Conservative treatment of children with vertebral compression fractures of the thoracic and lumbar spine in the Russian Federation: a literature review

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Abstract


Various options for medical treatment of children with compression fractures of the thoracic and lumbar spine include unloading of damaged segments by simultaneous or gradual reclination (e.g., functional traction and reclination of the spine); measures aimed at building and strengthening the muscular “corset” of the back; and the use of orthotic devices of various designs (e.g., fixating-discharging, fixating-correcting corsets, orthoses on a modular basis). Questions regarding the early and late use of orthotics in patients with compression fractures of the vertebral bodies are discussed. Literature analysis, considering different methods used in the treatment of these patients in terms of their effectiveness to restore the height and shape of the damaged spinal segment revealed the absence of a differentiated approach for choosing treatment and selection criteria for orthopedic management.

Treatment of children with compression fractures of the thoracic and lumbar spine remains a medical and social challenge.. This is due to the steady increase in the number of such patients in the overall context of musculoskeletal system injuries [1, 2]. Spinal fractures in children are the most common types of injury after tubular bone fractures, internal injuries, and cerebrocranial traumas [3]. Estimates of the incidence of spinal injury among children in the literature range from 1.9 to 19.9 per million children and spinal injuries account for between 1% and 10% of all musculoskeletal system traumas in children [3-6]. Compression fractures of the vertebral bodies account for 0.65%–9.47% of all spinal injuries in children [7, 8].

The above-mentioned estimates are consistent with statistics from St. Petersburg, Russia, where the percentage of all childhood vertebral compression fractures increased from 5% to 7% between 2010 and 2012 [9]. In St. Petersburg approximately 1,000 children (less than 18 years old) had vertebral compression fractures, based on reports from trauma centers. The treatment of these patients was traditionally inpatient, followed by a period of rehabilitation, and they were typically hospitalized in units with patients with acute spinal cord injury

The increase in compression fractures among children may be due to improved diagnosis or worsening health in this population. Compression fractures occur more frequently in children who are not very physically active. Pediatric patients with predisposing conditions and comorbidities (such as poor nutrition, juvenile osteoporosis or idiopathic arthritis, or bone dysplasia) had a higher incidence of compression fractures after minor trauma compared to children without these conditions [10]. Among patients with juvenile idiopathic arthritis, the incidence of vertebral compression fractures was between 11% and 28% and was higher than the incidence among children without idiopathic arthritis [7, 11-13].

Common conservative options of treatment for vertebral compression fractures in children include: a) single-step reclination of the spine followed by immobilization with a plaster cast; b) gradual reclination of the spine; and c) the Gorinevskaya and Dreving functional method [3, 14].

The single-step spinal reclination followed by immobilization with a plaster cast method is performed by careful overextension on a special fracture table (A. Davis or Z. Bohler) [14] and was first performed by Davis in 1929. According to Bazilevskaya, simultaneous apposition and fixation of the damaged spine does not lead to the desired results because when a complete break of the trabeculae of bone from the damaged vertebral body does not occur, there is a large amount of friction which prevents the successful external reclination and, consequently, achievement of the fracture apposition [1]. In addition, there is a high risk of 
secondary damage to the spinal cord when conducting manipulation in patients with fractures of the thoracic vertebrae. The plaster cast leads to atrophy of the back muscles and further contributes to collapse of the vertebral bodies because of increasing static loads on the spine [15]. Immobilization with a plaster cast for more than one month and low physical activity may initiate the development of secondary osteoporosis [16].

Gradual reclination in the acute phase of injury allows for restoration of the normal anatomic interactions in a damaged spine and avoids the complications related to the simultaneous apposition and fixation [14]. Distraction is carried out by the patient’s own weight with the patient in the supine position on an inclined plane. Fixation is performed using straps at the armpits.

