responses to LSO with thigh cuff

responses to LSO with thigh cuff

Jennifer Lee, CO

2/10/2008

My original post:



What is the consensus on the angle of a hip joint attaching an LSO
(anterior overlap style) to a thigh cuff when ?treating
spondylolithesis with a pars fracture in teenagers? ?Does the angle
depend on the amount of slippage?








It seems like the old school thought on the treatment was
to lock the joint in 20 degrees or even to not put in a joint and
fabricate the brace out of one piece of plastic, then cutting the thigh
cuff off after so many weeks in the brace.










But this seems to be the protocol for large unstable fractures at L4 and L5 now only.









It
seems that a pars fracture is sometimes now treated with an LSO with a
hip joint that has a drop lock on it. ?This would allow the patient to
sit easily but would lock their hip at 180 when standing or ambulating.










Any comments?? ?How are you treating these in your practice?









Jennifer Lee, CPO



Trumbull, CT



____________________________________________



Responses:




Hello Jennifer,
We see many Pars fracture referrrals from a local Spine Center. We have been
treating this patient population for the last 10+ years without using a
thigh extension and/or controlling flexion during ambulation and sitting.
We have found that a true custom molded high profile LSO works great for
pain control and healing. The motion control goals are to control flexion
and extension on this patient population. We do a very mild reduction in
lordosis by removing mass off of the buttox. This does not create a pelvic
tilt but rather creates a compression element low on the spine to capture
motion control at L4-5. Total contact and motion control is absolutely the
idea and is necessary. To acheive the outcomes you must use a molded design
not made to measurement or off the shelf LSO's.
Hope this helps.



In?my area north of?Boston, use of an anterior overlap antilordotic LSO
has been the standard for as long as I have been around (20+ years).?
The only thing that varies is length of duration of treatment (6- 12
weeks).?

A number of studies have been?done on the non-operative management
of spondylolysis and spondylolisthesis, and most suggest very good
outcomes with the combined recommendation of 1) cessation of sports
(typically for 3 months); 2) the use of an LSO, and 3) physical
therapy,?typically?focused on hamstring stretching and abdominal
strengthening.


?


Your question doesn't specify as to whether you're considering
this for non-operative, vs. post-operative care.? In my experience,
I've never utilized a hip extension to a spinal orthosis in the
non-operative management of either spondylolysis or spondylolisthesis.?
A point worth making, however:? Most studies have suggested an
anti-lordotic approach to bracing, whereas a handful of others have
specifically suggested to maintain the lordosis that is present.??
Typically, these patients have pain relief by?side-lying or supine with
their hips?flexed.? This would argue for the use of an anti-lordotic
design.? There are two points worth considering here:? First,?all LSO's
that will effectively?treat this condition share the common
characteristic of relying on increasing the hydrostatic?pressure of the
injured region, and with that, there can be a natural anti-lordotic
effect as a result - regardless of the angle or lordotic shape of the
posterior aspect of a given LSO.? Secondly, specifically for those with
a spondylolisthesis,?only those with low-grade slips (using the
Meyerding classification) are commonly?considered as candidates for
orthotic (conservative) treatment.? From a biomechanical standpoint,
mildly reducing the lordosis makes sense to me?- at least for the more
common lumbosacral application (L4-L5-S1).


?


For the post-operative treatment of either of these conditions
(spondylolisthesis being much more likely that spondylolysis), a hip
extension is occasionally advocated.? The primary role of this
extension from the LSO is intended to more effectively immobilize the
lumbosacral junction (as you eluded to).? With that being the goal, the
sagittal plane angle?that is set across the anatomical hip joint
doesn't play as critical of a role in most operative?slips (Grade III
or possibly IV)?in the heeling of the operated segments.? That said,
most operative cases still don't require the hip extension, and in fact
many younger patients (through adolescents) may not even require any
orthosis post-operatively.? In more severe cases, such as in
spondyloptosis, preventing flexion beyond 20 degrees in addition to an
LSO can be warranted since additional stress can be placed across the
site needing to fuse, especially in the typical presence of tighter
hamstrings.? In any case, if a hip extension is used, it is typically
removed in 6-8 weeks post-op in adolescents.


?


The bottom line is there is no real evidence?that I'm aware of in
the literature that demonstrates precisely what cases absolutely
require a hip extension, and for those that do, what angle is best for
select circumstances.? Variables such as the levels fused, the type of
fusion (instrumented and reduced vs. in situ) can also play a role in
this decision making.??So I'm unable to give you a precise answer, but
I hope you find this information helpful to help guide you.

Thanks to everyone who responded.?
 


?





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