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13 On- andOine Documentation ofSpine Procedures: Spine Tango
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Fig. 13.3 COMI patient assessment form for low back pain
tional consensus meeting was held in Zurich, involving clinicians from medical, surgical and conservative therapy
disciplines as well as researchers with data registry expertise.
The purpose was to redevelop the Spine Tango Conservative
form to improve capture of the complexities of single and
multidisciplinary conservative spinal care and to enable
direct comparison of conservative interventions with surgery. In the following 12 months, the Spine Tango
Conservative 2018 form was further rened, and it is now
available on the EuroSpine website. Although more detailed
than its predecessor, it is similarly quick to complete and
allows data analysis that is tailored to the needs of conservative clinicians and services and allows comparison with the
surgical treatment of similar pathologies.
13.3.8 Technology
Spine Tango has long left the early stage of a simple web
page for data entry and has grown into an international
project with a sophisticated information technology
structure and a multitude of clinical and scientific experts
serving the user community and developing the registry
further. The central database is now part of a documentation portal hosted by the Northgate Public Services, UK;
it offers various methods for clinical, implant and radiographic data collection and a multitude of possibilities
for data downloads and online statistical queries. An
important step was the implementation of the so-called
modules and national satellite servers that anonymise
data for protecting user’s and patient’s privacy in the
respective country before sending the clinical data set to
the central server in the UK (Fig.13.4). Such modules
are meanwhile installed in Germany, Austria, Belgium,
Italy, the UK, Australia, the USA, Mexico and Brazil.
Users whose country does not yet have such a national
filter server may use the Swiss/international module
under www.spinetango.org. Access to the servers is centrally routed via the EuroSpine home page under www.
eurospine.org—Spine Tango—access registry.
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Pe
@ UNIBE
ymous
P
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T. Zweig et al.
Registry
participants
rsonalized
registry data
Patient records
SSE module
@ eurospine.org
Fig. 13.4 Spine user routing and data segregation in the national modules
Hospitalization
atient
Homepage
www.eurospine.org
SSE central infrastructure
Individual hospital FU schemes to be respected
–3 months
–1 year and –2 years
Anon
registry
datasets
Discharge
Data collection
Pre-Op Consultation
COMI
Admission
OR
Surgery-Form
Fig. 13.5 Spine Tango pre- and postoperative physician- and patient-based data collection
1. Post-Op
Assessment
COMI
FU
2. and 3. Post-Op
Assessment
COMI
FU
r online and scanner assisted data
13 On- andOine Documentation ofSpine Procedures: Spine Tango
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89
Physician based data
D
A
Fig. 13.6 Possible modes of data collection with Spine Tango
B
C
C
B
Spine Tango database
13.3.9 Workow
Patient based data
Phone
D
Touch screen
Internet
Email
13.3.10 Spine Tango Publications
Workstation for online data entry
Workstation – scanner combination
fo
entry
Sent in by mail
Forms for physician based data
Forms for patient based data
A generic application which serves a multitude of hospitals
with different sizes, structures and staff coverage can only be
customised to a certain extent to the individual expectations
and needs of a user, that is, a single surgeon or a department.
Therefore, an intelligent and creative integration of the
Tango project and its processes into the day-to-day workows is key for success and a sustainable future of the data
collection efforts [17]. Direct online data entry, paper-based
data collection with OMR (optical mark reader) compatible
paper forms and simple PDFs for later data punching are
options which mainly depend on factors like web access and
number of web terminals in the OR, wards and outpatient
clinic; pre- and postoperative administration of patient questionnaires by face-to-face interview, mail or telephone interview in addition to the surgeon-based data collection
represents additional efforts that need the respective nancial and human resources (Fig.13.5). There are currently ve
possible ways by which forms and questionnaires can be
transferred to the database (Fig.13.6): online data entry (A),
paper-based data capture with OMR scanner-assisted entry
of data (B), paper-based data capture with data punching
using the online interface (C), paper-based data capture with
mailing of the forms to the IEFO or other partner institutions
for OMR scanner-assisted entry of data (D) and nally a
hybrid method of direct online entry of surgical data (A) and
OMR scanner-assisted entry of patient questionnaires (B) or
direct online entry of surgical data (A) and delayed online
entry of questionnaires that were completed on paper by the
patients (C).