A rolled towel is placed on the region of damaged spinal motion segment for unloading the anterior parts of the fractured vertebra body and creating the conditions for spine overextension. Distraction is performed for 4–6 weeks. Patients with lumbar spine fractures are placed into a hammock with reclination in the area of damage, or pelvic distraction with reclination is performed [17-19]. After the gradual apposition, a rigid brace should be used for 6–8 months to maintain the correction. Patients are recommended to perform a set of exercises based on the Gorinevskaya–Dreving functional method [20, 21], which has been in widespread use in Russian clinics since 1933 [3].

The main disadvantages of the gradual reclination treatment are its long duration, the need for a high degree of patient compliance with the treatment regimen, and the need for strict continuity between healthcare organizations at all stages of treatment. The prolonged stay in bed and dependence on nursing personnel and relatives affects patients’ mental health. These disadvantages negatively affect the patient’s recovery and drastically impact the patient's quality of life.

The “traditional method” to treat vertebral compression fractures is now used in children’s hospitals in St. Petersburg [9]. This multistage treatment includes continuation of outpatient rehabilitation services in the rehabilitation center after 
discharge.

The first stage lasts for 3–5 days. The purpose of this stage is to relieve acute pain and to unload the parts of a damaged spine. Physical therapy is performed, including breathing exercises to improve respiratory function and kinetic exercises for the distal extremities to improve blood circulation, and metabolism. All these exercises are performed in the supine position, and raising the head and lower limbs at this stage is not recommended.

The purpose of the second stage, which lasts for 10–15 days, is the normalization of blood flow to the area of the fracture.

The purpose of the third stage, which lasts for 7–10 days, is preparation for the formation of the muscle sling. The patient is still on bedrest during the functional distraction. On the 20th day of hospital stay, physical therapy with the patient on his or her hands and knees is started. The patient is transferred to a rehabilitation center for continuation of treatment, between the 25th and 30th days after the beginning of treatment.

The main disadvantage of this “traditional method” is the prolonged time spent in a hospital bed with little physical activity. In addition, some patients do not comply with the prescribed treatment regimen. Long-term conservative therapy for vertebral compression fractures with limited physical activity often leads to a deterioration in the health of children [22, 23]. Long involuntary bedrest, especially in conjunction with impairment of nutrient intake, adversely affects the structure of bone tissue [24, 25].

An integral component in the complex rehabilitation of children with vertebral compression fractures is the use of trunk orthoses, or braces. The main objectives of bracing therapy are to provide stabilization, unload the anterior parts of the injured spinal motion segment, and restore the correct position of the injured spine [20, 
26, 27].

For many years, the instructions for using orthopedic braces used in the orthotics practice stated that the indications for the prescription of braces were the same for vertebral compression fractures and tuberculous lesions of the spine. As a result, patients were administered fixating-discharging, fixating-correcting braces mostly with rigid structures made of nitrovarnish, gelatin, tire-rubber, or plastic, with or without thoracic crutches [28]. Designs of different braces, which are used in complex, conservative treatment for scoliosis, and can be used in the rehabilitative treatment of patients with vertebral compression fractures, have been described in the literature [20, 29].

In the literature, there are descriptions of Milwaukee braces (Fig. 1), designed by V. P. Blount and A. S. Schmidt, for the rehabilitation of patients with compression fractures [30]. These consist of a pelvic girdle, three metal sliding bars, and a neck ring. These products are simple in design and are made of standard parts. However, the entire unloading of the spine with these products is due to the pressure on the back of the head and lower jaw and prolonged use of the brace may lead to the malformation or progression of deformation in these 
parts.

In addition to the well-known braces, custom-made orthoses are used for spinal injuries. They are made from individual parts, such as polymer plates of standard size and shape, which are attached with straps or clamps. Depending on the level of the spinal lesions, different modules of orthoses were developed. In their manufacture, the common principle of three pressure points (sternum, pubic symphysis, and lumbar spine) is used, as is done in the case of reclining plaster casts [30]. This design of orthoses, with three pressure points is widely used for the treatment of patients with vertebral compression fractures in Germany and the USA 
[30, 31].

