Thank you for the opportunity to respond to the letter from Dr. Dabke regarding our article. We appreciate Dr.Dabke’s comments regarding the ongoing need to evaluate a controversial and important area pertaining to the role of bracing in spinal surgery.

The potential effectiveness of a brace depends on the potential goal(s) of therapy which include pain relief, reducing spinal mobility, and even positive re-assurance to patients. We acknowledge the variablility among different bracing regimens (day time, night time, full-time). In our study, we attempted to standardize the time patients spent in a brace by advising them to wear the brace full-time during the bracing period. Although not published in the paper (apart from brace compliance data), we did complete a bracing follow-up questionnaire and evaluation on randomized patients. There were no significant post-operative pressure sores relating to brace use. An open ended comment section on how patients responded to use of a brace demonstrated that approximately 5% of patients felt the brace was ‘too cumbersome to wear for the recommended duration’; another 5% of patients felt that the brace provided ‘tremendous re-assurance and support to their back’ in the post- operative period. There were also many non-responders to the above question.

In those patients randomized to the experimental group, there was no change in brace type during the bracing period. We do agree with Dr. Dabke that the question of whether bracing influences short term recovery remains unanswered as our study was primarily aimed at functional outcome measured at 1 and 2 years following surgery.

Although the period of hospitalization was not significantly different when comparing the two groups, a meaningful comparison of postoperative pain scores and analgesic requirements in the early post-operative period was not performed in our study and as such, is an acknowledged study limitation. We do agree with Dr. Dabke that the role of bracing may be more important following un-instrumented lumbar fusion. Ongoing study in further defining the potential role for bracing is warranted.

To the Editor:

I read with interest the study “Use of a Postoperative Lumbar Corset After Lumbar Spinal Arthrodesis for Degenerative Conditions of the Spine” by Yee et al. The authors need to be commended for conducting a scientific inquiry on a contentious but important issue. Since pedicle screw fixation systems are very effective in providing spinal stability (1,2), until now,some surgeons have logically assumed that as far as immobilisation is concerned bracing may not alter the final outcome (3,4). While the study by Yee et al, has confirmed these assumptions, the question of whether bracing influences short term recovery remains unanswered. The results would have been more meaningful if the outcome measures were to include parameters like postoperative pain scores, analgesic requirement, and period of hospitalisation. I am unsure why patients were advised to use a brace in bed and if so did they experience any difficulty in using the brace at night time? It would have been useful to know if any patient developed problems like pressure sores, related to the use of a lumbar corset and if patients required a change of brace for any reason. Bracing involves additional expenditure, so it would have been interesting to know whether there was a significant difference between the two groups in the total cost of treatment.

As spinal instrumentation provides immediate stability,the role of a brace is more significant following uninstrumented lumbar fusion.

References

1. Vanden Berghe L, Mehdian H, Lee AJ, Weatherley CR: Stability of the lumbar spine and method of instrumentation. Acta Orthop Belg. 1993; 59 (2): 175-80.

2. Johnsson R, Axelsson P, Gunnarsson G, Stromquist B: Stability of lumbar fusion with transpedicular fixation determined by roentgen stereophotogrammametric analysis. Spine 1999 Apr 1; 24(7): 687-90.

3. Connolly PJ, Grob D: Bracing of patients after fusion for degenerative problems of the lumbar spine- yes or no? Spine 1998 Jun 15; 23 (12):1426- 8.

4. Resnick et al: Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 14:brace therapy as an adjunct to or substitute for lumbar fusion. J Neurosurg Spine 2005 Jun: 716-24.