Up to date (July 2020), there have been 68 peer-reviewed
papers published on Spine Tango. In the rst decade of
Spine Tango’s existence, there were 12 papers published,
which mainly focused on set-up, rationale and handling of
the Spine Tango database. In the second decade, papers predominantly focused on outcomes (Yagdiran etal. Eur Spine
J 2020), comparative analyses (Zweig etal. 2017, Sabou
etal. J Z Spine 2019) and prediction models (Aghayev etal.
World Neurosurg 2020). However, one topic has remained
highly popular over all this time: low back pain (Sethi etal.
J Orthop 2019).
References
1. Röder C, El-Kerdi A, Grob D, etal. A European spine registry. Eur
Spine J. 2002;11:303–7.
2. American Society for Quality. Quality glossary. Qual Prog.
2002;35:43–61.
3. Garvin D. What does product quality really mean? Sloan Manag
Rev. 1984;26:25–43.
4. Röder C, Chavanne A, Mannion AF, etal. SSE Spine Tango–content, workow, set-up. Eur Spine J. 2005;14:920–4.
5. Campbell SM, Braspenning J, Hutchinson A, etal. Research methods used in developing and applying quality indicators in primary
care. BMJ. 2003;326:816–9.
6. Wensing M, Elwyn G.Methods for incorporating patients’ views in
health care. BMJ. 2003;326:877–9.
7. Sower S, Fair F.There is more to quality than continuous improvement: listening to Plato. Qual Manag J. 2005;12:8–20.
8. Chassin MR.Is health care ready for six sigma quality? Milbank Q.
1998;76:565–91.
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T. Zweig et al.
9. Impellizzeri FM, Bizini M, Leunig M, et al. Money matters:
exploiting the data from outcomes research for quality improvement initiatives. Eur Spine J. 2009;3:348–59.
10. Mannion AF, Elfering A, Staerkle AR, etal. Outcome assessment in
low back pain: how low can you go? Eur Spine J. 2005;14:1014–26.
11. Morris S, Booth J. Shaping conservative spinal services with the
Spine Tango Registry. Eur Spine J. 2018;27(3):543–55.
12. Mannion AF, Elfering A.Predictors of surgical outcome and their
assessment. Eur Spine J. 2006;1:93–108.
13. Deyo RA, Battie M, Boerskens AJ, etal. Outcome measures for
low back pain research. A proposal for standardized use. Spine.
1998;23(2):2003–13.
14. Bombardier C.Outcome assessments in the evaluation of treatment
of spinal disorders: summary and general recommendations. Spine.
2000;25:3100–3.
15. Mannion AF, Porchet F, Kleinstück FS, etal. The quality of spine
surgery from the patient’s perspective. Part 1: the core outcome
measures index in clinical practice. Eur Spine J. 2009;3:367–73.
16. Morris S, Booth J, Hegarty J.Spine Tango registry data collection
in a conservative spinal service: a feasibility study. Eur Spine J.
2016;25(9):2984–92.
17. Müller ME, Allgöwer M, Willenegger H.Die Gemeinschaftserhebung
der Arbeitsgemeinschaft für Osteosynthesefragen. Arch klin Chir.
1963;304:808–17.
Spinal Orthoses
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UweVieweg
14
14.1 Introduction and Core Messages [1–3]
The rst evidence of the use of spinal orthoses can be
traced back to Galen (131–201 AD). Primitive orthotic
devices were made of items that were readily available
during this period: leather, whalebone and tree bark.
