The orthotic treatment of acute and chronic disease of the cervical and lumbar spine

[Conservative treatment of trauma-associated fractures of the cervical spine with orthoses-A review]

BACKGROUND

Traumatic injuries of the cervical spine are common and can significantly differ in the prognosis and treatment depending on the structure affected. We present the current evidence for conservative treatment of these fractures with orthoses in this review.

METHODOLOGY

The literature search followed the PRISMA protocol. The risk of bias was assessed using ROBINS‑I and evidence levels were determined according to AHCPR.

RESULTS

A total of 22 studies were identified. The level of evidence according to AHCPR is limited (IIb, III and IV) and every study had a serious risk of bias in at least one subdivision. Of the authors 11 presented conservative treatment concepts for C2 dens fractures, 7 studies focussed on vertebral arch fractures and 9 on vertebral body fractures. Radiological parameters (kyphosis angle, bone consolidation) and the neurological status were frequently reported as endpoints.

CONCLUSION

Stable C2 dens fractures without relevant clinical restrictions allow conservative treatment in a rigid cervical orthosis under radiological monitoring every 1-4 weeks. Type II fractures require special attention due to the risk of instability. Hangman's fractures can be safely treated in rigid cervical orthoses. The current state of knowledge does not allow any recommendation for conservative treatment of Hangman's fractures with orthoses. Stable vertebral body fractures without involvement of the spinal canal can also be treated conservatively with orthotic devices. Randomized controlled studies are required to develop a secure state of evidence and are currently not available.

Spinal Orthoses in the Treatment of Osteoporotic Thoracolumbar Vertebral Fractures in the Elderly: A Systematic Review With Quantitative Quality Assessment

STUDY DESIGN

Systematic review.

OBJECTIVES

Spinal orthoses are frequently used to non-operatively treat osteoporotic vertebral fractures (OVF), despite the available evidence is rare. Previously systematic reviews were carried out, presenting controversial recommendations. The present study aimed to systematic review the recent and current literature on available evidence for the use of orthoses in OVF.

METHODS

A systematic review was conducted using PubMed, Medline, EMBASE and CENTRAL databases. Identified articles including previous systematic reviews were screened and selected by three authors. The results of retrieved articles were presented in a narrative form, quality assessment was performed by two authors using scores according to the study type.

RESULTS

Thirteen studies (n = 5 randomized controlled trials, n = 3 non- randomized controlled trials and n = 5 prospective studies without control group) and eight systematic reviews were analyzed. Studies without comparison group reported improvements in pain, function and quality of life during the follow-up. Studies comparing different types of orthoses favor non-rigid orthoses. In comparison to patients not wearing an orthosis three studies were unable to detect beneficial effects and two studies reported about a significant improvement using an orthosis. In the obtained quality assessment, three studies yielded good to excellent results. Previous reviews detected the low evidence for spinal orthoses but recommended them.

CONCLUSION

Based on the study quality and the affection of included studies in previous systematic reviews a general recommendation for the use of a spinal orthosis when treating OVF is not possible. Currently, no superiority for spinal orthoses in OVF treatment was found.

Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To evaluate systematically the complications of prolonged cervical immobilisation in a hard collar.

METHODS

Following registration with PROSPERO, a systematic search of electronic databases (MEDLINE, EMBASE) was conducted. Two reviewers independently screened the search results according to pre-determined search criteria. Data was extracted and tabulated. Joanna Briggs Institute checklists were used for assessing the quality of included studies.

RESULTS

The search identified 773 articles. A total of 25 studies were selected for final inclusion. The results largely comprised a mixture of case reports/series, cohort studies and reviews. The most commonly reported complications were pressure ulcers, dysphagia and increased intracranial pressure. A pressure ulcer pooled prevalence of 7% was calculated. There was insufficient data for quantitative analysis of any other complication.

CONCLUSIONS

There is significant morbidity from prolonged hard collar immobilisation, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.

[Treatment of trauma-related vertebral body fractures of the thoracic and lumbar spine with orthotic devices : A review]

BACKGROUND

Trauma-related fractures of the thoracic and lumbar spine occur after exposure to high kinetic energy. To assign patients to the correct kind of treatment the AO spine classification is used.

OBJECTIVE

The aim was to describe the role of orthotic devices in the treatment of thoracic and lumbar fractures in the nondegenerative spine.

MATERIAL AND METHODS

A review of the literature was carried out according to the PRISMA protocol (Preferred Reporting Items for Systematic reviews and Meta-Analyses) in PubMed, ScienceDirect, Cochrane and Google.Scholar. A total of 118 potentially important publications were found and 16 studies with a prospective study design could be included in this analysis. RoB 2 (Cochrane Risk of Bias tool in the second Version) in the case of randomized studies and the ROBINS‑I (Risk Of Bias In Nonrandomised Studies of Interventions) for nonrandomized studies were used to assess publication quality. The level of evidence was determined according to AHCPR (Agency for Health Care Policy and Research).

