria. Main Cobb angle at brace application was 28.60°±4.38°. Forty-two patients had at least a one-year minimum follow up post treatment. One year after discontinuing the brace, eight patients (19%) increased 5 or more degrees (5°, 6°, 7°, 8°) above their largest curve measurement during treatment. Mean progression one-year post brace discontinuation was 2.28°±1.23°. Final mean Cobb angle measured 32.07° for the group. Two patients in the group had a Cobb measurement above 40° at one year after treatment. No significant difference in Cobb angle was found between pre brace measurements and end of brace treatment, nor between the end of brace treatment and at final follow up. No patient in the group progressed to surgical intervention. Discussion Eight patients (19%) increased more than 4° one year after the end of brace treatment, but no patient progressed to a curve that necessitated surgical intervention. Sanders maturation stage 7 may be useful as a stand-alone criterion for termination of brace treatment in AIS.

Full‐scale tests on used steel storage racks

AbstractIndustrial storage operators use not only new pallet racking systems, but also old ones for which certification documents possibly do not exist. In order to check the carrying capacity of such racks, in addition to component tests, full‐scale experimental tests were carried out on complete structures to help the development of reliable numerical models. The racks were subjected to vertical and pushover loads in the laboratory using an improved version of the base plates to achieve fixed support conditions. Vertical loading was imposed by filling tanks with water, an operation that was activated and controlled through an innovative hydraulic network specifically designed for this purpose. During the vertical loading tests, a moderate earthquake took place near the experimental facility and this influenced the rack behaviour positively. The spine brace was too flexible in the out‐of‐plane direction and did not participate in the resistance to lateral forces. Distortional buckling of the columns was observed at high lateral loads. The experimental tests allowed the calculation of conservative values for the behaviour factor q.

The effect of a semi-rigid thoracolumbosacral orthosis (TLSO) on foot pressure in elderly subjects presenting with spinal hyperkyphosis

Purpose: The ageing process can be accompanied by a degeneration of the spine and increase the risk of thoracic hyperkyphosis (excessive spinal forward curvature) amongst elderly people. This condition can in turn impair mobility, reduce balance, and increase the risk of falling and mortality in affected individuals. The use of corrective orthotic bracing has been shown to improve spinal posture, and increase stability and balance amongst the elderly. However, there is little evidence that evaluates the use of corrective braces on foot pressure changes in these subjects.Methods: In this study, we evaluated the use of a thoracolumbosacral orthosis (TLSO) on 19 subjects over 60 years old who presented with hyperkyphosis. We measured foot pressure using the Pedar-X system before (without brace) and after (with brace) immediate using a TLSO in both static (quite standing) and dynamic (walking on a 5 meters freeway) scenarios.Results: The results demonstrated that using a TLSO immediately decreases forefoot pressures in stasis, and around the first metatarsal, as well as pressures relating to the second to fifth metatarsals under dynamic conditions. Hindfoot pressures were increased, but not significantly.Conclusion: This study showed that using a TLSO can be beneficial for elderly people with hyperkyphosis.Implications for rehabilitationThe ageing process can be accompanied by a degeneration of the spine and increase the risk of thoracic hyperkyphosis.The use of corrective orthotic bracing has been shown to improve spinal posture, and increase stability and balance amongst the elderly.Using a TLSO decreases forefoot pressures in stasis, and around the first metatarsal, as well as pressures relating to the second to fifth metatarsals under dynamic conditions.

