Spinal orthosis dr.aliaa

Dr. Aliaa Omar EL-Hady
MD. Physical medicine, Rheum. & Rehabilitation

• Ancient Egyptians used 1st
splints ~ 5.000 ys ago, 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
HISTORY

• Lorenz Heister is credited with
developing 1st 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.
HISTORY

SPINE BIOMECHANICS
• Three flexible curves of
vertebral column (cervical,
thoracic & lumbar)
• Transfers load from head &
trunk to pelvis.
• Protects spinal cord.
• Permits motion in three
planes.
• Vertebral bodies progressively
larger in size caudally to
sustain increasing
superimposed weight.

• Intrinsic Stability: Intervertbral disc + surrounding
ligaments.
• Extrinsic Stability: muscles

•Intervertbral discs bears & distributes loads &
restrains excessive motion.
•Intradiscal pressure is 1.5 times of external load
in compression.

Characteristics of spinal orthosis:
 Weight of the orthosis
 Adjustability
 Functional use
 Cosmesis
 Cost
 Durability
 Material
 Ability to fit various sizes of patients
 Ease of putting on (donning) and taking off
(doffing)
 Access to tracheostomy site, peg tube, or
other drains
 Access to surgical sites for wound care
 Aeration to avoid skin maceration from
moisture

Indications of spinal orthosis:
Pain relief
Mechanical unloading
Scoliosis management
Spinal immobilization after surgery
Spinal immobilization after traumatic
injury
Compression fracture management
Kinesthetic reminder to avoid certain
movements

The biomechanical principles of orthotic
design include :
 balance of horizontal forces.
 fluid compression.
 distraction.
 construction of a cage around the patient.
 skeletal fixation.
In general, structural damage to posterior
elements of the spine creates more instability
with flexion, whereas damage to anterior
elements creates more instability with
extension.

Construction of a cage around the
patient leads to:
 Balance of horizontal forces
 Increase intra-abdominal pressure
 Relieve load on vertebrae
 Prevention of certain movements
 Stability

Duration of use of spinal orthosis:
 Pain: 1-2 weeks.
 Instability: till the patient can
tolerate discomfort.
 Post surgical: after acute fractures
6-12 weeks
 Gradual removal + static EX

Complications of spinal orthosis:
 Discomfort & local pain
 Osteopenia
 Skin breakdown
 Nerve compression
 Ingrown facial hair for men
 Muscle atrophy with prolonged use
 Decreased pulmonary capacity
 Increased energy expenditure with ambulation
 Difficulty donning and doffing orthosis
 Difficulty with transfers
 Psychological and physical dependency
 Increased segmental motion at ends of the
orthosis
 Unsightly appearance
 Poor patient compliance

Success of spinal orthosis:
 Decreased pain
 Increased strength
 Improved function
 Increased proprioception
 Improved posture
 Correction of spinal curve deformity
 Protection against spinal instability
 Minimized complications
 Healing of ligaments and bones

CLASSIFICATION
According To Region Crossed
• Crevical (CO )
• Head Cervical Orthoses (HCO)
• Cervicothoracic Orthoses (CTO)
• Halo Device
• Thoracolumbar Orthoses (TLO)
• Lumbosacral Orthoses (LSO)
• Thoracolumbosacral orthosis ( TLSO)

CLASSIFICATION
According To Motion Restriction
• Flexion- Extension FE control
• Flexion- Extension- Rotation FER Control
• Flexion- Extension- Lateral bending-
Rotation- FELR Control

CLASSIFICATION
According To Materials Used
• Rigid
• Flexible

Cervical Orthosis
F-E
• Soft (zimmer)
• Hard (semi-rigid): moulded
• a. Thomas
• b. Philadelphia
• c. Aspen
• d. Miami
• Collars for weak neck extensors: Head master &
Executive
F-E-R • SOMI
F-E-L-R
• 1- Poster
• 2- Custom
• Minerva
• Cuirass
• 3- Yale
• 4- Halo vest

CERVICAL ORTHOSES (COLLARS)
Flexible Soft Collar
• Made from soft foam.
• Provide mechanical restraint (5-15%)
• Psychologic comfort.
• Head support when acute neck pain occurs.
• Relief from minor muscle spasm.
• Relief from cervical strain.

Soft cervical collar:
Polyethylene or foam
 Least limitation of cervical motion.
 Increase resistance to extension or hyperextension.
 Through feedback, it reminds the wearer to limit
neck movement.
 Retains heat; reduce muscle spasm and aid in
healing of soft tissues.

