Nonoperative Spinal Stabilization

The goal of stabilization is to reduce deformities and then restrict motion and maintain alignment. In the cervical spine, it is important to determine the adequacy of cervical bony reduction. Subluxations are generally reduced using Gardner-Wells tongs, which are placed into the soft tissue of the temples under local anesthesia. The location and type of injury determine the amount of weight applied. The upper cervical spine generally requires less weight for traction than the lower cervical spine. Depending upon location, initial weight should be started at 5 to 10 lb. Weight should be increased in 2.5-to 5-lb increments. Ideally, this should be done under fluoroscopic guidance. If fluoroscopy is unavailable, radiographs and neurologic examinations should be performed after each increment of weight. The radiographs should be evaluated for alignment of the spinal column and to ensure that overdistraction has not occurred. Neurologic performance can improve if reduction is achieved. Inability to achieve adequate reduction is an indication for early spinal decompression and fusion.

Spinal orthoses are used to immobilize well-reduced cervical fractures. The cervical spine is the region most effectively stabilized by external splinting devices. There is less soft tissue separating the brace from the spine at this level. In addition, some braces can be solidly secured by fixation points at the cranium and the thoracic cage. Cervical orthoses consist of cervical and cervicothoracic types. Cervical collars fit around the neck and contour to the mandible and occiput. They restrict flexion and extension in the middle and lower cervical spine. Lateral bending and rotational movements, however, are poorly controlled. Examples of cervical orthoses include the hard collar, the Philadelphia collar, and the Miami J collar. Cervicothoracic braces provide additional support. The "gold standard" is the halo cervical immobilizer, which provides the most rigid stabilization. Consisting of a halo ring pinned to the skull, a vest, and upright posts, it can be used for traction and reduction of unstable fractures as well as immoblization.

Immobilization of the upper thoracic spine by orthoses is difficult. Fortunately, an intact rib cage and sternum provide relative stability. Although brace immobilization is not always necessary in the treatment of these fractures, braces can provide additional comfort. Thoracic corsets provide minimal control of motion and are appropriate only for minor injuries. Jewett and Taylor braces provide intermediate control of spinal motion. Maximum limitation of motion is provided by the Risser jacket and the body cast.

The thoracolumbar junction and lower lumbar regions are also difficult to immobilize externally. The splints are limited by the lack of an adequate caudal fixation point. The functions of most thoracolumbosacral orthoses (TLSOs) are the following: to create an awareness and remind the patient to restrict movements, to support the abdomen and relieve some of the load on the lumbosacral spine, to provide some restriction of motion of the upper lumbar and thoracolumbar spine by three-point fixation, and to reduce lumbar lordosis in order to provide a straighter, more comfortable lower back.

Complications of external immobilization devices include pain, pressure, muscle weakness and disuse atrophy, venous compromise, psychological dependence, ineffective stabilization, and pin-site complications (halovest). 27

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