A vertebral compression fracture (VCF) occurs when a spinal bone collapses, often due to significant force or underlying conditions like osteoporosis. This injury typically causes immediate and severe pain, leading to spinal instability and an increased risk of future fractures. A spinal brace serves as an external skeletal support to stabilize the damaged vertebral body. The goals of wearing an orthotic device are to reduce pain by limiting movement, prevent further collapse of the fractured vertebra, and minimize the progression of a hunched posture known as kyphosis. Immobilizing the affected region encourages bone healing and allows for earlier patient mobilization.
Anatomical Coverage of Spinal Braces
Spinal orthotics are classified based on the regions they cover and stabilize. The two types most relevant to VCFs, which frequently occur in the lower thoracic and lumbar spine, are the Lumbosacral Orthosis (LSO) and the Thoracolumbosacral Orthosis (TLSO). An LSO stabilizes the lumbar spine, extending from the lower ribs down to the sacrum, primarily limiting lower back movement. A TLSO covers a greater anatomical range, extending from the shoulder blades (thoracic region) down to the pelvis (sacral region).
The necessary coverage is dictated by the precise location of the injury. Fractures in the mid-thoracic region (T6 to T8) generally require a TLSO to restrict movement effectively. Lower fractures, such as in the lumbar vertebrae (L4 or L5), may sometimes be managed with a less restrictive LSO. However, because VCFs commonly involve the thoracolumbar junction (T12-L2), the TLSO is often the standard prescription to ensure adequate stabilization of this transition zone.
Specific Designs for Compression Fractures
The design of a brace for a VCF counteracts the forces that caused the fracture, typically a flexion-compression injury. The brace must maintain the spine in extension to unload the damaged anterior section of the vertebra.
One common design is the Jewett brace, sometimes called a CASH brace. This design uses a rigid metal or lightweight alloy frame that applies pressure at three distinct points: one pad over the sternum, one over the pubic symphysis, and a third opposing pad in the mid-back. This three-point fixation mechanism keeps the torso upright, forcing the spine into slight hyperextension that relieves pressure on the front portion of the fractured vertebral body. This design is often utilized for stable wedge fractures in the T10 to L2 region.
For more unstable fractures, or those requiring maximum immobilization, a rigid, total-contact TLSO may be prescribed. These custom-molded orthoses, sometimes referred to as clamshell braces, are typically constructed from plastic and encompass the entire torso. They limit virtually all movement, including lateral bending and rotation.
A third option includes semi-rigid LSOs or TLSOs, generally used for less severe injuries or as a transitional device late in healing. These braces offer less restriction than their rigid counterparts but still provide necessary support and compression. The semi-rigid materials accommodate the patient more comfortably, allowing for a gradual return to activity once the fracture has achieved adequate stability.
Determining the Appropriate Brace
The selection of a specific brace is a clinical decision based on a thorough assessment of the injury characteristics and patient factors. Fracture stability is the primary determinant. Stable fractures, typically involving a wedge deformity without significant posterior column damage, are often managed with hyperextension braces like the Jewett. Conversely, unstable or burst fractures, where the vertebral body fragments into the spinal canal, almost always necessitate the maximum immobilization provided by a rigid, custom-molded TLSO.
The vertical location of the fracture is also paramount; a higher fracture, such as at T7, requires a TLSO that extends higher up the back than one at L4. The degree of the wedge deformity and the resulting kyphotic angle are measured on imaging studies to ensure the chosen brace prevents further collapse. Beyond the injury itself, patient factors significantly influence the prescription, especially in elderly patients who commonly sustain VCFs.
The patient’s ability to tolerate a rigid, bulky brace, their skin integrity, and their cognitive ability to comply with the strict wearing schedule must be considered. For example, a frail patient may not tolerate the pressure points of a Jewett brace, potentially leading to discomfort or skin breakdown. In such cases, a less restrictive brace may be chosen, balancing the need for stability with patient comfort and compliance to ensure the best possible outcome.
Patient Experience and Daily Wear
Living with a spinal orthosis requires adjustments to daily routines, starting with the proper technique for putting the brace on and taking it off (donning and doffing). Patients are typically instructed to apply the brace while lying down to maintain the spine in the correct alignment and prevent unwanted movements. Once secured, the brace should feel snug, but not so tight that it causes pain, bruising, or difficulty breathing.
Maintaining skin health is a constant requirement due to the tight contact between the rigid brace and the torso. Patients must wear a close-fitting, wrinkle-free shirt beneath the brace to protect the skin from friction and absorb moisture. The skin under the brace should be checked daily for areas of persistent redness that last longer than 30 minutes after removal, which can indicate excessive pressure and necessitate a brace adjustment.
Patients should avoid using lotions, oils, or powders beneath the brace, as these can soften the skin and trap moisture, leading to irritation or breakdown. Clothing worn over the brace should be loose-fitting to accommodate the increased bulk. The duration of wear is determined by the physician and typically lasts between six and twelve weeks, depending on the fracture’s healing progress, before a supervised weaning process can begin.