HEADMASTER COLLAR (ADJUSTABLE WIRE FRAME
CERVICAL COLLAR) - FLEXIBLE
 Lightweight, open, and is comfortable in warm climates.
 It is easily formed by hand to fit snuggly under the chin.
 It is made of a specially tempered wire frame which is
liberally padded with foam rubber covered in a soft,
washable fabric and uses a Velcro closure strap attached
to cushioned back piece.
 Used with weak neck extensors to prevent the head from
falling forward, however, if weakness is present in rotation
and/or lateral flexion

EXECUTIVE COLLAR:
 Comfortable, lightweight Kydex frame, open neck
design.
 An occipital strap can be positioned to fit any neck
circumference.
 Useful with patients with weak neck extensors to
prevent the head from falling forward.
 However, if weakness is present in rotation and/or
lateral flexion (i.e. when shaking the head "no" or
touching the ear to the shoulder), it will not be adequate
and more support is needed.

SEMIRIGID COLLAR
 These types of collars are semirigid types made
of anterior and posterior pieces fastened
together by Velcro.
 They provide FE> R> L motion restriction.
 All can be applied when lying down.
 The Phladilphia collar is washable while the
Aspen & Miami have washable padding.
 The Phladilphia can be applied during
showering while the second two had padding
which can be washed and replaced when dry.
 The three may have a tracheostomy opening

 Made of firm plastic with superior and inferior paddings
that wrap around the neck and is secured by velcro
 It may be adjustable in height or may contain an
adjustable chin piece
SEMI-RIGID THOMAS COLLAR:

SEMIRIGID COLLAR:
PHILADELPHIA COLLAR
Indications:
 Anterior cervical fusion, Halo removal, Dens type I
cervical fracture of C2, Anterior diskectomy.
 Suspected cervical trauma in unconscious patients,
Tear-drop fracture of the vertebral body (Note: Some
tear-drop fractures require anterior decompression and
fusion.)
 Cervical strain

thoracic extension can be added to increase
motion restriction and treat C6-T2 injuries.

MIAMI COLLAR
 Semirigid 2-piece
system made of
polyethylene, with
a soft, washable
lining
 same indications
for use as those
for the
Philadelphia collar.
 thoracic extension
can be added to
increase support
and treat C6-T2
injuries.

MALIBU COLLAR
 semi-rigid, 2-piece orthosis
 anterior opening for a
tracheostomy.
 indications similar to those for
the Miami J and Philadelphia
collars.
 comes in only one size
 adjustable in multiple planes to
ensure proper fit.
 Padding around the chin can be
trimmed to ensure proper fit
 thoracic extension can be added
to increase support and treat C6-
T2 injuries.

Semirigid and rigid plastics.
Provide more rigid stabilization of the
cervical spine.
Include Occiput & Chin to decrease ROM.
Used in stable spine conditions.
Supported chin is a common place for skin
breakdown.
Clavicle is area HCOs can cause skin
breakdown.
Long-term use associated with decreased
muscle function and dependency.

INDICATIONS:
 ANTERIOR CERVICAL FUSION .
 HALO REMOVAL .
 DENS TYPE I CERVICAL # OF C2.
 ANTERIOR DISKECTOMY.
 SUSPECTED CERVICAL TRAUMA IN
UNCONSCIOUS PATIENTS .
 MOST OF TEARDROP # OF VERTEBRAL
BODY.
 CERVICAL STRAIN .

 G R E AT E R M O T I O N R E S T R I C T I O N I N T H E M I D D L E
T O L O W E R C E R V I C A L S P I N E .
 U P P E R C E R V I C A L S P I N E H A S L E S S M O T I O N
R E S T R I C T I O N .
 U S E D I N M I N I M A L LY U N S TA B L E F R A C T U R E S .

STERNAL-OCCIPITAL-MANDIBULAR IMMOBILIZER (SOMI)
 CTO with anterior chest plate
extending to the xiphoid
process & metal or plastic
bars curve over the shoulder.
 Straps from the bars over the
shoulder & cross to opposite
side of the anterior plate for
fixation.
 2-poster CTOs start from the
chest plate and attach to the
occipital component.
 SOMI is ideal for bedridden
patients because it has no
posterior rods.

 removable chin piece with an optional headpiece
can be used if chin piece is removed for eating.
 Comfortable.
 Proper adjustment is crucial for motion restriction.

