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Post-Operative Bracing
After spinal fusion, bracing may aid in immobilization in the early stages of
fusion healing. However, due to the advances in internal fixation techniques,
not every patient will require a brace post-operatively. (88)
Lumbar Braces
Lumbar braces include corsets, bi-valve thoraco-lumbo-sacral orthoses (TLSO),
Boston Overlap braces, and chair-back braces. The need for bracing for thoracic
procedures is less, because of the stabilizing forces of the ribs and chest
cage.
Although a few studies have been attempted to explore the need for post-operative
bracing, no well-designed studies clearly show that bracing increases fusion
rates in the lumbar spine. Authors of a retrospective study analyzing cases
spanning 47 years suggested that more restrictive post-operative immobilization
in a body cast increased fusion rates over immobilization in a TLSO, but did
not control well for surgical approach (posterior only versus anterior/posterior)
or use of instrumentation. (89)
In one study, 95 patients undergoing instrumented lumbar fusions were randomized
to either eight weeks of external immobilization using a corset or no immobilization.
After only eight weeks, the authors concluded there were no differences in post-operative
outcomes measured by SF-36 scores, Dallas Pain Questionnaire, or fusion rates.
(90)
One small study (n=6) measured loads across implanted, calibrated, posterior
spinal fixators while patients were wearing three different types of braces.
The fixators consisted of longitudinal rods and hooks placed prior to anterior
interbody fusion in all but one case. The fixators were removed later. The authors
concluded that none of the braces reduced loads or forces measured across the
fixator. In fact, during some activities, wearing a brace tended to increase
loads on the fixator. It was not clear from the study whether posterolateral
arthrodesis was performed. It is important to note that this fixator did not
utilize pedicle screws; the form of instrumentation most commonly used in elective
lumbar fusion surgeries. The fusion rate was not an outcome measured by this
study. Despite the lack of clear evidence that bracing positively affects fusion
rates, many surgeons utilize some form of post-operative immobilization to help
moderate pain and remind patients of their activity precautions.
Cervical Braces
Cervical braces include types of soft cervical collars, AspenŽ collar, PhiladelphiaŽ
collar, J MiamiŽ collar, MinervaŽ collar, cervical-thoracic orthoses, and halo
vest immobilization. The halo brace was found to restrict motion in the upper
cervical spine best in a cadaver study, compared to a soft cervical collar,
MinervaŽ collar, and J MiamiŽ collar. (91)
Patients immobilized in cervical orthoses require meticulous nursing care to
prevent complications from the immobilization device. The most common complications
related to cervical orthoses include pressure ulcers on the chin, mandible,
ears, shoulders, and occiput; aspiration from impaired airway protection; progressive
neurologic deterioration related to ineffective immobilization; and marginal
mandibular nerve palsy (a branch of the seventh cranial nerve) causing sensory
disturbance and drooping of the lower lip. (92)
Cervical immobilization may also impair respiratory function. One prospective
randomized study compared the respiratory effects of cervical immobilization
in a hard plastic collar on a wooden back board to cervical immobilization with
a vacuum mattress and vacuum collar, consisting of a flexible plastic bag partially
filled with polystyrene beads. (93) Volunteers for the study were healthy individuals
divided into groups according to age. Children (aged 7-12), young adults (aged
22-32), and elderly (over 60) were analyzed separately. Lung spirometry was
performed at baseline (without immobilization) and during both methods of immobilization.
Both methods of immobilization reduced six out of eight pulmonary functions
measured by lung spirometry. Children and the elderly experienced the greatest
alteration from baseline.
Halo Vest Immobilization
Halo vest immobilization uses pins to affix the halo apparatus to the skull.
Special care is required to maintain the pin sites and keep the vest connections
tight. Tightening the halo pins to 6-in/lbs of torque at 24-hours and one-week
after application is associated with the least pin site complications. (94,95)
No clear consensus exists regarding pin site care for halo vests.
The purpose of pin site care is to keep the pin sites clean and prevent pin
site infections, which could lead to cellulitis, osteomyelitis, and more rarely,
brain abscess. (96,97) Pin sites should be cleansed at least once daily. (98)
After a review of the literature, Olson (99) recommended normal saline or soap
and water for cleansing, citing other studies that found povidone-iodine, hydrogen
peroxide, and chlorhexidine to be associated with increased infection, disruption
of the healing process, or disruption of the normal flora of the skin. Ointments
and gauze dressings should be avoided because they block drainage. Crusts should
be gently removed. (99)
Halo vest immobilization has emotional and self-care implications as well as
physical care requirements. In a retrospective study of patients previously
in halo vest immobilization, it was found that most patients required (but did
not receive) specific teaching regarding self-care, activities of daily living,
coping, and activity limitations. (100) In an extension of the same study, these
patients also expressed distortion in self-concept, body image, grief, and a
struggle for normalcy. (101)
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