Technology has revamped the eld of orthotics, with
new stronger and lighter materials. Although materials
available for orthotic construction have changed, the
types of pathologic conditions treated have remained
virtually constant for years. The primary goal of
modem orthoses is to aid a weakened muscle group or
correct a deformed body part. The clinician’s priority
should be to determine which spinal motion to control,
prefabricated versus custom orthoses. The availability
of prefabricated orthoses today presents the rehabilitation team with a variety of choices and some challenges. Many of the prefabricated orthoses come in
various sizes and can be tted to patients often with
little or no adjustment. While this can be a benet to
the patient and the team in terms of time, care should
be taken to ensure that the design and function of these
orthoses are appropriate for the patient’s condition and
not used purely for convenience. Custom orthoses, in
most cases, provide a more comfortable t with a
higher degree of control and can be designed to accommodate a patient’s unique body shape or deformities.
Computer-aided design (CAD) and computer-aided
manufacturing (CAM) technology is available to help
the practitioner improve efciency in design and fabrication, as well as reducing the invasiveness of orthotic
measurement of the patients. The development of
computer- aided design (CAD) and computer-aided
manufacturing (CAM) has allowed the fabrication of
orthoses today in less time than it took only a few years
ago. The BioScanner is one of the CAD-CAM systems
available.
14.2 Denition andClassication
[1, 4–6]
An orthosis is a singular device used to aid or align a weakened body part. Orthoses are made of elastic or solid plastic
materials or a combination of both, as well as drill and elastic
fabric. Reinforcements made of aluminium or steel are used
for elastic fabrics. Aluminium is preferred for its better X-ray
transparency and lighter weight. In terms of manufacturing,
supports can be categorized into bespoke body-surrounding
orthoses made of fabric, bodices or bandages and corsets or
trunk orthoses. Orthoses can also be active, with dynamic
muscle use, partially active, with the use of muscle power via
static mechanical inuences, and passive with a static
mechanical protection. Internationally, spinal orthoses are
classied according to the location of the spinal segments
(International Summary Description of Orthosis Types or
Orthoses for the Trunk and Pelvic Areas [6]). Some acronym
examples of spinal orthoses are the following:
CO: cervical orthosis
CTO: cervicothoracic orthosis
CTLSO: cervicothoracolumbosacral orthosis
TLSO: thoracolumbosacral orthosis
LSO: lumbosacral orthosis
SO: sacral orthosis
U. Vieweg (*)
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg,
Schwarzenbruck, Germany
e-mail: uwe.vieweg@sana.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_14
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14.3 Biomechanic
Orthoses perform the following main functions:
• Kinetic memory
The pressure of the orthoses stimulates the sensory system and provides a “reminder” to the patient of the correct
posture (the so-called reminder effect).
• Increased intra-abdominal pressure
Due to the increased intra-abdominal pressure, the socalled toothpaste tube effect on the bone corrects the spinal posture (see Fig.14.1).
• Three-point support
A number of orthoses use the three-point principle to
achieve correction and immobilization (lordosis, kyphosis, derotation)
• Extension
Vertebral segments are erected across to x bone points.
• Endpoint control
Depending on its design, the orthoses restrict movement
at the endpoints.
• Activating erecting function (reminding orthoses)
In the cervical region, axial rotation occurs at the special-
ized atlantoaxial joint. At the lower cervical levels, exion,
extension and lateral exion occur freely. However, the articular processes, which face anteriorly or posteriorly, limit
rotation. In the thoracic region, movement in all planes is
possible, although to a lesser degree. In the lumbar region,
exion, extension and lateral exion occur, but rotation is
limited because of the inwardly facing articular facets. An
understanding of the three-column concept of spine stability
is helpful to ensure that the proper orthosis is prescribed. The
anterior column consists of the anterior longitudinal ligament, the annulus brosus and the anterior half of the vertebral body. The middle column consists of the posterior
longitudinal ligament, the annulus brosus and the posterior
half of the vertebral body. The posterior column consists of
the interspinous and supraspinous ligaments, the facet joints,
the lamina, the pedicles and the spinous processes. The loss
of normal spinal anatomy can affect the stability of the spine.