Impact modelling for progressive collapse assessment of selective rack systems

Storage rack structures are pre-engineered light weight steel structures with standard details which can be quickly assembled because all building components arrive on site pre-fabricated in line with the agreed design. Since they are made using thin-walled perforated steel sections, mostly cold-formed, with mechanical joints, generally partial-strength, semi-rigid, and with a low structural redundancy, these structures are vulnerable to any action capable to induce a local damage of a member or connection. When heavily loaded, the local damage may spread progressively, generating an overall collapse or disproportional damages. Difficulties in predicting the structural behavior of storage pallet racks are amplified by the specific geometry of the structural components: members made by high slenderness thin-walled and open-section profiles (hence prone to global, local and distortional buckling problems), flexible beam-to-upright and baseplate connections with a non-linear behavior. Due to their peculiarities, additional modelling and design rules are required for these non-traditional steel structures and reference cannot be made to usual structural design recommendations and standards. In case of Selective Pallet Rack (SPR) structures, except for the earthquakes, collision of forklift trucks or other moving equipment with front upright is considered as one of the most frequent causes of local failure, with potential to develop into a progressive collapse. In the study, the robustness of SPR structures under accidental loading situations involving collision with forklift truck is assessed using both notional upright removal and explicit forklift impact approaches. Structural configurations are varied to consider different connection properties (upright base and beam-to-upright) and brace arrangements (spine bracing, top plan bracing). SPR structures are susceptible to global failure, especially if the spine bracing is in just a few spans and the rigidity of connections is low. The explicit modelling of the forklift impact provides the most accurate results, as the effects associated with the forklift impact are not properly captured when the response is evaluated using the dynamic analysis and notional upright removal approach. Non-linear static pushdown analysis can provide satisfactory results at the least computational effort, but the dynamic increase factors may require corrections.

Identifying a Niche: Development of the Orthopedic Radiation Oncology Clinic

The Orthopedic Radiation Oncology Clinic (OROC) was recently developed to identify patients at risk of pathologic fracture of weight bearing long bones, to provide education to patients and staff regarding fracture risk and weight bearing restrictions, to provide rapid access for radiation therapy services, to provide timely access for orthopedic surgical interventions and to provide follow-up services for patients with Metastatic Bone Disease (MBD). At our institution, prior to the development of the OROC clinic, on-call orthopedic evaluation was utilized to determine a patient’s pending fracture risk as identified in the radiographic report. The use of orthotic devices was limited to spinal braces and Radiation Oncology follow-up care and rehabilitation services was minimal and inconsistent. As orthopedic surgical intervention reduces pain, preserves function, minimizes fracture risk and improves quality of life, the OROC clinic was developed as an interdisciplinary assessment for patients with MBD to the appendicular skeleton. It is facilitated by an Orthopedic Oncology Surgeon, a Radiation Oncologist and a Clinical Specialist Radiation Therapist (CSRT) and operates weekly. The CSRT is the liaison and primary contact for referring physicians and specialists. Within the OROC clinic, the responsibilities of the CSRT are to triage referrals, identify diagnostic imaging required for patient fracture risk assessment, coordinate rapid access radiation therapy, patient navigation including assessment and education. From April to July 2018, a retrospective quality assurance chart review from the OROC clinic was completed. Information regarding fracture risk category and interventions including referrals, orthotic devices and patient education material were collected. 29 patient consultations and 9 follow-up visits occurred. 11/29 (38%) patients were identified as high risk of pathologic fracture and received restricted weight bearing instructions. 5/29 (17%) were offered prophylactic orthopedic intervention. 20/29 (69%) received palliative radiation therapy. 4/29 (14%) were referred for prosthetic and orthotic devices and 3/29 (10%) were referred for physiotherapy services. Preliminary data supports the interdisciplinary OROC objective of providing rapid access to centralized coordinated care in an effort to improve patient education, time to treatment, provide follow-up and rehabilitation services. Future partnership with a community based rehabilitation program will ensure consistency of post treatment care for patients with skeletal related events of the appendicular skeleton. Further research is required to measure outcomes in addition to establishing best practices for patients with MBD of the appendicular skeleton.

