The answer to the first of my questions to my orthotist confirmed what I had already suspected – that I was wearing the only one of my rigid neck braces that I could combine with the back brace I was also wearing at the time. Further, neither of us was aware of another type of neck brace that would be as effective under the circumstances in which I now found myself.
My neck brace was the moulded thermoplastic ‘doll’s collar’ which had seen such sterling service over the years. Of those I have worn, from time to time when necessary, this is still the one that I much prefer to wear, at least in public, when my cervical syndrome is acute. It offers the best trade-off between the firm support I require at such times, comfort and cosmetic appearance. I can disguise it beneath a skivvy or turtle-neck sweater, and it lacks the unsightly metal struts characteristic of my SOMI and other such rigid cervical orthoses.
For details of how I had come to acquire a variety of such equipment over the years, all of it effective in its respective ways, you may wish to refer to previous accounts of my experiences. These relate my having been put in, and subsequently liberated from, a full spinal brace (CTLSO), following spinal injuries sustained in an aircraft accident many years ago, and my experiences in the management of my back and neck problems since (Spinal Fracture and If the Brace Fits, Wear It!).
My orthotist had made the doll’s collar for me originally and seemed surprised that it had stood the test of time, despite my only having worn it for a small proportion of that time. I complimented him on his having provided me with an appliance that has served me so well and for so long whenever I have depended upon it.
If you have read the above accounts, you may be aware that I have had relatively few problems with my back, as apart from my neck, over the years. An occasional spell in traction has settled down the pain I sometimes get from disc lesions adjacent to the (lower thoracic) fracture site. In recent times, however, I had found that wearing another back brace been had been useful as well, keeping my lower- thoracic and lumbar spine in extension and preventing the sciatic pain that flexion can engender at such times.
A brief word about it may be of interest. It is a ‘Jewett’ hyperextension brace, named for its designer – an orthopaedic surgeon of the 1930s. Unlike the Taylor-type brace which had comprised the lower part of my original CTLSO, with its dorsal frame, it consists of a pad over the sternum, an anterior half-pelvic band and a dorsal pad in the lower thoracic/upper lumbar region, all connected to a laterally-padded anterior aluminium alloy frame. It is a fairly comfortable thing to wear, not restricting the shoulder girdle.
It is also very easy to don and doff. The webbing strap holding the dorsal pad attaches with a single fastener on one side – a ‘dot’ fastener with which you will be familiar if you have owned a sports car with a tonneau cover – and a tensioning lever on the other. You can get into or out of it in seconds!
When my back syndrome is acute, simply preventing flexion is usually sufficient to keep my symptoms (largely the sciatic pain) at bay. Thus, the hyperextension brace is ideal, controlling flexion but allowing some movement of the upper thoracic spine where it doesn’t matter. (The product, and medical, literature on these braces does not claim control of the spine above about T7, and, as my original lesion was at the T10 level, this upper-thoracic movement comes with no clinical disadvantage.)
This is in marked contrast to my neck, however, where the most effective treatment is maximal immobilisation of the mid-cervical spine in all planes, and taking (non- steroidal) anti-inflammatories until the symptoms, typically pain and paraesthesia due to nerve root pressure, settle down.
There are times when I need to wear my back brace, and others when I wear one of my neck braces. When I (fortunately rarely) experience a return of both my cervical and lower-back problems, I find that I can wear the back brace with my doll’s collar, as the sternal pad of the former rides easily over the collar’s close-fitting plastic shell. This is not possible with my SOMI or Minerva braces though – nor, I supposed, with any other cervical brace which extends to the thorax – as my orthotist had just confirmed.
This scenario is not a problem as long as the weather does not get too hot. As I have indicated elsewhere, it’s hot weather that makes the total-contact doll’s collar very uncomfortable and my SOMI preferable, despite its less-than-attractive appearance.
As to having to wear both braces in hot weather, the inevitable had to happen (said he tautologically!). I was offered a secondment with a division of my organisation in the tropics at a time when I needed to wear both!
