In early 2010, my wife’s back was held together with titanium, aluminum, and nylon straps. She’d suffered a major T12 burst fracture, along with a few other fractures in a car accident in Laos. It was braced (“fixated”) by surgically implanted titanium — bracing on the inside. After we’d spent a few weeks in hospital in Laos, we flew her home encased in a wearable spine brace as well: an elaborate contraption of bars and straps and covered in an almost fashionable taupe leather. It consisted mostly of metal in the back, which was tied to her as tightly as she could stand around the shoulders and belly. For weeks, every time she got out of bed, we had to strap her into that thing to protect her spine — allegedly.
I wondered all along if it was really doing anything. Her experience was inherently interesting, and full of lessons relevant to low back pain.
Ironically, her titanium fixations — we always just called them the bars, as in “How are the bars feeling today?” — actually broke during this period. I had been suspicious of this for some time. In certain positions, she even squeaked like a dry hinge — an unmistakable metal-on-metal sound! Muted by a little flesh.
This might have remained a permanent puzzle, until I personally confirmed the breakage studying MRI images. The radiologist had missed it!1 I am proud of making that discovery, even though it is not really as amazing as it sounds. Certainly it’s a minor embarrassment for the radiologist, but mostly his attention was properly on my wife’s bones and spinal canal, not so much her bars. The find was quickly confirmed by a surgeon, who was more amused than shocked (amused in a good, friendly way). “It’s rare. Less than 5% probably,” he explained. “But it does happen, and it’s really not that big a deal.” The bars are simply an internal brace, and are more or less useless dead weight once the bone has healed.
And maybe even long before.
My wife had the bars removed in early 2012. They had become bothersome — a constant, nagging, uncomfortable presence. The procedure and recovery went well. With the ordeal fully behind us, I decided it was time to write about the bracing question. It is not terribly relevant to most of my usual readers, who come here for good information about back pain, not back fractures.
But it is just interesting, and instructive about the nature of backs.
Back braces are routinely recommended to patients during rehabilitation from back injuries and surgeries. In particular, braces are usually assumed to be necessary either as the primary treatment method for a minor spinal fracture, or as a key factor in rehabilitation after surgical repair of a more serious fracture. Aggressive immobilization with a brace probably is necessary to treat a serious fracture without surgery — however, even that is not completely clear cut. It’s not clear that any back brace is actually working as advertised. There is a lot of debate and controversy. There are “better safe than sorry” surgeons and physiatrists who insist on them, and others who think it’s useless.2
It’s not a bad idea to stabilize an injured spine. The trouble is that it may just not be possible. It has always been a bit unlikely that a back brace is really capable of stabilizing the spine significantly — the spine is powerful and squirmy, back braces are awkward and external — and there is plenty of evidence that clearly suggests that it cannot.
There is a near total lack of good direct evidence directly comparing bracing and not bracing (in any kind of spinal patient).3 All the scientific literature has really shown so far that no one really knows whether bracing actually works or not. Not even the most expert experts can provide an opinion any better than an educated guess. This is surprisingly typical of surgery, which is less science-based than most people assume. When surgeries are properly tested — compared to a placebo, or no treatment — the results are often disappointing, and this is especially true about orthopedic surgeries like internal bracing.4
But it doesn’t take a genius to see this: if a back brace is physically incapable of significantly limiting spinal movement or reducing the forces on vertebrae and metal implants, then logically it cannot possibly be very stabilizing or important.
There are braces and there are braces!
Some braces are obviously better at immobilizing spines than others: custom-fitted “clamshell” braces that cinch your entire trunk into rigid plastic are certainly more likely to reduce spinal movement, especially bending and twisting. However, even the most aggressive braces can probably only do so much to resist the force of gravity. Why?
The ribs are quite flexible and mobile, and simply cannot provide firm enough resistance to prevent the weight of the upper torso settling onto the lower vertebrae. And any lesser brace simply stands no chance at all!
I suspect that even a remarkable amount of bending and twisting is still possible within any brace. It certainly seemed that way with Kim’s brace. Despite all the tight straps and clever bars, she could definitely still squirm around inside that thing.
All of this was shown quite clearly by German researchers in 1999.5 They used “telemeterized” implants — steel fixation rods with meters on them! so cyborgy! — to measure the effect of common external braces on spinal forces. This is a clever science experiment. If you have implants stabilizing your spine internally, measuring the stresses on them directly is a good way of checking to see if an external brace is doing anything.
They found that “none of the braces studied were able to markedly reduce the loads” on the implants. There was some reduction — just not “marked,” nothing to write home about.
More surprisingly, some of their measurements showed that bracing actually increased forces on the implants! That’s extremely interesting. I couldn’t have predicted it, but it does seem possible.
The spine is an extraordinarily dynamic structure. Somewhat like slouching into a comfortable chair, a brace may actually cause some sloppiness of spinal function, resulting in “resting” on the fixations, rather than using muscle to support and control the spine. Somewhat like slouching into a comfortable chair, a brace may actually cause some sloppiness of spinal function, resulting in “resting” on the fixations, rather than using muscle to support and control the spine. That’s just a guess, but it seems like a reasonable one to me.
One of the most recent bracing compared bracing to no bracing in a fair number of patients with minor (stable) burst fractures, and simply found no difference at all, suggesting that such fractures are “inherently a very stable injury and may not require a brace.”6
Considering all factors, I think it’s a bit of a no-brainer that back bracing is probably pretty unimportant for the minor spinal fracture or surgery patient. As some doctors believe, it may simply do nothing at all except inconvenience the patient.
The more interesting question is whether or not it matters to more seriously injured patients. Should someone with a scarier low back fracture wear a brace, just in case? Kim was certainly such a patient — right on the brink of paralysis. It was a very close call.
But such a patient will almost always be fused surgically, as the evidence about that is quite clear: it works. And once an unstable fracture has been fixated it quickly becomes quite similar to a stable fracture as well. And if a brace made no difference at all to recovery from minor burst fractures, it’s doubtful that it would make any significant difference in more serious ones that have been repaired with steel implants. Especially since we already know that a typical brace can’t actually take the pressure off of the steel implants at all!
Back braces are notoriously frustrating for patients, and all the more so in cases where they are supposedly more necessary. Patient compliance is definitely a problem (I certainly saw that with my own eyes). Patients flat out ignore physician recommendations, and cheerfully push the limits.
And yet there’s clearly no epidemic of patients who have suffered serious complications from failing to use their brace properly.
Even though Kim’s fixations broke, there’s a good chance that they were sound enough for long enough that, by the time she was starting to get up and around, her vertebra had already healed enough that she needed neither the metal inside or the metal and straps outside. We’ll never know.
— Added citations to Louw and Harris about ineffective surgeries in general.
This research is really just asking two experienced surgeons their opinion on the value of bracing after back surgery (for non-traumatic back problems). They disagree. “Dr. Connolly argues that an external orthosis is advisable in many cases; Dr. Grob feels that the rigidity of internal fixation should be adequate to obviate the need for external bracing.”BACK TO TEXT
Researchers reviewed several studies that have attempted to determine if bracing works in patients with traumatic thoracolumbar fractures. The results? Inconclusive.BACK TO TEXT
A review of a half dozen high quality tests of four popular orthopedic (“carpentry”) surgeries, all showing a lack of efficacy compared to placebos. As of 2016, this review is the best single academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” It’s also an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.BACK TO TEXT