MON-410 Ectopic ACTH- Secreting Tumor Causing Rapidly Progressive Cushing’s Syndrome Remains an Elusive Localization Diagnosis

Background: 68Ga-DOTATATE PET-CT (DOTATATE-PET) has higher sensitivity and positive predictive value than other studies, reason for which it has become the imaging modality of choice for Neuroendocrine tumor (NET) localization, but data on ACTH-secreting NET is scarce. Case summary: 61 year old female with history of right hepatic lobe lipoma resection, T2DM (A1c 9.4%), HTN, and benign thyroid nodule that was evaluated for cushingoid features with facial and lower extremity edema, progressive generalized weakness, difficulty climbing stairs, 20 lbs weight loss and intermittent hypokalemia while on a diuretic plus three other antihypertensives over a six month period. ACTH-dependent hypercortisolism was confirmed with a non-suppressed ODST 11.27mcg/dL (normal <1.8), elevated 24 hr urine free cortisol 525 mcg/24h (RR 4.0-50.0, total volume 3.85 L, creatinine 0.92 g/24 hr), midnight salivary cortisol 1.13 mcg/dL(RR ≤0.09), and ACTH 122 pg/mL (RR 6-50). Additionally, plasma metanephrines were negative, aldosterone <1 ng/dl (RR ≤21) and renin activity 0.58 ng/mL/h (RR 0.25-5.82). Cushing’s disease was suspected since her 8am cortisol suppressed >50% after 8 mg dexamethasone (dexa) overnight (pre-dexa cortisol 33.78 mcg/dL, post-dexa cortisol 6.59 mcg/dL). However, MRI Sella did not show a pituitary adenoma and IPSS was compatible with Ectopic ACTH-secretion (EAS). CT chest, abdomen, pelvis with contrast did not reveal any frank lesion that could be the culprit of EAS. Octreoscan and FDG-PET were negative. DOTATATE-PET reported a mild focus of uptake on the medial aspect of the right upper lung lobe, thought to be a branching blood vessel since no anatomic lesion was seen on CT Chest that would correspond to the possible area of uptake. In the interim, she developed diffuse ecchymosis with worsening of her functional status, needing a walker and assistance with activities of daily living. She had several falls complicated by multiple lumbar compression fractures, rib, right pubic ramus and bilateral sacral insufficiency fractures for which she received reclast, a back brace and physical therapy. She was started on ketoconazole and titrated up, but due to rapid progression of her Cushing syndrome over five months without an identifiable source of EAS, the decision was made to proceed with bilateral adrenalectomy and perform surveillance imaging to identify growth of a possible occult NET. Conclusion: In our case, DOTATATE-PET did not help to localize an ACTH-secreting NET, suggesting that the sensitivity of this study might not be as good as reported for other types of NET. Therefore, Occult EAS remains a diagnostic challenge and clinicians may resort to bilateral adrenalectomy for permanent biochemical control and serial CT imaging to detect an incipient NET.

In-brace alterations of pulmonary functions in adolescents wearing a brace for idiopathic scoliosis.

Despite the common use of braces to prevent curve progression in idiopathic scoliosis, their functional effects on respiratory mechanics have not been widely studied. The objective was to determine the effects of bracing on pulmonary function in idiopathic scoliosis. A total of 27 adolescents with a mean age of 14.5 ± 1.5 years and idiopathic scoliosis were included in the study. Pulmonary function evaluation included vital capacity, forced expiratory volume, forced vital capacity, maximum ventilator volume, peak expiratory flow, and respiratory muscle strengths, measured with a spirometer, and patient-reported degree of dyspnea. The tests were performed once prior to bracing and at 1 month after bracing (while the patients wore the brace). Compared with the unbraced condition, vital capacity, forced expiratory volume, forced vital capacity, maximum ventilator volume, and peak expiratory flow values decreased and dyspnea increased in the braced condition. Respiratory muscle strength was under the norm in both unbraced and braced conditions, while no significant difference was found for these parameters between the two conditions. The spinal brace for idiopathic scoliosis tended to reduce pulmonary functions and increase dyspnea symptoms (when wearing a brace) in this study. Special attention should be paid in-brace effects on pulmonary functions in idiopathic scoliosis. Bracing seems to mimic restrictive pulmonary disease, although there is no actual disease when the brace is removed. This study suggests that bracing may result in a deterioration of pulmonary function when adolescents with idiopathic scoliosis are wearing a brace.

