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Scientific Articles   |    
Use of a Postoperative Lumbar Corset After Lumbar Spinal Arthrodesis for Degenerative Conditions of the SpineA Prospective Randomized Trial
A.J. Yee, MD, FRCS(C)1; J.U. Yoo, MD2; E.B. Marsolais, MD3; G. Carlson, MD5; C. Poe-Kochert, CNP4; H.H. Bohlman, MD4; S.E. Emery, MD6
1 The Spine Program, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, 2075 Bayview Avenue, Room MG 371-B, Toronto, ON M4N 3M5, Canada. E-mail address: Albert.Yee@sunnybrook.ca
2 Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098
3 1611 South Green Road, South Euclid, OH 44121
5 Orthopaedic Specialty Institute, Medical Group of Orange County, 850-1140 West La Veta Avenue, Orange, CA 92868
4 Department of Orthopaedic Surgery, University Hospitals Spine Institute, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106
6 Department of Orthopaedics, West Virginia University, 1 Medical Center, Morgantown, WV 26506
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Medtronic Sofamor Danek. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Medtronic Sofamor Danek) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
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Investigation performed at the Spine Institute, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Oct 01;90(10):2062-2068. doi: 10.2106/JBJS.G.01093
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Abstract

Background: Lumbosacral corsets and braces have been used to treat a variety of spinal disorders. Although their use after lumbar arthrodesis for degenerative conditions has been reported, there is a lack of evidence on which to base guidelines on their use. The purpose of this study was to evaluate the effect of a postoperative corset on the outcome of lumbar arthrodesis.

Methods: A prospective randomized trial was performed in which patients who wore a postoperative lumbar corset for eight weeks full-time after a posterior lumbar arthrodesis for a degenerative spinal condition were compared with those who did not use a corset after such an operation. Ninety patients were randomized to one of the two treatments. A history was recorded and patients were assessed with a physical examination, radiographs, and functional outcome questionnaires (the Dallas Pain Questionnaire [DPQ] and the Short Form-36 [SF-36]) preoperatively and at one year and two years following the surgery. The primary outcome measure of the study was the DPQ, a disease-specific patient-derived functional measure of the spine, and secondary end points included the SF-36 scores, complications, rates of fusion as determined radiographically, and reoperation rates.

Results: Follow-up analysis was performed for seventy-two patients, thirty-seven randomized to the brace (experimental) group and thirty-five randomized to the control group. Regardless of the treatment method, the patients had substantial improvement in the disease-specific and general health measures by two years postoperatively. At two years, there was no difference in the DPQ category scores (the primary outcome parameter) of the two treatment groups. There was also no difference in the mean SF-36 component scores at two years. Postoperative complications occurred in 22% and 23% of patients in the experimental and control groups, respectively, and a subsequent lumbar spinal operation was performed in 19% and 14%, respectively. Seven patients (five in the experimental group and two in the control group) with radiographic evidence of nonunion underwent revision surgery.

Conclusions: This study does not indicate a significant advantage or disadvantage to the use of a postoperative lumbar corset following spinal arthrodesis for degenerative conditions of the lumbar spine.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Albert JM Yee, MD, FRCS(C)
    Posted on March 05, 2009
    Dr. Yee responds to Dr. Dabke
    Sunnybrook Health Sciences Centre

    Thank you for the opportunity to respond to the letter from Dr. Dabke regarding our article. We appreciate Dr.Dabke’s comments regarding the ongoing need to evaluate a controversial and important area pertaining to the role of bracing in spinal surgery.

    The potential effectiveness of a brace depends on the potential goal(s) of therapy which include pain relief, reducing spinal mobility, and even positive re-assurance to patients. We acknowledge the variablility among different bracing regimens (day time, night time, full-time). In our study, we attempted to standardize the time patients spent in a brace by advising them to wear the brace full-time during the bracing period. Although not published in the paper (apart from brace compliance data), we did complete a bracing follow-up questionnaire and evaluation on randomized patients. There were no significant post-operative pressure sores relating to brace use. An open ended comment section on how patients responded to use of a brace demonstrated that approximately 5% of patients felt the brace was ‘too cumbersome to wear for the recommended duration’; another 5% of patients felt that the brace provided ‘tremendous re-assurance and support to their back’ in the post- operative period. There were also many non-responders to the above question.

    In those patients randomized to the experimental group, there was no change in brace type during the bracing period. We do agree with Dr. Dabke that the question of whether bracing influences short term recovery remains unanswered as our study was primarily aimed at functional outcome measured at 1 and 2 years following surgery.

    Although the period of hospitalization was not significantly different when comparing the two groups, a meaningful comparison of postoperative pain scores and analgesic requirements in the early post-operative period was not performed in our study and as such, is an acknowledged study limitation. We do agree with Dr. Dabke that the role of bracing may be more important following un-instrumented lumbar fusion. Ongoing study in further defining the potential role for bracing is warranted.

    Harshad V. Dabke
    Posted on December 10, 2008
    Use of Lumbar Corset after Lumbar Spinal Arthrodesis
    Salisbury District Hospital, Wiltshire, UK

    To the Editor:

    I read with interest the study “Use of a Postoperative Lumbar Corset After Lumbar Spinal Arthrodesis for Degenerative Conditions of the Spine” by Yee et al. The authors need to be commended for conducting a scientific inquiry on a contentious but important issue. Since pedicle screw fixation systems are very effective in providing spinal stability (1,2), until now,some surgeons have logically assumed that as far as immobilisation is concerned bracing may not alter the final outcome (3,4). While the study by Yee et al, has confirmed these assumptions, the question of whether bracing influences short term recovery remains unanswered. The results would have been more meaningful if the outcome measures were to include parameters like postoperative pain scores, analgesic requirement, and period of hospitalisation. I am unsure why patients were advised to use a brace in bed and if so did they experience any difficulty in using the brace at night time? It would have been useful to know if any patient developed problems like pressure sores, related to the use of a lumbar corset and if patients required a change of brace for any reason. Bracing involves additional expenditure, so it would have been interesting to know whether there was a significant difference between the two groups in the total cost of treatment.

    As spinal instrumentation provides immediate stability,the role of a brace is more significant following uninstrumented lumbar fusion.

    References

    1. Vanden Berghe L, Mehdian H, Lee AJ, Weatherley CR: Stability of the lumbar spine and method of instrumentation. Acta Orthop Belg. 1993; 59 (2): 175-80.

    2. Johnsson R, Axelsson P, Gunnarsson G, Stromquist B: Stability of lumbar fusion with transpedicular fixation determined by roentgen stereophotogrammametric analysis. Spine 1999 Apr 1; 24(7): 687-90.

    3. Connolly PJ, Grob D: Bracing of patients after fusion for degenerative problems of the lumbar spine- yes or no? Spine 1998 Jun 15; 23 (12):1426- 8.

    4. Resnick et al: Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 14:brace therapy as an adjunct to or substitute for lumbar fusion. J Neurosurg Spine 2005 Jun: 716-24.

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