INDICATION:
 S O M I C O N T R O L S F L E X I O N I N C 1 - C 3 S E G M E N T S
B E T T E R T H A N C E R V I C O T H O R A C I C B R A C E .
 AT L A N T O A X I A L I N S TA B I L I T Y ( R A ) .
 N E U R A L A R C H F R A C T U R E S O F C 2 ( F L E X I O N
C A U S E S I N S TA B I L I T Y ) .

(F-E-R) SOMI COLLAR
F-E-R control orthosis (sterno-occipital mandibular
immobilizer):
The mandibular support can be removed and the patient can
eat, wash, or shave while supine

MOTION RESTRICTIONS ASSOCIATED WITH THE SOMI
INCLUDE
 Cervical flexion and extension are
limited by 70%-75%
 Lateral bending is limited by 35%
 Rotation is limited by 60-65%

CERVICAL FELR CONTROL ORTHOSIS
 Four Posters
 Cuirass
 Yale
 Minerva
 Halo

Four-Poster
The four-poster is a rigid cervical orthosis with
anterior and posterior sections consisting of
pads that lie on the chest and are connected by
leather straps.

4 POSTERS CERVICAL ORTHOSIS
Mandibular support Occipital support
Double anterior uprights
Double posterior uprights
Sternal Plate Interscapular Plate

MOTION RESTRICTIONS ASSOCIATED WITH THE
4-POSTER ORTHOSIS
 Flexion and extension are limited by 80%.
 Lateral bending is limited by 55%-80%.
 Rotation is limited by 70%.

Yale
 The Yale orthosis consists of chin and occipital pieces that
extend higher on the skull in the posterior region; this
increases comfort.
 The Yale orthosis is a modified Philadelphia collar with a
thoracic extension.
 The extension consists of fiberglass that extends both
anteriorly and posteriorly, and has thoracic straps that
hold the sections together.
 The thoracic extension to the orthosis helps to stabilize
injuries at the vertebral levels of C6-T2

Minerva Brace (custom moulded)

The Minerva collar has
head straps to provide
additional support and to
keep head immobilized
throughout ttt.

• The halo orthosis provides flexion, extension,
and rotational control of the cervical region.
• Pressure systems are used for control of motion,
as well as to provide slight distraction for
immobilization of the cervical spine.

• This orthosis provides maximum restriction in motion of all the
cervical orthoses. It is the most stable orthosis, especially in the
superior cervical spine segment.
• A halo is used for approximately 3 months (10 to 12 weeks) to
ensure healing of a fracture or of a spinal fusion.
• Usually a cervical collar is indicated after the halo is removed,
because the muscles and ligaments supporting the head
become weak after disuse.
• All pins on the halo ring should be checked to ensure tightness
24 to 48 hours after application.

Indications
• Dens type I, II, or III fractures of C2 .
• C1 fractures with rupture of the transverse ligament
• Atlantoaxial instability from RA, with ligamentous
disruption and erosion of the dens.
• C2 neural arch fractures and disc disruption between C2
and C3. Bony, single-column cervical fractures
• Cervical arthrodesis - Postoperative
• Cervical tumor resection in an unstable spine -
Postoperative
• Debridement and drainage of infection in an unstable
spine - Postoperative
• Spinal cord injury (SCI)

Contraindications
• Concomitant skull fracture with cervical injury
• Damaged or infected skin over pin insertion sites
Relative contraindications
• Cervical instability with ligamentous disruption
• Cervical instability with 2- or 3-column injury
• Cervical instability with rotational injury involving
facet joints

Complications
• Neck pain or stiffness - 80%
• Pin loosening - 60%
• Pin site infection - 22%
• Scarring - 30%
• Pain at pin sites - 18%
• Pressure sores - 11%
• Redislocation - 10%
• Restricted ventilation - 8%
• Dysphagia - 2%
• Nerve injury - 2%
• Dural puncture - 1%
• Neurological deterioration - 1%
• Avascular necrosis of the dens
• Ring migration
• Inadequate bony healing
• Inadequate ligamentous healing

Complications of cervical orthosis:
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)
The soft-tissue structures around the neck (eg,
blood vessels, esophagus, trachea) limit the
application of aggressive external force.
Cervical orthosis offer no control for the head or
thorax; therefore, motion restriction is minimal.
(Cervical orthosis serve as a kinesthetic reminder
to limit neck movement.)

