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Introduction   

Damage to the spinal cord or the nerves at the spinal canal can result in spinal cord injuries, impairing an individual’s ability to carry out normal functions. Spinal cord injury results in complete or incomplete alteration in strength, sensation, and body function below the level of the injury. It impacts the postural balance and confines the affected individual with limitations. The independent or optimal activity of daily living (ADL) management of spinal cord injury patients is challenging.  

Orthoses play an important role in the multidisciplinary approach to managing spinal injury patients and successful rehabilitation. Different orthoses are applied to spinal cord injury patients to achieve and regain movement, balance, and pain relief (1). 

The purpose of orthoses in spinal cord injury patients is to increase stability, support movement, and physical activity to make them independent during sitting, standing, or walking. The spinal cord is the main channel through which sensory and motor information is communicated between the brain and the body. It is the injury of the spinal cord from the foramen magnum to the cauda equina that causes neurological lesions with severe socioeconomic impact on the affected individual (1). 

Thoracolumbar (TL) spine injuries account for the highest incidence of spinal injuries. The TL spine injuries range from mid-back pain to deformity, paralysis, and loss of function. Treatment is often surgical fixation or conservative management, and this is usually determined by the type of fracture, neurological status, and the patient’s comorbidities (7).  

Non-operative management of thoracolumbar spinal fractures continues to be controversial with the use of bracing. The thoracolumbar sacral orthosis (TLSO) brace is a device mainly used for the nonoperative management of spinal fractures. TLSO is a device with a relatively extensive lock position that helps in the healing process, aids with scoliosis by diminishing the load transfer via the anterior column by limiting segmental motion, and is helpful in pain control, it has been used postoperatively as well (7). However, several studies have shown the prolonged use of the TLSO may lead to skin breakdown, diminished pulmonary capacity, and weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without the brace (1). 

Definition 

Patients with a spinal cord injury may experience voluntary recovery of sensory and motor functions. The location and severity of the lesion determines the clinical and functional outcome in a spinal cord injury patient. Injuries at the cervical level cause tetraplegia while lesions at the lower thoracic region are associated with paraplegia. The neurological assessment after 72 hours of injury is an important predictor to determine the functional recovery of injury that depends on whether the injury was complete or incomplete (7). 

The thoracolumbar sacral orthosis (TLSO) is used to limit the torso movement during the healing process for conditions such as injuries/fractures of the spine, scoliosis, and post-spinal surgery. The polymer orthosis (brace) provides total contact, meaning that it does not exert a single point of pressure. The orthosis controls motion in three planes of the thoracic lumbar sacral region (7). The TLSO brace is used as ordered by the provider. The brace is usually ordered to be used when the patient is sitting, standing, or walking, but sometimes it is ordered for when the patient is in bed (7). 

Historical Background 

Ambrose Pare’ 1510-1590, was a French army surgeon considered to be one of the “fathers of modern surgery” and the developer of the first supportive back brace to treat spinal deformities (2). In the 1940’s the Milwaukee brace was developed by Walter Blount, and this was the first cervical thoracolumbar sacral orthosis (CTLSO). The Milwaukee Brace is symmetrical with a harness-like hip area and metal straps rising to the chin where a collar, or neck ring is held in place (2). This brace was very uncomfortable for those with scoliosis and back problems. The Milwaukee brace was the precursor to the modern spinal orthotic brace. 

The next modern treatment developed for scoliosis was by Luis Albert Sayre. Sayre, a staff physician at Belleview Hospital in New York City, NY is best known for using traction in conjunction with a plaster cast to correct and hold spinal deformities (2). In 1969 the Wilmington brace developed by G. Dean MacEwen and colleagues was one of the first low-profile TLSO braces. This brace was removable and constructed of durable, semi-rigid moldable plastic that provided passive correction of deformities with apices at or below the T7. The Wilmington brace continues to be one of the more popular TLSOs in use today (2). 

In 1972 at Boston Children’s Hospital, John Hall and his orthopedist William Miller jointly created a low-profile TLSO brace that differs from the Wilmington brace in one important aspect: it was not custom molded and fabricated on the patient from a cast but created from prefabricated modules of different sizes that were custom modified to achieve correction of the individual’s patient deformity (2). This method of creating a low-profile TLSO by custom modification of preferred fabricated modules or molds is the Boston brace system which is one of the most popular methods of TLSO fabrication (2). 

