What are the most commonly used types of fullcontact TLSOs

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CUSTOM-MOLDED TLSO (Fig. 18-15)

Design. Plastic jacket provides total body contact except over bony prominences. Available in one- or two-piece construction with anterior, posterior, or side-opening styles

Indications. Immobilization of the spine between T8 and L4. Provides adequate rotational control for treatment of stable spine fractures in this region

CUSTOM-MOLDED TLSO WITH CERVICAL EXTENSION (Fig. 18-16)

Design. Custom-molded TLSO with attached chin and occiput support

Indications. Immobilization of the spine between T1 and T7. Provides adequate rotational control for treating stable spine fractures in this region

CUSTOM-MOLDED TLSO WITH THIGH CUFF (Fig. 18-17)

Design. Custom-molded TLSO with attached thigh cuff. Thigh cuff may be fixed or may be attached via hinges with a drop lock

Indications. Immobilization of the spine between L4 and S1

Figure 18-15. Custom-molded thoracolumbosacral orthosis.

Figure 18-16. Custom-molded thoracolumbosacral orthosis with cervical extension.

Figure 18-17. Custom-molded thoracolumbosacral orthosis with thigh cuff.

Figure 18-15. Custom-molded thoracolumbosacral orthosis.

Figure 18-16. Custom-molded thoracolumbosacral orthosis with cervical extension.

Figure 18-17. Custom-molded thoracolumbosacral orthosis with thigh cuff.

HYPEREXTENSION CAST (Fig. 18-18)

Design. Custom-molded cast is placed with the patient positioned on a table or frame, which extends the injured spine segment Indications. Treatment of select thoracolumbar fractures (burst fractures without neurologic deficit, Chance fractures involving only bone). A reasonable option in unreliable patients who are likely to be noncompliant with bracing

18. When an orthosis is indicated for immobilization of a stable thoracic or lumbar fracture, what are the most important factors to consider in selection of the appropriate type of orthosis?

The level of injury is a critical factor to consider in orthotic selection for a thoracic or lumbar fracture. For an orthosis to limit motion in a specific region of the spine, the orthosis must extend proximal and distal to the level of injury and immobilize the adjacent spinal segments. A TLSO is generally recommended if rigid immobilization is required from the T8 to L4 level. If the fracture involves L5, a thigh cuff should be added. If control is required proximal to T8 level, a cervical extension should be added. A halo or Minerva orthosis can effectively immobilize from the T1 level cephalad. The type of spine fracture, associated injuries (e.g. pulmonary, abdominal), and the patient's body habitus are additional important factors to consider in decision making.

19. What are some contraindications to orthotic treatment for thoracic and lumbar spine fractures?

• Unstable fracture types (fracture-dislocation, significant ligamentous injury, e.g. Chance fracture, flexion-distraction injury)

• Incomplete neurologic deficit (surgery for decompression and stabilization indicated)

• Morbid obesity

• Polytrauma or associated injuries that prohibit brace wear (e.g. pulmonary or abdominal injury)

• Impaired mental status

• Impaired skin sensation

• Noncompliant patient

20. What are reasons to consider use of an orthosis following a spinal fusion procedure?

At present, spinal fusion procedures are most commonly performed in conjunction with the placement of segmental spinal instrumentation. If the patient is reliable, possesses good bone quality, and multiple fixation points are used, postoperative bracing is not mandatory after a spinal instrumentation and fusion procedure. Reasons to consider use of a spinal orthosis following a spinal fusion procedure.

• To provide a splinting effect to relieve pain and limit trunk motion. Use of an orthosis can increase intraabdominal pressure, which has the potential to provide a splinting effect that may help relieve pain during the initial recovery period. An orthosis can also provide a postural reminder to limit extreme body motions

• To protect spinal implants from excessive forces. Young children tend to become active prematurely and may disrupt spinal fixation. Adults with osteopenia may also benefit from bracing to protect the implant-bone interface

• To provide immobilization after a lumbar fusion performed without use of spinal implants

21. What are the most commonly prescribed orthoses for treatment of lumbar and lumbosacral disorders?

Various types of LSOs exist ranging from custom-molded LSOs to elastic binders. LSOs stabilize the lumbar and sacral regions by encircling the upper abdomen, rib cage, and pelvis. Motion restriction provided by molded LSO does not approach the restriction provided by a molded TLSO. In contrast to a TLSO, an LSO does not extend over the thorax and cannot limit motion by a three-point bending mechanism. Instead, LSOs function by fluid compression of the abdominal cavity and restriction of gross body motion. They provide only mild restriction of flexion and extension and minimal restriction of side bending and rotation. LSOs are not sufficiently restrictive for immobilization of lumbar spine fractures. Nonrigid LSOs such as corsets, sports supports, and binders do not provide meaningful restriction of spinal motion but exert an effect providing a reminder to maintain proper posture, supporting weak abdominal musculature and reducing pain by limiting gross trunk motion. CUSTOM-MOLDED LSO (Fig. 18-19) Design. Custom made from patient mold

Indications. Chronic low back pain of musculoskeletal origin, postsurgical immobilization

Figure 18-18. Hyperextension cast.

CHAIRBACK LSO (Fig. 18-20)

Design: Composed of a posterior frame of Kydex with a fabric abdominal panel. Adjustable laces provide side closure and front straps provide front tightening Indications: Low back pain exacerbated by lumbar extension CORSET (Fig. 18-21)

Design: Canvas garment with side-pull tightening straps and paraspinal steel stays Indications: Mechanical low back pain ELASTIC BINDER (Fig. 18-22)

Design: Broad elastic straps are fastened with Velcro closure

Indications For postural support with minimal discomfort. Good choice for a patient with a pendulous abdomen or weak abdominal musculature SPORTS SUPPORT (Fig. 18-23)

Design: Consists of a heavy-duty elastic binder with a posterior neoprene pocket. The pocket holds a thermoplastic panel that is heated and contoured to the patient's lumbosacral region Indications: For patients whose shape or activity level precludes use of a more restrictive orthosis SACROILIAC ORTHOSIS (Fig. 18-24)

Design: Belts that wrap around the pelvis between the trochanters and the iliac crests

Indications During pregnancy when laxity of the sacroiliac or anterior pelvic joints may cause pain or for other conditions affecting the sacroiliac joints

Figure 18-19. Custom molded lumbosacral Figure 18-20. Chairback lumbosacral Figure 18-21. Corset.

orthosis. orthosis.

Figure 18-19. Custom molded lumbosacral Figure 18-20. Chairback lumbosacral Figure 18-21. Corset.

orthosis. orthosis.

Figure 18-23. Sports support.

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