 All orthotics tend to control flexion better than
extension
 Limitation of flexion at C1-C3
Halo > 4-poster > CTO
 CTO are best at controlling flexion and
extension at C3-T1
 SOMI brace is best at controlling flexion from
C1-C5
 SOMI is less effective in controlling extension
 Limitation of rotation and lateral bending C1-C3
Halo > cervico-thoracic brace
Cervical Immobilization Pearls

 Extends from sacrum to above the inferior angle of scapula
 Contain thoracic and pelvic bands
 Used to support and stabilize the trunk
 Used in cases of truncal paralysis, post-spinal fusion, post-
scoliotic surgery
 To prevent mild scoliosis 20-45º
 Work through increase intra-abdominal pressure and
reduce weight on vertebral body
 Used in intervertebral disc diseases
TLS Orthoses

a.The TLS F-E control orthosis (Taylor brace)
b.The TLS F-E-L control (Knight Taylor brace)
c.The TLS F-E-R control orthosis (Cowhorn brace)
d.The TLS flexion (F) control orthosis
 Jewett or Becher TLSO
 Cruciform anterior spinal hyperextension (CASH) TLSO
e. The TLS F-E-L-R control (TLS jacket)
f. Boston TLSO
Extends from sacrum to above the inferior angle of scapula

Knight-Taylor brace
 Has two lateral and two posterior uprights and shoulder straps.
 Reduce lateral bending, flexion, and extension.
 The brace can be prefabricated and made with polyvinyl chloride
or aluminum.
 The posterior portion of the brace has added cross supports
below the inferior angle of the scapula and a pelvic band fitted at
the sacrococcygeal junction.
 The anterior corset is made of canvas and provides intracavitary
pressure.
 The anterior corset is laced to the lateral uprights.

Indication:
 To provide flexion immobilization to treat thoracic and
lumbar vertebral body fractures.
 Post-surgical support (for years) of traumatic fractures,
spondylolisthesis, scoliosis, spinal stenosis, herniated
disks, and disk infections.
 However, clinicians typically now prefer the custom-
molded TLSO body jackets, because better control of
position is obtained

Motion restrictions:
control of flexion, extension, and a minimal axial
rotation via the three-point pressure systems for each
direction of motion. For e.g, flexion is controlled by:
the posteriorly directed forces applied through the
axillary straps and the abdominal apron, and an
anteriorly directed force through the paraspinal
uprights.

 Knight-Taylor has an additional thoracic band
that extends from the uprights just below the
inferior angle of the scapula to the midsagittal
plane, and a lateral upright on each side that
connects the pelvic band and the thoracic band.
 These bands provide additional lateral support
and motion control to the trunk.

Jewett hyperextension brace
 uses a 3-point pressure system with 1 posterior and 2 anterior pads.
 The anterior pads place pressure over the sternum and pubic symphysis.
 The posterior pad places opposing pressure in the mid-thoracic region.
 The posterior pad keeps the spine in an extended position

 Lightweight design that is more comfortable than the CASH brace.
 Pelvic and sternal pads can be adjusted from the lateral axillary
bar where they attach.
 No abdominal support is provided with this device.
 When the patient is seated, the sternal pad should be half an inch
inferior to the sternal notch, and the pubic pad should be half an
inch superior to the pubic symphysis.

Indication
 Symptomatic relief of stable spinal fractures T6 to L1
not due to osteoporosis
 Immobilization after surgical stabilization of thoraco-
lumbar fractures
 Postural Kyphosis.
Advantage
 Prevents flexion & limits extension of spine
 Controls thoracic spine
 Does not prevent extension
 More comfortable on women
 Velcro closure

Contraindication:
 Three column spine fractures involving anterior,
middle, and posterior spinal structures
 Compression fractures above T6 since segmental
motion increases above the sternal pad
 Compression fractures due to osteoporosis
More effective than the CASH brace.