RESULTS

In the case of fractures (AO types A0-A3) without degenerative changes in the bone structure of the thoracic and lumbar spine without indications for operative procedure, conservative treatment with analgesia, physiotherapy and early mobilization is recommended and orthotic treatment is not superior. Surgical treatment, even in cases where conservative treatment was possible, led to improved functionality and pain sensation faster but there were no differences in the long-term results. Assessing the neurological functional deficit, the functional success of the treatment and the kyphosis angle were measured in different ways, reducing the extent of comparability. Although mainly a level of evidence Ib-IIa could be assigned, nearly all included studies had a high risk of bias.

CONCLUSION

In individual cases treatment with an orthotic device could be a helpful add-on in conservative treatment of fractures in the thoracic and lumbar spine. A treatment with orthotic devices alone cannot be recommended in these cases.

Retro-Odontoid Pseudotumor Formation in the Context of Various Acquired and Congenital Pathologies of the Craniovertebral Junction and Surgical Techniques

Retro-odontoid pseudotumor formation consists of an abnormal growth of granulation tissue typically posterior to the odontoid process, resulting as a manifestation of atlantoaxial instability. This instability can occur as a result of conditions ranging from severe mechanical trauma to metabolic disease or autoimmune conditions such as rheumatoid arthritis. A pseudotumor may impinge on the spinal nerves or even the spinal cord and brainstem, manifesting symptoms from severe neck pain to cervicomedullary compression or myelopathy, and in some cases even sudden death. The objective of this review is to consolidate the findings in published case reports and relevant prior literature reviews regarding the formation of retro-odontoid pseudotumor. We address the pathophysiology involved in acquired and congenital pseudotumor formation, including those associated with rheumatoid arthritis (panni). Additionally, we discuss past and current operative techniques designed to curtail and ultimately regress a retro-odontoid pseudotumor and pannus. Surgical techniques that are addressed include ventral decompression (both transoral and transnasal), dorsal decompression, and indications for posterior instrumentation in pannus formation, particularly in cases that may be sufficiently treated in lieu of an anterior approach. Finally, we will examine the role of external orthoses as both a method of conservative treatment as well as a potential adjunct to the aforementioned surgical procedures.

New Optimal Needle Entry Angle for Cervical Transforaminal Epidural Steroid Injections: A Retrospective Study

Objective: A cervical epidural steroid injection is one of the most commonly performed interventions to manage chronic neck pain and cervical radiculopathy. Despite its many severe complications, cervical transforaminal epidural steroid injection (CTFESI) is a clinically necessary modality for managing neck pain and cervical radiculopathy. We aimed in this study to find a safer optimal needle entry angle to decrease the chance of an accidental vertebral artery (VA) puncture even with a proper needle entry angle and to visualize the target of the needle tip. Methods: This retrospective study included 312 patients with neck pain or cervical radiculopathy who had undergone magnetic resonance imaging scans for diagnosis and treatment. The first line was drawn from the midpoint of the two articular pillars and passed through the exact midline of the spinous process. The second line was drawn parallel to the ventral lamina line (conventional transforaminal approach line, CTAL). The third line was drawn parallel to the ventral margin at the midpoint of the superior articular process's ventral border (new transforaminal approach line, NTAL). The angle of intersection between the midline and CTAL versus with NTAL were measured from both sides (right and left) at C5-6, C6-7, and C7-T1 levels. Also, the distance of CTAL and NTAL from VA were measured from both sides at each level. We examined whether the CTAL and NTAL would penetrate the ipsilateral VA, internal carotid artery (ICA), and internal jugular vein (IJV). Results: There were significant differences between CTAL and NTAL angles at all levels (P < 0.001). There were significant differences between the distance of CTAL and NTAL from VA at all levels (P < 0.001). There were also significant differences between the observed frequency of CTAL and NTAL that would penetrate the major ipsilateral vessel (VA, ICA, and IJV) on all levels and sides (P < 0.001~0.030). Conclusion: The angle of NTAL (approximately 70°) is safer than the angle of CTAL (approximately 50°) when considering vascular injuries to vessels, such as the VA, ICA, and IJV.

Effectiveness of a back care pillow as an adjuvant physical therapy for chronic non-specific low back pain treatment: a randomized controlled trial

[Purpose] The aim of this study was to investigate the effect of a back care pillow (BCP) on pain, lumbar range of motion (LROM) and functional disability of patients with chronic non-specific low back pain (LBP). [Subjects and Methods] Fifty-two subjects who were aged between 20–69 years old, who presented with LBP of more than 3 months duration with a numerical rating scale (NRS) value of at least 4 were randomly assigned to treatment (BCP) and control (CON) groups. Participants in each group received six sessions of the 30 minutes treatment for two weeks. The BCP group was asked to wear the BCP during the daytime during the study period. Pain, lumbar ROM and functional disability were assessed before and after the 2-week treatment, and at the end of a 12-week follow up. [Results] After the 2-week treatment and 12-week follow up, all outcomes had improved in both groups; the BCP group had maintained the decrease in pain intensity and improved lumbar ROM in the extension position after the 12-week follow up, and showed better improvements in all outcomes at 2 weeks and after the 12-week follow up. [Conclusion] BCP combined with physical therapy had better pain, lumbar ROM and functional disability outcomes than physical therapy alone.