What is the role of bracing in the treatment of acute pars interarticularis injuries?

Updated: Jan 22, 2019
  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD  more...
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Indications for the use of a brace are lack of symptom improvement by 2-4 weeks, the presence of a true fracture, the presence of a spondylolisthesis, the need for pain control, and the lack of patient compliance to activity restrictions. [56]

There are no randomized, double-blinded studies of brace application in the treatment of spondylolysis; however, several authors have demonstrated good results. In 1985, a widely referenced study by Steiner and Micheli evaluated 67 patients with symptomatic spondylosis or low-grade spondylolisthesis via plain film or planar bone scan without a control group. [57] A rigid, antilordotic, modified Boston brace was applied for 23 hours per day for 6 months, followed by 6 months of weaning. Follow-up at an average of 2.5 years demonstrated good or excellent results, and 23% of patients showed bony healing on radiograph.

Furthermore, Blanda et al examined 62 patients with spondylolysis and found that 84% had excellent results with conservative treatment, which included using a lumbar brace, at an average follow-up of 4.2 years. [25] Overall, the results of bracing vary from complete healing with resolution of back pain to nonunion, persistence of pain, or progression to spondylolisthesis. Using return to sport as the end point, the success of bracing has ranged widely from 7-84%. [25, 58, 59, 60, 61]

In contrast to the above studies, several authors have reported on the treatment of patients with symptomatic spondylolysis using a soft brace or no brace instead of a rigid brace. Rigid braces do not have a stabilizing effect on the sagittal, vertical, and transverse intervertebral translations and provide gross limitation of body motion.

Morita et al studied 185 adolescents with spondylolysis and classified the pars defects into early, progressive, and terminal stages. [61] Conservative management included the use of a conventional lumbar corset for 3-6 months. Follow-up radiographs showed healing without the use of a rigid brace in 73% of the patients in the early stage, in 38.5% of those in the progressive stage, and in 0% of those in the terminal stage. [61]

Jackson et al also examined 7 athletes who had a positive bone scan with negative lumbosacral plain films and discovered that if the bony reaction was recognized early, healing at the subroentgenographic level could occur with rest and activity modification without the use of a brace. [62] Furthermore, Congeni et al examined 40 young athletes diagnosed with spondylolysis on bone scan and followed a treatment protocol of nonrigid bracing, specific educational guidelines instructing patients to avoid hyperextension activities, flexibility training, strengthening, and cardiovascular activities. [49] Only 2 of 40 patients needed to switch to a rigid brace after 4 weeks due to persistent pain. None of the patients required surgical intervention at a follow-up period ranging from 3 months to 5 years. [49]

Research on the biomechanical effects of bracing and its effect of immobilization on the spine has been performed. Axelsson et al studied 7 patients following posterolateral lumbosacral fusions without internal fixation. [63] These individuals were examined by roentgen stereophotogrammetric analysis in supine and erect positions 1 month postsurgery without lumbar support, with a molded rigid orthosis, and with a canvas corset with a molded plastic posterior support. Neither of the 2 types of lumbar support showed any evidence of a stabilizing effect on the sagittal, vertical, or transverse intervertebral translations.

Lantz and Schultz also reviewed 4 trunk movements in 5 young men wearing a lumbosacral corset, a chairback brace, and a molded plastic thoracolumbosacral orthosis (TLSO) in standing and sitting positions. [64] All 3 orthoses restricted some gross body motion, approximately one half to two thirds more than in patients without an orthosis. Both studies confirmed that a lumbosacral orthosis restricts gross motions of the trunk rather than intervertebral mobility in the lumbar spine.

Willems et al investigated whether plaster casts actually immobilize the lumbosacral joint. They studied 10 patients placed in a plaster cast and examined the lumbosacral joint of these patients, using a 3-dimensional (3-D) motion analysis system in static and dynamic test conditions. Willems et al found that plaster casting did decrease lumbosacral mobility during static test conditions and did not significantly decrease the mobility of the lumbosacral joint in dynamic test conditions. [65] Hence, the most consistent effect of the lumbosacral orthoses appears to be the limitation of gross body motion. The rigid bracing seems to be the most effective.

Sairyo et al assessed the efficacy of using a hard brace to restrict lumbar rotation and extension. They treated 37 patients younger than 18 years with incomplete pars interarticularis injury. They stratified the patients into 4 categories: early, progressive with high signal intensity, progressive with low signal intensity, and terminal defects. The union rates for early defect were 94%, progressive with high signal intensity were 64%, progressive with low signal intensity were 27%, and terminal were 0%. They also showed that based on CT findings, the mean time to heal was 3.2 months for the early-defects group, 5.4 months for the progressive with high signal intensity group, and 5.7 months for the progressive with low signal intensity group. They concluded that patients with early-stage defects are the best candidates for conservative treatment with a hard brace based on their findings. [66]

Based on current literature, the need for bracing is limited. Bracing can be considered in patients who continue to have symptoms despite a period of rest. For most of these patients, nonrigid bracing is adequate. The Sairyo et al study suggests that patients younger than 18 years with early defects on CT scan may be good candidates for rigid hard bracing for 3 months, owing to the high rate of union in their study. [66]

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