Spinal Bracing: Jürgen Harms, MD Interview

Jürgen Harms, MD Medical Director, Orthopaedics and Spinal Column Surgery Klinikum Karlsbad-Langensteinbach Karlsbad, Germany

Bracing is commonly used in the nonsurgical treatment and postoperative care of spinal disorders.  Doctor Jürgen Harms, one of the world’s most experienced spine specialists, provides his opinions of and concerns related to the current use of spinal orthotics.

What has patient experience taught you about brace construction?

            JH:  Patient compliance in orthotic treatment is of great importance in conservative and postoperative rehabilitation.  A patient will not wear a brace if it pinches or is otherwise disturbing.  The outward appearance of the spinal orthotic plays a role in patient compliance, as a brace cannot always be hidden beneath the patient’s clothing.  Not only should a spinal brace be simple to put on, but tension application should be straightforward and easy to accomplish.

When may a spinal brace be prescribed?

            JH:  If spinal instability exists, which is clearly defined by the physician, wearing an orthosis is reasonable until the instability is rectified.  While the term instability can be clearly defined by biomechanical nomenclature, the treatment course is physician-directed based on the diagnosis.

            We know that increase of abdominal inside pressure leads to a significant improvement in thoracic and lumbar spinal support.  It has been proven that the increase of abdominal inside pressure can reduce strain in the L4-L5 and L5-S1 regions by 20-30%.  This is of crucial significance in conservative and surgical therapies.

Please tell us how Bauerfeind braces prevent musculature atrophy.

            JH:  SofTec® Lumbo and SofTec® Dorso are designed as dynamic orthoses.  This mean rigid fixation does not occur.  Rather, the muscular function, in particular the function of the abdominal muscles, is fully preserved by means of the design of these braces.  Preservation of muscular function is ensured because only a posterior supporting frame is inserted.  The active support is provided by increased pressure within the abdomen combined with lateral-diagonal tension; a significant difference from other orthoses.  The design of these Bauerfeind products avoids passive support and guarantees that both the spinal and abdominal musculature remains functional and not subject to atrophy.

In postoperative bracing, what is of primary importance?

            JH:  Stability of the surgical results (e.g. instrumentation) is crucial to allow the patient to immediately stand upright and competently distribute forces through the spine at rest and during restricted movement.  One postop purpose of bracing is to provide spinal support while fusion heals.  Of course, when radiographic evidence of bony incorporation occurs, then prescribed wear (e.g. hours per day, during activity) is adjusted and eventually the bracing is discontinued.

Is the maintenance of postoperative muscle output important to outcome?

            JH:  Naturally, the retention or reinforcement of muscular strength after spine surgery is of great importance in patient outcome.  Remember, the goal of surgery is to treat the patient brace-free in the medium term.  This is the reason why an orthosis should be designed to avoid muscle atrophy.

Is there a difference in bracing techniques when instrumentation is involved?

            JH:  I don’t see any difference in the bracing technique in conservative or surgical therapy – not even in regard to the insertion of metal spinal implants.  Bracing (orthotics) has no direct effect on the implant position or fixation.  In the case when an implant is not successfully implanted and/or no intraoperative stability occurs, an orthosis cannot help.  Rather, reduced mobility and an increase of pressure inside the abdomen enhance the safety of the implant.

Dr. Harms, thank you for your responses.