The TLS flextion (F) control orthosis
Cruciform anterior spinal hyperextension
brace with round anterior chest pads. (CASH)

Indication
 Immobilization of compression
fracture of vertebral bodies from
T6 to L1
 Reduction of kyphosis not in
patients with osteoporosis
Advantage
 Prevents flexion of spine
 Controls thoracic spine
 Does not prevent extension
 More comfortable on women
 Velcro closure
CASH Orthosis

Motion restrictions : Limits flexion from T6-L1
Contraindications :
Three-column spine fractures involving anterior,
middle, and posterior spinal structures .
Compression fractures due to osteoporosis

Custom-molded plastic body jacket
(calmshell)

PLASTIC BODY JACKET
•Fabricated with high-temperature co-
polymer plastics.
• Well-fitted body jacket restrict motion
in all planes.
•Anterior and lateral trunk containment
elevate intracavitary pressure.
•Decrease demands on the vertebral
discs.
• Body jackets are frequently used post
surgically or during an acute trauma.
(flexion-extension-lateral –rotary control)

 Lightweight design and is easy to don and doff.
 Material is easy to clean and comfortable to wear.
 The TLSO provides efficient force transmission as
pressure is distributed over wide surface area, which is
ideal for use in patients with neurologic injuries.
 Use it with an undershirt to absorb perspiration and protect
the skin.
 Frequent checks to ensure proper fit help prevent pressure
ulcers.
 Velcro straps are used to tighten the brace.

Indications
 Immobilization for compression fractures from
osteoporosis
 Immobilization after surgical stabilization for spinal
fractures
 Bracing for idiopathic scoliosis
 Immobilization for unstable spinal disorders for T3
to L3

Motion restrictions custom-molded TLSO
Limits side-bending , flexion ,extension and rotation to some
extent
 It is more effective in preventing idiopathic scoliosis curve
progression than the Milwaukee and Charleston braces.
 The mean curve progression with TLSO is less than 2°
while the Charleston and Milwaukee braces have a curve
progression greater than 6°.
 Fewer than 18% of patients treated with TLSO brace
required surgery for scoliosis compared to 23% for
patients treated with a Milwaukee brace.

 Plastic TLS jacket that extend upward to the mandible and
mastoid.
 The Milwaukee brace, (CTLSO) used for scoliosis has a rigid
plastic pelvic girdle connected to a neck ring over the upper
thorax by one anterior and two posterior uprights.
 Pads strapped to the uprights apply forces to correct the
scoliotic curve.
 It is used for curves at or below T6

Extend from sacrum to the inferior scapular
angle
a.The LSO (F-E) control orthosis (Chairback orthosis)
b.The LSO (F-E-L) control othosis (Knight spinal)
c.The LSO (E-L) contorl orthosis (Williams brace)
d.The LSO with hip spica or thigh cuff
e.The LS jacket (Boston overlap brace)

Rigid short LSO with 2 posterior uprights with
thoracic and pelvic bands.
 The abdominal apron has straps in front for
adjustment to increase intra-cavitary pressure.
The thoracic band is located 1 inch below the inferior
angle of scapula.
Chairback brace

The thoracic band extends laterally to the mid-axillary
line, and the pelvic band extends laterally to the mid-
trochanteric line.
Position the posterior uprights over the paraspinal
muscles.
Uprights can be made from metal or plastic.
 The brace uses a 3-point pressure system and can
be custom molded to improve the fit for each
individual patient.

Indications :
 Unloading of the intervertebral discs and transmit
pressure to soft tissue areas
 Relief for LBP
 Immobilization after lumbar laminectomy
 Kinesthetic reminder to patient following surgery
Motion restrictions :
 Limits flexion and extension at the L1-L4 level
 Limits rotation minimally
 Limits lateral bending by 45% in the thoracolumbar spine

Chairback Ortho-Mold brace
 Similar to the chairback brace, but it has a rigid
plastic back piece custom molded to the patient.
 The plastic back can be inserted into the canvas
and elastic corset.
 Indications for use are the same as the
chairback brace.

Williams brace
 Short LSO with an anterior elastic apron to allow for forward
flexion.
 Lateral uprights attach to the thoracic band, and oblique bars are
used to connect the pelvic band to the lateral uprights.
 The abdominal apron is laced to the lateral uprights.
 The brace limits extension and lateral trunk movement but allows
forward flexion.
 The brace is indicated to provide motion restriction during
extension to treat spondylolysis and spondylolisthesis.