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Indication for Use 

There are three types of thoracolumbar sacral orthosis (TLSOs). The traditional rigid TLSO, such as the Jewett brace or Knight Taylor brace, provides more rigid stabilization but is poorly tolerated and may lead to paraspinal muscle atrophy. Custom or off-the-shelf semi-rigid TLSOs have fewer rigid alternatives when severe spinal restrictions are not indicated (3,4).  

There are many uses for TLSO braces such as adolescent idiopathic scoliosis, kyphosis, acute vertebral fractures, vertebral body compressions, posterior stability, and gait. TLSOs are commonly prescribed for pain management, to facilitate early mobility and optimize functional performance (3,4). Often, young adolescents do not find braces to be physically appealing and they may develop social anxiety and negative image issues (4).  

Wearing the TLSO braces is important in the incomplete spinal cord injury condition where the patient can ambulate. Standing and movement assisted with orthoses reduce spasticity, (muscle tone) improves bowel and bladder function, and reduces the chance of ulcers, osteoporosis, paralysis, and depression (7). 

The demographic information collected at the initiation of brace treatment includes age, sex, body mass index, and Risser sign (5). Patients are required to undergo full spinal posterior, anterior, and lateral radiographic assessments after the brace has been removed for over 24 hours at each visit during follow-ups (5).  

The Risser-Sign is a method of analyzing X-rays to determine the spine’s maturity, this is also a reliable method for assessing the maturity of a patient’s bones and determining if there may be further growth in their spine. The Risser Sign grade is based on iliac Crest divided into 4 quadrants; therefore, the grades will be observed as follows:  

• Risser 1: 25% iliac apophysis classification 

• Risser 2: 50% iliac apophysis classification 

• Risser 3: 75% iliac apophysis classification 

• Risser 4: 100% iliac apophysis classification 

• Risser 5: Iliac apophysis fuses indication cessation of growth. A Risser sign of 5 is found in adults ranging from age 17 and greater (5). 

Nursing Care 

Caring for the patient with a TLSO brace requires great assessment skills from the nurse. The nurse should assess the following every 8 hours if on the floor and every 4 hours if in the ICU: 

• Respiratory status 

• Chest pain  

• Tingling numbness of extremities 

• Cracked or broken brace 

• Signs of pneumonia (coughing, fever, sputum color) 

• Skin breakdown/pressure areas/irritation each time the brace is removed (5). 

The care and maintenance of the TLSO by the nurse should include ensuring the brace is worn as ordered by the provider. Clarify if the patient is to wear the brace continuously while lying in bed and consult with the provider as to whether the brace may be removed to inspect the skin for potential breakdown. Encourage patients to lie down in bed without the brace periodically throughout the day unless otherwise ordered to wear a brace at all times. Ensure the patient is wearing a t-shirt or hospital gown under the brace. For those patients who must wear the brace while in bed consult with the brace manufacturer’s orthotist (5). 

The nurse should ensure the brace is fitted correctly and tighten/reapply the brace as needed. Assist the patient with repositioning, reapplying, and removing the brace while lying in bed. If the brace causes discomfort or pinches the skin, you may need to readjust the brace. Avoid lotions, creams, and powders under the brace. Ensure the skin is clean and dry (5). 

The nurse should instruct the patient to report any pain, pinching of skin under the brace discomfort caused by the brace, respiratory distress, chest pain with or without coughing, or redness persisting for more than 10 minutes. The nurse should instruct the patient not to bend or twist at the waist or spine, not to raise hands above the head, not to move in a way that causes discomfort due to the brace and to always ask for assistance when applying or removing the brace or getting out of bed. It is the nurse’s responsibility to make sure that the patient is well-informed about the TLSO brace (5). 

Safety Considerations 

Use of the TLSO brace can cause many problems if not worn correctly and is as prescribed. The use of the TLSO brace can cause sudden or worse shortness of breath, calf pain, soreness or swelling, and sudden chest or back pain with or without coughing (4). 