I had flown up to our office there, for a couple of days, to discuss the possible transfer with colleagues, and this experience had reaffirmed that my doll’s collar was simply not an option in the hot and humid tropical conditions. My original CTLSO, made for me at the time of sustaining my injuries initially, may have been, but it had long since been discarded.
Which brings me back to the appointment with my orthotist and my second question to him. Was there a ready solution to my problem without having to have another such appliance custom-made for me? Well, it appeared that there might be. Together, we examined a catalogue of various spinal orthoses manufactured by a supplier in Florida. Depicted was a variety of Jewett-type hyperextension braces, two-poster cervical braces and, as you may have guessed from the title of this article, combinations of the two.
The cervical braces looked familiar. I remember having tried on a similar one several years ago before electing to wear a SOMI instead. These two-posters comprised occipital and mandibular pads attached to a yoke over the shoulders and a sternal pad respectively, these two joined, and with struts extending anteriorly and posteriorly to lower-thoracic pads joined by webbing straps around the torso. I had thought at the time that such a device was too restricting and had settled for the SOMI instead – a touch ironic in the current circumstances!
I have mentioned cervical braces plural, and the variants illustrated were of interest. The brace that I recalled had had webbing straps connecting the yoke to the sternal pad and leather ones connecting the mandibular and occipital pads, with snap fasteners at the mandibular ends – much the same as with my SOMI. With these, though, alternative connectors were offered in the form of rigid aluminium bars which replaced the straps.
The spinal braces looked similar to the one I was wearing but with some differences – of which more later. As I have mentioned, there was also an illustration of a device which combined a hyperextension brace with a cervical one as described above, but with the anterior strut attaching to the top of the frame of the back brace, instead of to sternal and abdominal pads. The remainder of the cervical component, with its yolk, occipital and posterior thoracic pads connected by a strut were largely as I remembered.
My orthotist checked and confirmed the availability of such a prefabricated CTLSO. We then considered the straps vs rigid-bar options available with it and settled for the latter – given that the greater the immobilisation of my cervical spine when acute, the better. He also observed that rigid connectors between the occipital and mandibular pads would avoid the pressure of the latter against the front of the neck, an uncomfortable outcome which can occur when these sorts of braces are set up as firmly as would be necessary in my case.
Having decided on the specifications for what was to be my new replacement for them, I removed my neck and back braces and he took appropriate measurements (chest and waist circumferences, distances between anatomical landmarks etc.). As I donned them again, we both noted the small amount of relative movement between my neck and back braces, an advantage of which I was already aware. Wearing separate ones means that I have that little bit of flexion and rotation at the upper thoracic/lower cervical level, where it doesn’t matter clinically for me, and am able to look down, and from side to side, to a limited degree without bending at the hips or rotating my whole body.
It was brought home to me that these small relative movements are nice to have and that I was probably going to lose them. I would also, of course, lose in appearance, replacing my reasonably cosmetic collar with an orthosis which would again have my neck supported by the sorts of metal struts that I find, even after so many years, to be a real turn-off aesthetically, especially in public, making you look as if you have been swallowed by a radar antenna!
As I left, I contemplated what was in store for me, and how significant the loss of that small amount of movement might prove.
The day for the fitting of my new cuirass came soon enough and I arrived at the orthotist’s with a little trepidation, despite my long association with a variety of spinal orthoses. Illustrations are all very well, but when you first actually wear a new brace, especially one as restrictive as this one would be, you can get a surprise or two and have to be prepared for a period of adjustment to your new equipment – however beneficial it might be for you in the long run.
I again removed my back brace and collar and my orthotist helped me into, my new rig. The new back brace component was similar, but with some differences. Whereas the one I had been wearing has a half-pelvic band at the front, the new one had the anterior frame curving inwards above, and downward between, the anterior superior iliac crests (hip bones), terminating at a pad over the pubic symphysis. I would discover that this was an important difference.