Spine motion can be classied with reference to horizontal
(transverse), frontal (coronal) and sagittal planes. The spinal
motion can shift the centre of gravity, which is normally
located approximately 2–3cm anterior to the S1. In the cervical region, axial rotation occurs at the specialized atlantoaxial joint. At the lower cervical levels, exion, extension
and lateral exion occur freely. However, the articular processes face anteriorly or posteriorly. In the cervical spine,
extension occurs predominantly at the occipital C1 junction.
Lateral bending occurs mainly at the C3-C4 and C4-C5 levels. Axial rotation occurs mostly at the C1-C2 levels. In the
thoracic spine, exion and extension occur primarily at the
T11-T12 and T12-L1 levels. Lateral bending is fairly evenly
distributed throughout the thoracic levels. Axial rotation
occurs mostly at the T1-T2 level, with a gradual decrease
towards the lumbar spine. The thoracic spine is the least
mobile because of the restrictive nature of the rib cage. In the
lumbar spinal segment, movement in the sagittal plane
occurs more at the distal segment, with lateral bending predominantly at the L3-L4 level. Knowledge of the normal spinal range of motion helps in understanding how the various
cervical orthoses (CO) can limit that range.
Fig. 14.1 The toothpaste tube effect on the bone corrects the spinal
posture (reproduced with permission from Bauerfeind AG, Germany
[2])
14.4 Cervical Orthoses (CO) [1, 2, 4]
The halo orthoses provide exion, extension and rotational
control of the cervical region. Pressure systems are used for
control of motion, as well as to provide slight distraction for
immobilization of the cervical spine. This orthosis provides
maximum restriction in motion of all the cervical orthoses. It
is the most stable orthosis, especially in the superior cervical
spine segment. A halo is used for approximately 10–12weeks
to ensure healing of a fracture or of a spinal fusion. Usually
a cervical collar is indicated after the halo is removed,
because the muscles and ligaments supporting the head
become weak after disuse. All pins on the halo ring should be
checked to ensure tightness 24–48h after application.
Cervical orthoses Philadelphia or Miami (see Fig.14.2)
provide some control of exion, extension and lateral bending and minimal rotational control of the cervical region.
Pressure systems are used for control of motion, as well as to
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Fig. 14.2 Cervical orthoses—Philadelphia
provide slight distraction for immobilization of the cervical
spine. Circumferential pressure is also intended to provide
warmth and as a kinaesthetic reminder for the patient. These
orthoses are prefabricated, consisting of one or two pieces
that are usually attached with Velcro straps. Other options
include a Schanz compression collar (tricoprene elastic bandage) or a soft cervical support (see Fig.14.3).
14.5 Cervicothoracic Orthosis (CTO)
93
Fig. 14.3 Soft cervical orthoses
patients who are restricted to bed, because there are no posterior rods to interfere with comfort of the patient. A headband can be added so that the chin piece can be removed.
This maintains stability but improves accessibility for daily
hygiene and eating. The SOMI is prefabricated, consisting of
a cervical portion with removable chin piece and bars that
curve over the shoulders. Also used are posts that xate the
cervical portion to the sternal portion of the orthosis. The
anterior section supports the mandible and rests on the superior edge of the sternum, with the inferior anterior edge terminating at the level of the xiphoid. The posterior aspect of
the orthosis supports the head at the occipital level.
Indications are cervical sprains, strains, stable fracture protection and limited mobility during the healing process in the
postoperative patient. Contraindications are unstable fractures with ligament instability. The Yale orthosis consists of
chin and occipital pieces that extend higher on the skull in
the posterior region; this increases comfort. The Yale orthosis is a modied Philadelphia collar with a thoracic extension. The extension consists of breglass that extends both
anteriorly and posteriorly and has thoracic straps that hold
the sections together. The thoracic extension to the orthosis
helps to stabilize injuries at the vertebral levels of C6-T2.
The four-poster is a rigid cervical orthosis with anterior and
posterior sections consisting of pads that lie on the chest and
are connected by leather straps.