The brace will limit your ability to move in certain directions. You will not be able to sit in certain chairs and your balance will be greatly affected. The individual will need to use cane crutches or walkers to improve strength and flexibility.  

There are restrictions to explain when wearing the TLSO brace (4): 

• Do not bend or twist at the waist 

• Do not lift anything heavier than 5 lbs. for the first two weeks after the injury or surgery 

• Avoid raising your hand over your head 

• Do not sit longer than 30 minutes at a time 

• Avoid sitting in low deep couches or chairs 

A chair with arms, a firm seat, and an upright back is the best way to sit (4). 

Patient and Family Education 

It is very important to provide education to the patient and family regarding the TLSO brace. Educate the patient and family on the following: 

• Explain the purpose of the TLSO. 

• Helps control and support the spinal posture, helps reduce pain, prevents further injury, and promotes healing. 

• Serves as a reminder to keep your back straight and upright. 

• Wearing the TLSO should be uncomfortable when the patient begins to move into positions they should avoid (6). 

• Follow the physician’s advice because he/she determines how long the patient will wear the brace. 

• After the patient has their TLSO fitting, someone must drive them home. Make sure the patient bends their hips and knees and not the back when getting in and out of the car. To relieve pressure from the front pads while sitting lean back over a firm pillow or try sitting in a recliner (6). 

Wearing Instructions 

Remember the patient must wear the brace as ordered by their physician. To remove it, have the patient lie down and open the straps, making sure not to twist or bend their back while the brace is loosened or off. 

• Have the patient log roll onto their side. 

• Flip the latch on the left side. 

• Roll the patient onto their back.  

• While on their back, open the keyhole latch on the right side and open the brace like a book. 

• Have a helper slide the brace out from under the patient  

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Putting on the TLSO 

Always wear the TSO over a clean T-shirt and the brace must be put on while lying down. 

• With the help of someone, have the patient roll onto their back pad and strap without bending or twisting. 

• To close the strap, insert the right-side keyhole-shaped piece over the peg and pull to tighten, slip the bigger end of the hole over the peg, then pull to engage the smaller part of the hole. Then close the brace like a book over the front of the patient’s body. Flip the latch on the other side to make it snug. Close the straps snugly so the straps don’t dig into the patient’s sides (6). 

Showering and Bathing 

The patient can wear braces in the shower or while taking a sponge bath. After the shower, someone can dry the pads and straps with a hair dryer set on low (6). 

Cleaning instructions 

Outside: Wipe off the outside with a damp or soapy cloth then dry. 

Inside: While the brace is off, wipe the inside with a damp cloth. 

Make sure to observe the skin for red spots around the brace. When it’s over a large area of skin or pink skin is normal (6). 

Case Study 1 

Jack is a 17-year-old high school football player who was injured during a game. He was taken to the emergency room because he was complaining of severe mid to lower back pain. X-rays revealed he had a T6 and T7 incomplete compression fracture. His vital signs are 98.2-98-18-176/98.  

Neurologically he is stable. Jack weighs 195 lbs. and stands at six foot one. Jack decided he didn’t want surgery and is open to wearing a brace because he wants to get back to his activity level as soon as possible. He will need extensive training regarding the TLSO brace he has chosen to wear. 

Case Study 2 

Tracy is an 85-year-old female who was walking her dog and tripped over the sidewalk fell and hurt her back. She was taken to the ER in excruciating pain. Her vital signs are 99.3-110-22-180/101. She complains of numbness and tingling in her lower extremities. She has been diagnosed with a complete compound fracture at T6-T7. She states she’s afraid to have surgery because she does not respond well to anesthesia. She is open to wearing a TLSO brace but thinks her daughter should be taught how to care for her while she wears it.  

Conclusion

Orthoses such as TLSO braces are medical devices that are applied externally to prevent contractures, increase function, maintain the functional position of a bony segment, stabilize the body, and assist weak muscles, and its function/application results in increased motor control and balance gait. It is also applied to preserve the results of surgical procedures for successful rehabilitation and prevent recurrences. Early rehabilitation is important to restrict the loss of muscle strength and joint contracture and maintain bone density to secure normal functioning. 

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