The method of attachment and adjustment of the posterior pad differed too. Instead of the convenient ‘dot’ fastener on, one side and tensioning lever on the other, this had (two) straps fixed on the left side, passing through loops on the pad and terminating in a worm-drive mechanism. This was in turn positioned behind a hook attached the frame on the right hand side, so shaped that, when the mechanism was wound up, it could not be detached without unwinding it. Donning and doffing were not going to be achieved nearly so rapidly, and certainly not ‘in seconds’, but the attachment was very secure and to a small extent adjustable.
The other difference was, of course, the mandibular pad which cupped my chin, attached by its short single strut to the top of the brace’s frame.
Next came the remainder of the cervical extension. Its yolk was placed over my shoulders and the aluminium bars connecting it to the frame positioned over threaded posts and secured with knurled nuts. Similarly-attached bars coupled the mandibular and occipital pads. Finally, webbing straps attaching the additional posterior pad to the frame were tensioned and the assembly of my new CTLSO was complete.
I walked around in it and then sat down. I then realised the importance of the pubic pad vis-a-vis the pelvic band. With the latter, your upper thighs press against the band and displace the sternal pad of the brace superiorly a little. This movement does not matter with the back brace alone, but would have been a real problem had that movement been transferred to the cervical extension.
‘I know what it’s like to have to wear one of these things,’ I said as I explored the minimal amount of movement possible in my new appliance, ‘but what reactions do you get from people who are put in them for the first time?’ My orthotist replied that they could be fairly dramatic, with some patients being quite apprehensive about their new-found restriction and appearance.
I also enquired as to the sorts of conditions for which CTLSOs were prescribed (as well as for patients such as myself who need stabilisation of the spine at more than one level. He cited high-thoracic fractures and conditions involving a general deterioration of the intervertebral joints.
‘It’s fairly seldom that I am called upon to fit one though.’ he observed. ‘Most people are prescribed a neck brace, perhaps a Philadelphia collar, or a SOMI or Minerva like yours for more serious conditions, or a back brace alone. When I do fit a full spinal brace, it’s usually a moulded jacket with a SOMI or Minerva extension attached.’ ‘That’s not something I’d want to wear where I am going!’ I observed, and he agreed. ‘I think that this is a very good solution for your situation. I certainly can’t think of a better one.’
With both of us satisfied with the initial fit of my new brace, I went out to the waiting cab. You can forget about driving in these sorts of rigs. You can’t look to the side, nor even ahead unless sitting bolt upright. Any leaning back, even with a slightly flexed neck, gives you an excellent view of the car’s head lining!
If there is a real social disadvantage to wearing a CTLSO – apart from the appearance of the metal struts – it is, for me, not being able to drive or fly, at least without another (safety) pilot. (You may recall that I am a glider pilot and I also fly light aeroplanes.) With a separate neck brace, you can loosen it or take it off (or detach the chin piece of a SOMI), being careful with your neck movements of course. But in a full CTLSO, it’s all or nothing – you can’t readily take the whole thing off or remove the cervical bit!
Day-to-day activities are to some extent curtailed also. Working at a desk, a stand to hold reading materials helps of course, as does a repositioned computer keyboard. Going to the bathroom, at least at home, can also be challenging, and being seated for all performances can be a very sensible idea for males as well!
During my period of readjustment to a brace that immobilises the entire spine, not having had to wear one for many years, it was again brought home to me what a serious piece of equipment a CTLSO really is. Wearing a neck brace or a TLSO, and especially the two together is restricting enough (on your activities, not just your. movement) but a full spinal brace is something else again. It is not surprising to read in the medical literature of poor patient compliance with such devices. Were it not for necessity, and perhaps being prepared by earlier experiences, I may well have had real misgivings about pursuing this course myself.
Certainly, the wearing of such a piece of equipment as this is not a decision to be undertaken lightly (assuming that you have any choice in the matter – something which, initially, I did not). Even for one with my first-hand knowledge of wearing such spinal orthoses, the experience, at least initially, can be an interesting one!