14.5.1 Sternal Occipital Mandibular
Immobilizer (SOMI)
The biomechanics provide control of exion, extension, lateral bending and rotation of the cervical spine. Pressure systems are used for control of motion, as well as to provide
slight distraction for immobilization of the spine. A benet
of the SOMI orthosis is that it can be done while the patient
is in the supine position. The SOMI is a good choice for
14.6 Cervicothoracolumbosacral Orthoses
(CTLSO)
The Milwaukee orthosis is used for scoliosis management
and provides control of exion, extension and lateral bending of the cervical, thoracic and lumber spine.
The Milwaukee orthosis is a good choice for patients who
need correction in the higher thoracic region of the spine.
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U. Vieweg
Indication is the scoliotic management of the high thoracic
curves. Contraindications are lower thoracic and lumbar
curves.
14.7 Thoracolumbosacral Orthoses (TLSO)
14.7.1 Torso Orthoses
Torso orthoses are mainly used for conditions affecting the
lumbar spine or the thoracolumbar junction. Orthoses should
always be regarded as just one element of a multimodal reactivating treatment concept. The aim of the treatment should
always be to develop the body’s own supportive “corset” of
muscles. A common indication for prescribing an orthosis
for this part of the body is lumbago which is proving resistant to therapy; in this case, the orthosis is used to complement the existing therapy. It is important that there is a clear
indication for use of a particular type of orthosis, that is, the
physician responsible for the patient’s treatment must have a
clear idea about the aims of the orthosis therapy. Lumbar
supports (Fig.14.4a–c) can be used for acute lumbar spine
syndrome and mild degeneration of the spine. These products are made from breathable, elastic fabric, and they support and relieve the lumbar spine. An integral pad in the
lumbar area can help to relieve tension and pain. The lumbar
corset is a support for the spine which is used for patients
with lumbago and pain in the lumbar region. There is an integral pad in this region to relieve pain and support the lumbar
area. The corset can be prescribed as a ready-made product,
or a custom-made solution can be produced. However, the
orthosis is contraindicated for obese patients. The length and
height of the pad must be selected to suit the region where
relief is required. It is important to establish whether the pad
needs to be adjusted to provide support or to reduce the lordosis of the spine. The Lindemann corset based on a grid of
stays has a more complex design and is used to relieve, support and restrict the movement of the lumbar spine and thoracolumbar junction. The corset can be used temporarily, for
long-term treatment, or post-operatively, and it is indicated
for static muscular insufciency, mild osteoporosis, lumbago, degenerative changes in the lumbar spine, Baastrup’s
disease and grade 1 spondylolisthesis. The traditional
Lindemann corset/corset based on a grid of stays consists of
an elastic, raised, 2/3 corset with a circular pelvic frame and
tensioning strap system. Eight to ten plastic or spring band
steel back stays, which are connected together without elasticity of extension, are integrated into the corset to provide
additional stabilization for the relevant section of the spine.
The main effect is achieved through compression of the soft
tissues and the lordosing effect of the orthosis. As well as
made-to-measure products, prefabricated lumbar orthoses
made from modern knitted fabrics and strap systems are
increasingly used nowadays. The exion orthosis is indicated
for dorsal vertebral joint syndromes in particular, with indications including facet syndrome, lumbar syndrome, lumbar
spinal stenosis and sciatica. It is also suitable for postoperative care following intervertebral disc prolapse surgery.
