Position of waist rolls in a spinal brace - replies

Position of waist rolls in a spinal brace - replies

Lucy Best

9/1/2006

Many thanks to all those who responded to my question on waist roll position in a scoliosis brace. The full question was:

Most of the training manuals I have read for spinal braces say that the
waist rolls (or iliac crest rolls) are positioned at the level of the L2 -
L3 disc space. However, looking at X-rays where the outer skin is visible,
it seems that the mid point of the waist indents are lower than this, so
that the proximal edge of the waist roll would be at the L2 - L3 disc space.
Have any of you altered the position of the waist rolls in this way and if
so, what do you think?

Lucy Best, prosthetist/orthotist, UK

Here are the replies:


Dear Lucy:
I agree with your observation. We'll typically bisect the body of L3 as a point of reference. This location can vary, however, as for most radiographs we're taking measurements in the treatment of scoliosis. So if a lumbar curve is present, the relationship between the true anatomical waist roll and where it corresponds with the vertebral segments can change. In general, bisecting the centroid of L3 works well, but if anything, the location of the waist roll of an orthosis can correspond a bit more inferior then even that level with deformity.
All that said, an other key point is to consider from which point on an orthosis are you comparing measurements when you consider the superior slope of the waist from anterior to posterior. That is, the more anterior the reference point anatomically (in the sagittal plane), the more inferior the vertebral reference point. I hope that makes sense. These are all pretty subtle changes, especially considering other variables such as how tight an orthosis is worn. The example being with a posterior opening design, the tighter the orthosis, the more superior the migration. All of this can influence where key components of an orthosis (trimlines, corrective pads for deformity, etc.) apply forces to the spine.
That may be more than you were asking for, but I hope it helps.
Kindest regards,
Don Katz, CO, LO, FAAOP
Director, Orthotics Department
Texas Scottish Rite Hospital for Children
Dallas, Texas

Dear Lucy,
I believe the function of the waist rolls is to stop the brace from moving proximally and distally and to some extent stabilise the pelvis as well. As such the position should be in between the iliac crest and also the last rib. Usually that's around the L2-L3 region but not always the case and should not be used as a rule.
Hope the info helps
Daryl Lim
Manager
Prosthetics & Orthotics Dept


Dear Lucy Best,
Patients vary and do not always follow the book. I find that most of my
waist rolls end up near the distal endplate of L3. This is also near the
midpoint between the iliac crests and the inferior ribs. (The waist is
higher in obese patients.) I specifically rivet straps at the waist
level, so that I can compare my anticipated waist level with the actual
position on the in-brace radiograph.
I hope that this is helpful.
Sincerely,
Kevin Felton, CO, LO, FAAOP, Education Coordinator, Orthotics Department
Texas Scottish Rite Hospital for Children



Hi,
Indeed I was also taught that the waist, or crest rolls were at L2/L3, per the text books. I agree with you that this frequently is not the case. I evaluate each x-ray closely to determine where the patient's waist crease is. When a spinal orthosis is donned, the patient does elongate some, raising where the crest rolls are located. Even with this elongation, I have seen many patients with crest rolls much lower than L2/L3, more like L4. If the L2/L3 level is used as the baseline waistcrease without questioning if this is the case with this specific patient, an incorrectly made TLSO could occur with pad levels and initial trimlines translated incorrectly low.
Tom Colburn CO

Lucy,
Our students are taught to centre the rolls 1/2 the distance from the superior aspect of the iliac crest to the most inferior costal margin. The spinal level isn't an issue.
All the best,
Robert


Please excuse as I likely misunderstand question..? Waist rolls are simply
modifications with primary purpose of reducing superior migration. Once
established they may be used as reference point for donning, establishing
trimlines or to locate other orthotic interventions (i.e. pads for scoli,
outriggers, etc.). Their location is NOT established radiographically by
aligning them with vertebrae. Like almost ALL orthotic design
modifications/components, location-alignment is established by palpable
landmarks: they are placed BETWEEN inferior costal margin and iliac crests
at anatomical waist. Just so happens this is GENERALLY in the L2-3 area,
like the xiphoid is APPROXIMATELY at T8 area, sternal notch NEAR T-whatever,
etc. Radiograph may be used to refine locations of pads, move pads to
improve corrective force or accommodate growth, etc. However, surprisingly
enough waist rolls are located in the waist regardless of x-ray findings
or best intentioned training manuals. Also can't resist noting
superior/inferior should be used rather than proximal/distal when
referencing axial skeleton, perhaps this was missed in training manual.
Again, a thousand pardons if question was misunderstood.
Cheers,
Frank @ PENN Prosthetics & Orthotics