My Wife's Back.

My Wife's Back.

Is routine MRI of the spine necessary in trauma patients with ankylosing spinal disorders or is a CT scan sufficient?

BackgroundAnkylosing spinal disorder (ASD) patients are at a greater risk for spinal fractures due to osteoporosis and rigidity of the spinal column. These fractures are associated with a high risk of neurologic compromise resulting from delayed or missed diagnoses. Although computed tomography (CT) is usually the initial imaging modality, magnetic resonance imaging (MRI) has been proposed as mandatory to help identify spinal injuries in ASD patients with unexplained neck or back pain or known injuries to help identify noncontiguous fractures. However, some studies have also shown that neurological injury can result from the required patient transfer and positioning for an MRI. PurposeThe purpose of our study was to assess the frequency with which an MRI identified an injury not previously identified with CT, and whether this affected the treatment and outcome of the patient. Secondarily, we attempted to identify clinical or CT findings that may render an MRI particularly useful. Study DesignRetrospective review. Patient SamplePatients with ASD who sustained acute spine fractures from 2005 to 2015. Outcome MeasuresAcute fractures identified by CT scan and MRI upon admission; neurologic status upon admission and discharge, mode of injury, type of fracture, and final intervention before and after MRI assessment. MethodsA total of 124 patients with a diagnosis of diffuse idiopathic skeletal hyperostosis (DISH) or ankylosing spondylitis (AS) were identified by searching the radiology database of a level I trauma center with diagnosis keywords. Final radiology reports were assessed to determine presence and type of fracture(s) from CT. MRI report was then reviewed to assess if additional fractures or injuries were identified beyond that already known from the CT. Neurologic status upon admission and discharge, mode of injury, type of fracture, and final intervention were determined by inpatient notes and/or operative reports. No source funding or conflict of interest was present pertaining to this study. ResultsIn the designated time frame, 124 ASD patients with injuries of the spine were identified who had obtained both a baseline CT and MRI. Six patients (4.8%) had additional injuries on MRI that had not been identified with CT. Four of these six patients had a change in treatment plan (three operative and one nonoperative) based on subsequent MRI findings. These included a (1) C4–5 hyperextension injury, (2) C6–7 hyperextension injury, (3) C7 bony fracture with C5–T4 epidural hematoma, and (4) C5–C6 hyperextension injury treated in a brace. Two of the six patients that had additional injuries identified on MRI had no change in their treatment plan. One patient had an additional lumbar extension injury identified above a previously diagnosed injury on CT, which was managed with a Thoracolumbosacral Orthosis (TLSO) according to the original plan. One patient died who had a known odontoid fracture and a suspected C6–7 hyperextension injury, and was identified on MRI as also having a C3–C4 hyperextension injury and a C2 spinal cord transection. ConclusionsIn this study, 3.2% (4/124) of patients with ASD who presented to a level I trauma center with an acute spine injury identified with CT required a change in their treatment plan based on subsequent MRI findings. Only one fracture was missed on CT imaging, with the other missed injuries all being either disco-ligamentous hyperextension injuries through mobile discs or intracanal pathology. Our recommendation is that the routine use of MRI be limited to patients with nonankylosed levels in which a disco-ligamentous injury may have occurred, and in patients with neurological deficits that require investigation of the spinal canal to assess for causes of neurological injury.

Reducing Radiation and Lowering Costs With a Standardized Care Pathway for Nonoperative Thoracolumbar Fractures.

