The Use of Spinal Orthoses After Spinal Cord Injury David X

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The Use of Spinal Orthoses After Spinal Cord
Injury

• David X. Cifu, M.D.
• The Herman J. Flax, M.D. Professor and Chairman
• Department of Physical Medicine and
  Rehabilitation
• Virginia Commonwealth University

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SCI Rehabilitation Model Systems Project

• 16 centers across the United States with uniform
  admission criteria and rehabilitation care
  protocols.
• More than 20,000 subjects since mid-1970s.
• This research supported by the National Institute
  on Disability and Rehabilitation Research, Office
  of Special Education and Rehabilitation and
  Rehabilitative Services, U.S. Department of
  Education Grant H133N50015

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Spinal Cord Injury

• SCI incidence in the United States is 30 to 40
  per million, or 7000-10,000 new cases annually.
• While SCI occurs predominantly in individuals
  aged 16 to 30 ( 60), over the past quarter
  century the age at time of SCI has been rising .
• Nearly 20 of new SCI injuries occur in those
  over 60 years

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Spinal Cord Injury

• Short term costs range from 100,000 - 1 million.
• Lifetime medical costs exceed 1 million/person.
• Significant burden on non-medical system (family,
  vocational, formal support systems)

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Spinal Cord Injury

• Extensive short and long-term medical issues
• Neurogenic bowel and bladder
• Cardiovascular
• Pulmonary
• Integument (Skin)
• Osteoporosis
• Pain

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Spinal Orthoses History

• Ancient Egyptians used first splints nearly 5,000
  years ago, but 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

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Spinal Orthoses History

• Lorenz Heister is credited with developing the
  first 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.

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Spinal Orthoses Principles

• Four objectives of spinal orthoses
• controlling spinal position by external forces
• applying corrective forces to abnormal curvatures
• providing spinal stabilization when soft tissues
  cannot
• restricting spinal segment movement after trauma

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Spinal Orthoses Principles

• Orthoses work through the biomechanical effects
  of a three-point pressure system on
• trunk and head support
• motion control
• spinal realignment
• partial weight transfer of the head to the trunk
  when in upright

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Spinal Orthoses Principles

• Orthoses effectiveness is affected by
• points of application
• direction and magnitude of the forces applied
• tightness of the device
• type of trauma/injury and the instability
  produced
• body habitus of the individual wearing it

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Spinal Orthoses Principles

• Spinal orthoses can also have significant
  negative effects
• axial muscle atrophy secondary to reduced
  activity
• immobilization can promote contractures
• excess pressure, irritation, and moisture
  build-up can result in skin breakdown
• psychological dependency can occur that increases
  physical dependence
• significant functional limitations of orthoses
  can have untoward psychosocial and economic
  effects

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Cervical Orthoses

• To be effective they must control both gross and
  intersegmental movements of the head and neck.
• C0-C1 segment involves significant
  flexion-extension, minor lateral bending and
  little rotation.
• C1-C2 segment involves primarily rotation (50 of
  all rotation) with limited flexion-extension.
• C3-C7 segments involve flexion extension (C5-C7),
  lateral bending (C2-C3), and rotation (C2-C3).

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Cervical Orthoses

• Challenges to immobilization
• extremely mobile joint complex with multiple
  planes
• little body surface available for contact
• high incidence of skin breakdown (occiput, chin)
• pressure-related pain common (clavicles, chin)
• hygiene issues limit comfort (shaving)
• Opportunities
• strong interest in pre-hospital immobilization
  systems
• 40-million/year market

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Cervical Orthoses Collars

• Cervical collars 25-100 normal motion
• soft/foam - inexpensive and comfortable no
  immobilization provides warmth and psychological
  support primarily serves as a reminder 75-100
  normal motion
• hard/rigid - mildly limits flexion/extension if
  optional occipital/mandibular struts in place no
  limitation of lateral bending or rotation
  painful at clavicles
• Philadelphia - significantly limits
  flexion/extension primarily 25-30 normal motion
  uncomfortable at clavicles
• Other - Jobst Vertebrace, Miami J, Aspen/Newport,
  NecLoc may be slightly superior to Philadelphia

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Cervical Orthoses Posters

• Poster Appliances 10-28 normal motion
• Four poster - mandibular/occipital supports with
  struts to anterior/posterior thoracic plates
  excellent limitation of flexion/extension.
• Guilford/Two Poster - similar to four poster with
  addition of axilla straps and thoracic belt.