Contraindication :
 in spinal compression fractures.
Motion restrictions of the Williams brace include the
following:
 Limits extension
 Limits side bending at terminal ends only

 A custom-made orthosis molded
over the iliac crest for improved fit.
 Plastic anterior and posterior shells
overlap for a tight fit.
 Velcro closure in the front is
designed for easy donning and
doffing.
 Multiple holes can be made for
aeration to help decrease moisture
and limit skin maceration.
 The rigid LSO can be trimmed
easily to make adjustments for
patient comfort and may be used in
the shower if needed.
Rigid LSO

Indications:
 Post-surgical lumbar immobilization.
 Treatment of lumbar compression #.
Motion restrictions:
 Limits flexion and extension
 Limits some rotation and side bending

 uses a thigh piece on the symptomatic side and extends to 5 cm
above the patella.
 The hip is held in 20° of flexion to allow sitting and walking.
 Some patients require a cane for ambulation after application.
Indications
 Immobilization to treat lumbar instability from L3-S1
 Immobilization after LS fusion with anchoring to the sacrum
Motion restrictions
 Limits flexion and extension
 Limits some rotation and side bending
Rigid LSO with hip spica

Corsets (Flexible Spinal Orthoses)
 Made of fabric with pouches for vertical stays
 No thoracic or pelvic bands
 The vertical stays are made of plastic or rigid steel
 Create similar forces as rigid SO
 Do NOT restrict movement or spinal re-alignment
 Increase intra-abdominal pressure more than rigid SO
 Used in direct contact with skin

 Has metal bars within the cloth material posteriorly that can be
removed and adjusted to fit the patient.
 The anterior abdominal apron has pull-up laces from the back to
tighten. The abdominal apron can come with Velcro closure for
easy donning and doffing.
 It has a lightweight design and is comfortable to wear.
 The corset increases intracavitary pressure. Anteriorly, the brace
covers the area between the xiphoid process and pubic symphysis.
 Posteriorly, the brace covers the area between the lower scapula
and gluteal fold.
The Standard LSO corset

Indications:
 Treatment of LBP
 Immobilization after lumbar laminectomy
Motion restrictions: limitation of F-E.

The TLS corset:
 Restrict spinal motion at thoracic and lumber spine
 Increase intra-abdominal pressure to remove load from vertebrae
 Remind the wearer to avoid abrupt trunk motion and to lift properly
The LS corset (Richard’s corset)
 It extends to below the inferior angles of the scapulae instead of
the midscapular level
 Same function as TLS corset but does not restrict thoracic spinal
motion

Sacroiliac (SI) Corsets
a.Sacroiliac corset :
 from illiac crest to symphysis pubis
 Used in low back pain and stabilization of sacroilliac joint
b. Sacroiliac belt :
 Encircle the pelvis between the illiac crests
 The belt passes below the anterior superior pelvic spine
 Used in post surgical conditions of pelvis
c.Elastic sacroiliac corset (binder) with plastic insert:
 Similar to the corset
 Mainly used to correct back posture and low back pain

The main goal:
 prevent further deformity
 Prevent or delay need for surgery.
 If surgery is needed, delaying the procedure as long as possible
helps optimize spinal height and avoid stunting of truncal
growth.
 Assessing the degree of skeletal maturity in a child with
scoliosis is important because with more advanced skeletal
maturity, you expect less further skeletal growth and thus less
progression of the scoliosis.
 This has obvious implications when forming a treatment plan.

Risser classification of ossification of the iliac epiphysis:
Used to evaluate skeletal immaturity.
• Ossification of the iliac crest occurs from ASIS to PSIS.
• When ossification is complete, fusion of the epiphysis occurs to the iliac crest.
• Risser staging is based on using radiographs to determine what % of the excursion
(along the length of the iliac epiphysis) has ossified.
• Risser score of 0-I with a curve of 20-30° indicates nearly 70% chance of progression.

Risser stages are defined as follows:
Stage 0 = 0% excursion
Stage I = 25% excursion
Stage II = 50% excursion
Stage III = 75% excursion
Stage IV = 100% excursion and correlates with end of spinal growth
Stage V = fusion to ilium, indicating cessation of vertical height growth
The younger the age, the larger the curve, the shorter the duration of
curve progress and the more the liability to surgery.

 The most common time to lose control of
idiopathic curves is at puberty.
 Boys tend to show less curve progression than
girls, and tend to have later onset of curve
progression between 15-18 years.
 Younger patients show greater initial in-brace
correction.
 Curve correction with bracing >50 degrees is
expected to have final net correction, whereas
curve correction < 50 is expected to have limited
progression.
 Generally, curves between T8-L2 have the best
correction.
 Young patients with large curves usually fail
treatment with a brace.