Study Design:Retrospective observational study.Objective:There is marked variation in the management of nonoperative thoracolumbar (TL) compression and burst fractures. This was a quality improvement study designed to establish a standardized care pathway for TL fractures treated with bracing, and to then evaluate differences in radiographs, length of stay (LOS), and cost before and after the pathway.Methods:A standardized pathway was established for management of nonoperative TL burst and compression fractures (AOSpine classification type A1-A4 fractures). Bracing, radiographs, costs, complications, and LOS before and after pathway adoption were analyzed. Differences between the neurosurgery and orthopedic spine services were compared.Results:Between 2012 and 2015, 406 nonoperative burst and compression TL fractures were identified. A total of 183 (45.1%) were braced, 60.6% with a custom-made thoracolumbosacral orthosis (TLSO) and 39.4% with an off-the-shelf TLSO. The number of radiographs significantly reduced after initiation of the pathway (3.23 vs 2.63, P = .010). A total of 98.6% of braces were custom-made before the pathway; 69.6% were off-the-shelf after the pathway. The total cost for braced patients after pathway adoption decreased from $10 462.36 to $8928.58 (P = .078). Brace-associated costs were significantly less for off-the-shelf TSLO versus custom TLSO ($1352.41 vs $3719.53, respectively, P < .001). The mean LOS and complication rate did not change significantly following pathway adoption. The orthopedic spine service braced less frequently than the neurosurgery service (40.7% vs 52.2%, P = .023).Conclusions:Standardized care pathways can reduce cost and radiation exposure without increasing complication rates in nonoperative management of thoracolumbar compression and burst fractures.

Effects of a Standardized Care Protocol for Patients with Degenerative Spine Disease

Background:Many patients facing spinal surgery experience fear and anxiety about surgery, anesthesia, risk of postoperative pain or complications, or even death. Spinal surgery patients often experience mobility disorders due to lasting postoperative pain and require aids such as spinal braces, which can induce depression. Alleviating patients’ anxiety and depression during the perioperative period by utilizing consistent and standardized information is required for high-quality care.Objective:We developed and assessed a standardized care protocol for degenerative spinal surgery patients.Methods:The protocol was developed through focus group interviews with spinal surgery patients and the recommendations of an expert panel. Then, a quasi-experimental design was employed to comparatively study patients undergoing spinal surgery. Ninety-eight Patients were assigned to either a treatment group (n= 49) or a control group (n= 49). The treatment group received an intervention based on the newly developed standardized care protocol, while the control group received traditional care. After treatment, participants’ anxiety, depression, uncertainty, and care satisfaction were compared between groups.Results:Patients who had received the care protocol-based intervention showed lower anxiety, depression, and uncertainty, and higher satisfaction than did those who received traditional care.Conclusion:The developed care protocol may be useful for reducing anxiety and depression and for improving the healthcare provided to spinal surgery patients, as it involves the proactive dissemination of accurate information throughout the hospitalization process. The protocol also positively affected patients’ uncertainty and satisfaction with their medical care.

Predictive factors for brace treatment outcome in adolescent idiopathic scoliosis: a best-evidence synthesis.

To evaluate predictive factors for brace treatment outcome in adolescent idiopathic scoliosis (AIS) by a systematic review of the literature. Eligible studies evaluating one or more predictive factors for brace treatment outcome were included following a systematic search in PubMed and EMBASE on October 23, 2017. Inclusion criteria were: (1) subjects diagnosed with AIS, (2) age ≤ 18years, (3) treated with a thoraco-lumbo-sacral orthosis (TLSO), and (4) evaluated one or more predictive factors of treatment outcome (failure and/or success). The methodological quality of included studies was independently assessed by two authors. Pooling was not possible due to heterogeneity in statistical analysis. Predictive factors were presented according to a best-evidence synthesis. The literature search identified 26 studies that met the inclusion criteria, and multiple types of TLSO braces were identified (Boston, Wilmington, Chêneau, Osaka Medical College, Dresdner Scoliosis Orthosis and SPoRT). A total of 19 radiographic and 8 clinical predictive factors were reported. Strong evidence was found that lack of initial in-brace correction is associated with treatment failure. Moderate evidence suggests that brace wear time is associated with failure and success, whereas initial curve magnitude and curve type are not. The results of this review suggest that lack of initial in-brace correction is strongly associated with brace treatment failure. Future studies on the threshold for minimal immediate in-brace correction, as a potential indication for brace treatment, are recommended. These slides can be retrieved under Electronic Supplementary Material.