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Cervical Orthoses CTOs

• Cervicothoracic Orthoses 10-25 normal motion
• Yale - Combination of a high Philadelphia collar
  with thoracic jacket and axillary straps
  Excellent flexion/ extension control Fair
  rotation control
• SubOccipital Mandibular Immobilizer (SOMI) -
  Similar to four poster with crisscrossing full
  thoracic body jacket removable head strap to
  allow mandibular support to be removed with
  eating may be applied w/o turning patient
  comfortable Fair restriction of
  flexion/extension only

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Cervical Orthoses Halos and Beyond

• Halo devices 10-25 normal motion
• Halo Vest - metal/graphite ring attached to the
  skull in 4 points affixed to full thoracic vest
  by 4 posters Excellent control of all motions
• Halo Cast - similar to vest except cast is
  fabricated to get improved purchase
• Thermoplastic Minerva Body Jacket (TMBJ)
• improvement over casted version (lighter) may be
  as effective as Halo vest non-invasive (no pins)

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Cervical Orthoses Utility

• Orthoses do not achieve total or near total
  immobility. Overall fit quite variable and will
  change with usage.
• In the face of neurological deficit, non-surgical
  patients require 3 months orthosis.
• When good anatomic alignment can be achieved,
  need for surgery is unclear.
• Non-surgery patients have better long-term ROM.
• Surgical patients require 6 weeks orthosis.

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Cervical Orthoses Utility

• Higher cervical injuries are better immobilized.
• Individuals with injuries to the facet joints
  (dislocation /- fracture) are most likely to
  need surgery.
• A patient who is unstable at 6 weeks
  (post-surgery) or 12 weeks (non-surgical) despite
  orthosis use will need later surgery (although
  instability is not necessary absolute
  indication).
• Rapid mobilization achieved with either method.

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ThoracoLumbar Orthoses

• More commonly prescribed than cervical orthoses.
• Similar immobilization issues as in cervical
  region. Sacrum is the foundation of the spine.
• Actual control of motion poorly studied.
• Extensive research on the usage of TLOs
  (variable types) in the prevention of injuries
  has not demonstrated any reduction in stresses to
  the spine, muscles, or abdominal contents with
  these devices.

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ThoracoLumbar Orthoses

• Thoracic Motion
• horizontally-oriented facets and ribcage
  attachments to sternum limit flexion/extension,
  exc. In lower region.
• 6-9 degrees of lateral bending and rotation in
  each segment.
• Lumbar motion
• Predominant motion is flexion/extension, followed
  by lateral bending and then rotation.
• Greatest flexion/extension and least
  bending/rotation at L5-S1.

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Lumbosacral Orthoses Types

• Lumbosacral Orthoses
• Chairback brace - anterior corset/apron with
  midaxillary metal uprights controls flexion
  extension
• Williams brace - allows free flexion and limits
  extension uses lever action and abdominal
  support to decrease lordosis

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ThoracoLumbar Orthoses Types

• Thoracolumbar Orthoses (TLSOs)
• Taylor brace - Thoracolumbar corset with axillary
  straps designed to limit flexion/extension Poor
  efficacy
• Molded jackets - thermoplastic or casted highest
  efficacy to control post-fracture/injury spinal
  motion
• Jewett Hyperextension brace - three-point
  pressure over sternum, pubis and posterior lumbar
  spine prevents flexion used with compression
  fractures not indicated with osteoporosis
  secondary to excess forces generated

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Thoracolumbar Orthoses Utility

• Orthoses do not achieve total or near total
  immobility. Overall fit quite variable and will
  change with usage.
• In the face of neurological deficit, surgery is
  typically performed.
• Even when good anatomic alignment can be
  achieved, surgery is often needed.
• Non-surgery patients have better long-term ROM.
• Surgical patients require 6 weeks orthosis.

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Thoracolumbar Orthoses Utility

• Thoracic injuries are better immobilized than
  lumbar.
• Individuals with significant ligamentous injury
  and instability are most likely to need surgery.
• A patient who is unstable at 6 weeks
  (post-surgery) or 12 weeks (non-surgical) despite
  orthosis use will need later surgery (although
  instability is not necessary absolute
  indication).
• Rapid mobilization best achieved with surgery.

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Summary

• SCIs are an infrequent but potentially
  devastating injury that greatly stress healthcare
  and psychosocial resources.
• Integrated systems of care are necessary to
  optimally manage care after SCI.
• Rapid and safe mobilization with surgery and
  orthoses is key to efficient and successful
  rehabilitation.
• Initial and long-term orthosis fitting is crucial.

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SCI Classification

• ASIA Classification identifies lowest level of
  normal function (C1 - S5) and degree of
  completeness
• A - Motor and Sensory Complete
• B - Motor Complete
• C - Motor Incomplete but non-functional
• D - Motor Incomplete, functional
• E - Recovery of Neurologic Function

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SCI Classification

• Tetraplegia - Arms and Legs involved (C1-7)
• Paraplegia - Trunk and Legs involved (T1-S5)
• Central Cord - Arms predominantly involved
• Brown Sequard - Motor weakness on one side of
  body and sensation deficits on other
• Cauda Equina - Predominant bowel and bladder
  deficits with mild leg weakness

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SCI Common Issues

• Spinal Stability
• Pulmonary
• Neurogenic Bowel and Bladder
• Immobility Skin Breakdown/DVT
• Spasticity
• Autonomic Dysreflexia/Cardiovascular
• Bracing/Equipment
• Heterotopic Ossification
• Pain

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SCI Spinal Stability

• Stabilizing the spine is necessary before
  mobilization to prevent worsened injury and
  decrease pain.
• Surgery has not been specifically demonstrated as
  superior to bracing, but typically performed. May
  allow earlier mobilization.
• Spinal bracing often present for 6-12 weeks.
  Uncomfortable and difficult to maintain.