I spent a day or two in my new rig full-time during the day (and wearing my relatively comfortable Minerva or SOMI at night, as usual when my neck is acute), getting used to the increased restriction that it imposed and to identify any pressure points or other problems (and, frankly, to get used to appearing in public in such a rig again).
There were very few physical problems – a tribute to the excellent initial fit of the appliance. Adjustments to achieve the best compromise in flexion, by varying the length of the anterior strut and the rigid connectors (a new experience) were all that were necessary when I returned to the orthotist. These latter were also trimmed to length. I then, gratefully, went back to the relative freedom of my old back brace and doll’s collar until my interstate move.
To jump forward, and to make this rather long account a little shorter, after two or three months in the lovely tropical coastal city to which I had been posted, wearing the CTLSO became less of a necessity and I weaned myself from it, wearing others of my braces as necessary during the readjustment. This process has to be gradual, as you are left’ with muscle weakness and previously-denied exercise becomes a necessity, as does regaining range of movement. Gratefully, I finally returned to a brace-free life again, at least for the time being.
Since then, my flair-ups have been relatively minor, have not involved my back and neck together, and the need for a return to total spinal immobilisation has not since arisen. Touch wood!
You, the reader, may ask why I continue to tolerate the restriction and inconvenience that the orthotic management of my spinal problems imposes, especially in an appliance as serious as a CTLSO. The answer is fairly simple however, at least for me. In these accounts, you read only of the times when I am acute, and that is, happily, a small proportion of the time – a total of a few months over a number of years. Most of the time, I am pain- (and spinal brace-) free.
Further, when acute, I am much less dependent on analgesic and other drugs than I would otherwise be and my recovery is relatively rapid – usually within months – and, paradoxical as it may seem, my braces actually contribute to my mobility and productivity at such times. I can be at work in a brace instead of being home in bed, or drug dependent for normal functioning.
If my syndrome (s) were chronic, and I had to wear such equipment for significantly greater amounts of time (or all of it), I might well consider a spinal fusion or fusions. But I work on the principle that I would rather be inconvenienced for relatively short periods than to have some degree of pain or disability all of the time – not to mention the permanent loss of movement that a fusion must inevitably entail.
Further, even though the probability of an adverse surgical outcome might be small, the effects of one may not be reversible. And I have read, and heard first-hand, of too many accounts of failed procedures to contemplate the possibility.
Happily, both my medical advisers and my darling wife agree with my decisions in these matters and support me through my acute phases in their own ways. And the amount of sick leave I have had to take due to spinal problems is, over the years, minimal (leaving aside my initial hospitalisation).
Having said that however, I can understand how some people could not handle wearing the gear that I have worn and continue to wear when necessary, and have chosen, or have been encouraged into, surgical or pharmacological solutions when perhaps a non-invasive orthotic approach may have been a more desirable alternative.
I trust that you have found this account of my experiences of being fitted with, and living with, another fairly serious spinal brace to be of interest.
I sometimes wonder whether some such narrative as this should be desirable reading for professionals who prescribe and fit these things – if for no other reason that they might well gain insights into the physical, and indeed psychological, implications that the prescription of such orthotic devices has for their patients, despite the obvious benefits.
Perhaps, as part of their training, they could be encouraged (or even required?) to spend a week or two full-time in a CTLSO, perhaps a pair of leg braces, or even both in turn. It’s an interesting thought.
Anyway, enough of my editorialising. For myself, it seems that I shall, probably, have to wear one or more of these arcane orthopaedic appliances, from time to time at least, for the foreseeable future. I hope though that the necessity of having to wear my most recently acquired CTLSO does not occur too frequently. Nevertheless, it sits there, propped up in a comer of our walk-through wardrobe, reminding me of its availability to keep me well supported and relatively pain-free when and if the need to wear it again should arise.
As I said though, I hope that such a necessity will not arise too soon. Everyday life is so much more convenient without it!
The above story is more great work from the author of “Spinal Fracture” & “If The Brace Fits, Wear It” Again this story was based on true facts — Our thanks to the anonymous author for a another great job — we look forward to more stories in the future!