Rigid braces for stabilizing the thoracic and lumbar spine use a metal frame made of four pieces fastened together with corrugated plates, rigidly mounted to the frame bandages [32]. This is a low-tech device and is heavy because of the large number of fastening elements and overhead supports, connecting plates (Fig. 2).

It is difficult or impossible to make the brace according to the precise anthropometric measurements of the patient without risking plastic deformation of the frame. This is especially difficult near the connecting plates, as the metal at these points can be up to 6–8 mm thick.

In the past, it was believed that the braces should be used for patients with vertebral compression fractures no sooner than 2–2.5 months after the injury to support the spine after functional treatment methods [26, 28]. However, because children usually do not comply with bedrest, and prolonged time in a horizontal position causes adynamia and decreased muscle tone, a number of authors recommend earlier use of a brace, which may shorten the patient’s stay in the hospital [20, 33]. Skryabin and Smirnih recommend abandoning the traditional method of treatment of patients with compression fractures, and allow for an early vertical position and fitting of braces [33].

Several researchers suggested that the use of spinal braces in the first days after the trauma allows for earlier transfer to an outpatient rehabilitation and achieving true recovery of the affected vertebrae [17, 18, 33]. However, no studies confirming or refuting this hypothesis have been performed.

Matskevich et al. examined 60 children with various pathologies of the spine, who used corrective orthoses, and concluded that treating an isolated fracture of the thoracic spine using a reclining orthosis КР1-10,12 in combination with physical therapy produced good results in all patients. The patients had no complaints of back pain, and there was physiological restoration of the frontal and sagittal spine profiles as well as normalization of spinal mobility within normal limits. In a comparative evaluation of the X-ray data in children under 12 years of age with the same damage, regeneration occurred earlier and more fully than in older patients [34].

In addition to these braces, after treatment, a reclinator brace with air bags was used for children with compression fractures of the thoracic and lumbar vertebrae bodies. The reclinator brace consists of three air bags connected by rigid rods and flexible straps of adjustable length, which allows for use of the device by patients with different anthropometric measurements and allows for constant reclining of the compressed vertebrae. The disadvantage of this device is its complexity, which creates inconvenience for the patient due to the large footprint of the air bags, and insufficient reclining force from air bags to reliably heal the damaged vertebra.

For pain syndrome in children with vertebral compression fractures, the lined Leningrad brace is the most widely used, but it does not allow for reclination and unloading of the thoracic spine 
(Fig. 3).

If there is only one affected vertebra in the thoracic region, a reclinator consisting of two parts is used. These parts are shoulder loops connected to a base, turning in the belt, and fasteners, parts of which are located on belts [35]. Some authors assumed that these reclinators provide the required force on the spine in the sagittal plane, hold it in the corrected position, prevent the progression of deformity, and provide partial unloading of a damaged spine by transferring the weight of the trunk from the vertebral bodies to the posterior parts of the spine [36]. In addition, these reclinators reduce the longitudinal force of compression and the effects of bending and torsional moments on the damaged spine.

The disadvantages of the brace reclinator include poor strength, inability to retain the shape of the brace during long-term use, and the inability to create significant forces that can change the direction of correction. Due to the insufficient strength of these devices, they do not provide the required therapeutic effect [33].

Some supporters of the conservative tactics of treatment for spine injuries believe that one should not aim for full anatomical restoration of the injured vertebral body, as compensation is achieved by changing the position of adjacent spinal motion segments [35].

However, according to other authors, even slight wedge deformity of the vertebral bodies, especially in the area of the thoracolumbar transition, in the late periods after injury often leads to complications in the form of spine deformation, severe pain syndrome, and functional failure of the spine [37]. Compensatory increases of physiological kyphosis flexure due to impairment of biomechanics inevitably leads to spine deformation, early development of degenerative disc disease, and pain syndrome in the area of damage. Even with gradual reclination, the body height of the injured vertebra is restored only in very rare cases [38-40].