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SCI Pulmonary

• Pulmonary compromise is common with injuries
  involving the cervical region. Diaphragm
  innervated from C3-5. Also, muscles of chest wall
  and abdomen are needed for optimal breathing.
• Individuals with C4 injuries (motor complete) and
  above may require lifetime ventilation. Newer
  techniques are improving this.
• Higher short and long-term incidence of pneumonia
  in individuals with cervical injuries.

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SCI Neurogenic B/B

• Control of Bowel and Bladder function maintained
  at 3 levels
• Frontal Cortex Social control empty at set
  volumes
• Pontine Hyperreflexic B/B may empty partially,
  need assistance with full (intermittent
  catheterization, bowel program)
• Lumbar Hyporeflexic B/B Bladder and Rectum are
  like flaccid sacs, emptying occurs with excess
  volumes Good control challenging

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SCI Sexuality

• Sexuality entails much more than the waterworks,
  however challenging for younger individuals to
  get beyond it.
• Cervical and thoracic injuries are more likely to
  have reflex erectile function (rarely enough to
  achieve penetration/ejaculation).
• Lumbar and sacral injuries rarely demonstrate
  erectile function.
• Interventions range from Viagra to Pneumatic
  devices. Electroejaculation available.

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SCI DVT

• Deep venous thromboses are blood clots in the
  venous system related to vessel wall trauma,
  hypercoagulability from trauma, and immobility.
• Occur in 40-60 of SCIs. Most common cause of
  late death. Often asymptomatic acutely. Cause
  chronic edema and pain.
• Prophylaxis with anticoagulant is effective and
  needed for 8-12 weeks.
• Treatment with anticoagulant is necessary for 3-6
  months.

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SCI Skin Breakdown

• Due to the inability of individuals with SCI to
  move/turn in bed and chairs, excess skin
  pressures occur rapidly. Skin breakdown occurs
  within 2 hours of immobility.
• Decreased sensation limits patient input.
• Initially, repositioning every 2 hours is needed.
• Skin ulcers are common and take weeks to months
  to heal (25,000 each). Healing occurs with
  preventing pressure and keeping area clean/dry.

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SCI Spasticity

• Any upper motor neuron (brain/spinal cord) injury
  can result in an imbalance of excitatory to
  inhibitory neurotransmitter release to muscles.
• Spasticity is increased, velocity dependent
  resistance to stretch in muscle groups.
• Limits motion of joints and utility of preserved
  muscle strength, may be painful, may cause falls
  or functional deficits. On the other hand, may
  maintain muscle bulk, decrease pressure ulcers,
  and prevent DVTs.

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SCI Spasticity

• In many patient, spasticity improves over first
  3-6 months.
• Treatment initially entails decreasing irritant
  foci that may potentiate (full bladder, pressure
  ulcer, ingrown toenail, tight fitting garments)
• Treatment also entails stretching, positioning,
  and desensitizing extremities.
• Numerous systemic (Baclofen, Dantrium) and focal
  (Botox, Myobloc) medications that are effective.

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SCI Autonomic Dysreflexia

• In individuals with SCI above T6 level, there is
  a disconnect between the sympathetic and
  parasympathetic autonomic nervous systems.
• Stimuli of parasympathetics may set off unblocked
  sympathetic response resulting in elevated BP and
  headache. Can result in stroke/death if
  untreated.
• All individuals with SCI experience significant
  cardiovascular deconditioning over time,
  accelerated compared to non-SCI. Close medical
  f/u and encouraging aerobic exercise is vital.

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SCI Bracing

• Extensive assortment of arm and leg orthoses to
  stabilize joints, substitute for weak muscles,
  and facilitate function.
• Upper extremity devices to achieve various types
  of gripping and holding for C7 and higher
  individuals are commonly used long-term.
• Lower extremity braces that allow functional
  transfers or walking, without the assist of
  another, are also commonly used long-term.

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SCI Wheelchairs

• Individuals with C6 and below SCI can
  independently propel W/Cs. Electric W/Cs are
  common above.
• Lightweight (20 lbs) chairs are typical for
  functional mobilizers.
• Individuals with C5 and below can commonly
  operate motor vehicles (with/without
  modifications).

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SCI Heterotopic Ossification

• Abnormal deposition of calcium in muscle or
  around joints in the first 4-12 weeks
  post-injury.
• Unclear etiology, although traumatized joints and
  muscle at highest risk.
• Symptoms include pain, swelling, and redness.
  Occurs below the level of the lesion.
• Treatment is early identification to facilitate
  rapid mobilization and medication management.

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SCI Pain

• Pain is common symptom following trauma of SCI as
  well as neurologic disruption.
• Soft tissue pain usually improved by 6 weeks.
• Neuropathic pain common at zone of injury.
  Challenging to treat, often undertreated.
  Medications include antiepileptics (Tegretol,
  Neurontin), tricyclic antidepressants (Elavil),
  antiinflammatories, narcotics, local patches
  (Lidocaine) and liniments (Capsaisin).

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Thank you for your attention