Biomechanics:
• It is used for scoliosis management.
• It provides control of flexion, extension, and lateral bending of the cervical,
thoracic, and lumber spine.
• It also provides some rotational control of thoracic & lumbar spine.
• Pressure systems are used for control of motion, as well as to provide
correction for the spine.
• It is a good choice for patients who need correction in the higher thoracic
region of the spine.

Design and Fabrication:
The Milwaukee is custom made, consisting of a cervical
portion with the option of a removable cervical ring.
Also used is the thoracolumbar section of the orthosis in
which the correction of the lower thoracic and lumbar spines
is achieved.

 Uprights have localized pads to apply transverse force, which is effective for
small curves.
 The main corrective force is the thoracic pad, which attaches to the 2
posterior uprights and 1 anterior upright. The lumbar pads play a passive
role compared to the thoracic pads.
 The uprights are perpendicular to the pelvic section
 Any leg-length discrepancy should be corrected.
 The neck ring is another corrective force and is designed to give longitudinal
traction.
 Jaw deformity is a potential complication of the neck ring. The throat mold,
instead of a mandibular mold, allows use of distractive force without jaw
deformity.

During the child's growth, brace length can be
adjusted. Pads also can be changed to
compensate for spinal growth. The brace needs to
be changed if pelvic size increases.

Indications
• Patients with a Risser score of I-II, as well as a curve >
20-30° and that progresses by 5° over 1 year
• Curves of 30-40°, but not curves < 20°.
• Curves of 20-30°, with no year-over-year progression,
require observation every 4-6 months.
• The Milwaukee brace is used for curves with apex above
T7.

The Milwaukee brace's duration of use:
• Daily use ranges from 16-23 hr/ day.
• Treatment should continue until the patient is
at Risser stage IV or V.
• If the curve is > 30°, consider continued use
of the brace for 1-2 years after maturity,
because a curve of this magnitude is at
risk of progression.

Advantages
• It may remove for activities of
daily living.
• Because its open design,
there is minimal restriction of
respiration.
• It allows good air circulation
to minimize skin problems.
• It is adjustable to growth and
curve changes.
• Because it has cervical ring
we could use it for high level
curve deformity.

Problems associated with the use of a Milwaukee
brace:
• Jaw deformity
• Pain
• Skin breakdown
• Unsightly appearance
• Difficulty with mobility
• Difficulty with transfers
• Increased energy expenditure with ambulation

 Is a prefabricated symmetric thoracolumbar-
pelvic mold with built-in lumbar flexion that
can be worn under clothes.
 Lumbar flexion is achieved through
posterior flattening of the brace and
extending of the mold distally to the buttock.
 Braces with superstructures have a curve
apex above T7.
 Curves with an apex at or below T7 do not
require superstructures to immobilize
cervical spine movement.
 Unlike the Milwaukee brace, cannot be
adjusted if the patient grows in height.

Indications for the use of a Boston brace
• A curve of 20-25° with 10° progression over 1 year
• A curve of 25-30° with 5° progression over 1 year
• Skeletally immature patients with a curve of ≥ 30°.

ADVANTAGES
• The Boston brace, in contrast to the Milwaukee brace are
low profile (underarm) an can be worn under clothing.
• The Boston brace fabrication is quicker than Milwaukee
brace.
• Three-point pressure application in The Boston brace.

Problems that are associated with the use
of a Boston brace
• Local discomfort
• Hip flexion contracture
• Trunk weakness
• Increased abdominal pressure
• Skin breakdown
• Accentuation of hypokyphosis in the thoracic
spine, above the brace (contraindication).

Duration of Boston brace use is determined by several
factors:
 Daily use ranges from 16-23 hours per day.
 Treatment should continue until the patient is at Risser stage IV or V.
 If the curve is greater than 30°, consider continued use for 1-2 years
after maturity since these curves are at risk for progression.
 The Boston brace with and without superstructure is equally effective
in treating curves below T7.

CHARLESTON BENDING BRACE
Is a nocturnal only treatment.

CHARLESTON BENDING BRACE (1979)
 It is worn only at night,
which is why it's also
known as a "part-time"
brace
 The Charleston Bending
Brace is molded while he
or she is bent towards
the convexity—or
outward bulge—of the
curve, the concept
behind this design being
that it "over-corrects" the
curve during the eight
hours the brace is worn.
For 20-35 degrees & apex of the curve below the level of the shoulder blade.

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