According to some authors, 20% of patients are at risk for progression of traumatic kyphosisas as a result of conservative treatment in children with compression fractures of the thoracic and lumbar spine, in the case of endplate damage and compression of the anterior vertebral body column 
[41, 42].

Research, using inconsistent methods, over several decades has shown that conservative treatment in patients with vertebral compression fractures yielded a high percentage of unsatisfactory results (such as increases of the kyphotic deformity and pain) accounting for 11% to 57.2% 
[1, 7, 38].

Principles of modeling for hyperextensioning braces in different orthotics schools differ as they are based on subjective and specialized experience (Perie et al., 2003) and are under-represented in the scientific literature [43].

Current strategies to treat spinal injuries must take into account the whole complex of pathogenic factors and be directed to the creation of physiological conditions for recovery of the lost functions of the spinal column in the implementation of early patient activity [33]. Vertebral compression fractures are stable injuries and can be cured in the conservative way with the restoration of normal interactions in the vertebral motion segment [30].

Optimal treatment for vertebral compression fractures is a reliable immobilization of the injured vertebral motion segment, which simultaneously would not prevent the creation of muscular “corset.”

The basic principles of treatment are unloading of the damaged spinal segment, adequate fixation, and early initiation of activity by the patient, which results in the most rapid and effective restoration of the anatomical relationships in the injured segment.

Thus, analysis of published data confirms that there is no differentiated approach to the choice of treatment and selection criteria for orthopedic support for compression fractures of the thoracic and lumbar spine in children [22, 44, 45]. In the complex structure of treatment of patients with vertebral compression fractures, orthotics are currently used in a long-term rehabilitation period for fixation of the therapeutic effect after functional treatment methods. Braces with ribs or tire-rubber orthotic devices that have been used in recent years do not meet the medical requirements for use in the early period of treatment in patients with vertebral compression fractures and do not allow for full restoration of the form and height of the fractured vertebra. In addition, no method of application for spine orthoses with hard hyperextension for vertebral compression fractures in children has been developed. There are no defined timelines for their administration and cessation. Positive messages about the use of orthosis in the early treatment of children with compression fractures based on observations from authors’ practices show the possibility of using braces with hyperextension to restore the height and form of the affected vertebrae [33]. This problem requires further investigation and evaluation of study results.

Alexei G Baindurashvili

The Turner Scientific and Research Institute for Children’s Orthopedics

Author for correspondence.
Email: turner01@mail.ru

Russian Federation д.м.н., профессор, чл.-корр. РАН, заслуженный врач РФ, директор ФГБУ «НИДОИ им. Г.И. Турнера» Минздрава России; заведующий кафедрой детской травматологии и ортопедии ГБОУ ВПО «СЗГМУ им. И.И. Мечникова» Минздрава России

Sergei V Vissarionov

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: fake@ECO-VECTOR.RU

Russian Federation д.м.н., заместитель директора по научной и учебной работе, руководитель отделения патологии позвоночника и нейрохирургии ФГБУ «НИДОИ им. Г.И. Турнера» Минздрава России; профессор кафедры детской травматологии и ортопедии ГБОУ ВПО «СЗГМУ им. И.И. Мечникова» Минздрава России

Ivan V Pavlov

North-Western Scientific and Practical Centre for Prosthetics and Rehabilitation “Ortetika”

Email: fake@eco-vector.com

Russian Federation врач травматолог-ортопед. Северо-Западный научно-практический центр протезирования и реабилитации «Ортетика».

Dmitriy N Kokushin

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: fake@ECO-VECTOR.RU

Russian Federation научный сотрудник отделения патологии позвоночника и нейрохирургии ФГБУ «НИДОИ им. Г.И. Турнера» Минздрава России.

Grigoriy A Lein

North-Western Scientific and Practical Centre for Prosthetics and Rehabilitation “Ortetika”

Email: fake@eco-vector.com

Russian Federation к.м.н., травматолог-ортопед. Северо-Западный научно-практический центр протезирования и реабилитации «Ортетика».

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