This type of orthosis consists of a ready-made corset with an
integrated raised pad or bridging frame. This bridging frame
distributes forces away from the lumbar spine out towards
the thoracic spine, pelvis and sacrum. This effect can be further supported by means of an abdominal pad which compresses the abdominal cavity and straightens the spine. In
this case too, it is generally industrially manufactured products that are used. If greater restriction of movement is
needed, for example, for a more pronounced diagnosis, the
rigid Hohmann bridging corset can be prescribed. The corset
is designed to bridge the lordosis and is therefore able to
compensate for the increased lordosis and, at the same time,
to immobilize the painful section of the spine. The extensive
immobilization of the lumbar spine is effected by means of a
Fig. 14.4 Lumbar support corset: (a) illustration (reproduced with permission from Bauerfeind AG, Germany [2]), (b) side view, (c) front view
cab
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rigid drill fabric corset. There are dorsolateral aluminium
braces, connected by rigid rods, which encompass the pelvis
and torso and provide a frame structure to stabilize the bridging corset at the torso. Extension and exion movements as
well as tilting to the side are all largely prevented. The bridging corset is indicated for intervertebral disc conditions with
severe pain, paralytic scoliosis in the lumbar region, tumour
metastasis, osteoporosis and post-operative segmentary
instability and for follow-up treatment for fractures as well
as for discitis. The thoracolumbar orthosis can be used for
senile osteoporosis and degenerative changes of the thoracic
and lumbar spine and for stable fractures. This orthosis,
which extends up into the thoracic region, consists of a semielastic corset, a pelvic harness, two paravertebral longitudinal rods and two shoulder loops for straightening purposes.
The orthosis straightens, stretches and supports the spine.
Overall, mobility is not restricted as much as it is with a
framed support corset. As a result of the shoulder strap
arrangement, no pressure is exerted on the thoracic region, so
there is a very good acceptance of this orthosis. The framed
support corset (see Fig.14.5a, b) offers maximum immobili-
zation of the torso, and it is only indicated for severe pain.
Indications are inammatory and destructive processes of
the lumbar spine and of the lower to middle thoracic spine
(but not above this level), severe osteoporosis with vertebral
fractures and unstable fractures in the thoracic spine (not
above the level of the middle thoracic spine). The aim of the
orthosis therapy is to immobilize the lumbar and thoracic
segments of the spine and to prevent inclination, rotation and
lateral movement to the side. The bridging corset has a frame
design with torso braces which encompass the thoracic
region or reclination pads which are positioned below the
claviculae. The pelvis is immobilized by means of a plastic
pelvic cage.
The three-point corset (see Fig.14.6a, b) is used in the
conservative treatment of stable fractures of the lumbar and
lower thoracic spine. However, the corset is contraindicated
in the case of unstable vertebral fractures, which must be
stabilized surgically. The aim of the orthosis therapy is to
straighten and stabilize the lumbar and lower thoracic spine.
The three-point corset connects the pubic bone, sternum and
spine by means of a rigid pelvic ring. Nowadays, the orthoses are usually supplied as ready-made products in a range of
sizes. It is important to ensure that the orthosis is sitting correctly and that there is good support at the sternum and pubic
symphysis. Indications are traumatic or pathologic spinal
fractures in the mid to lower thoracic region or lumbar
region. Contraindications are obesity, excessive lordosis and
a need for increased lateral stability. The cruciform anterior
spinal hyperextension (CASH) orthosis controls the exion
for the lower thoracic and lumbar regions. The system consists of posteriorly directed forces through a sternal and
suprapubic pad and an anteriorly directed force applied
through a thoracolumbar pad attached to a strap that extends
to the horizontal anterior bar. When properly tted, the sternal pad is 1½in. below the sternal notch, and the suprapubic
pad is 1½ in. above the symphysis pubis. Indications are
mild compression fractures of the lower thoracic and thoracolumbar regions. Contraindications are unstable fractures
or burst fractures.
Fig. 14.5 Frame support
corset: (a) illustration
(reproduced with permission
from Bauerfeind AG,
Germany [2]), (b) ready-made
frame support corset
ab
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Fig. 14.6 Three-point corset:
(a) illustrations in (a) (front)
and from (b) (back)
(reproduced with permission
from Bauerfeind AG,
Germany [2])
U. Vieweg
14.8 Lumbosacral Orthosis (LSO)
aids in compression of the pelvis. This orthosis is usually
made from cloth that wraps around the pelvis and hips. Some
The biomechanics of the lumbosacral orthosis are the anterior and lateral trunk containments. The restriction of exion
and extension can be achieved with the addition of steel stays
posteriorly. Design and fabrication are made from cloth that
wraps around the torso and hips. Adjustments are done with
laces on the sides, back or front. Closure can be with hook
models also include laces on the side in which adjustments
can be made, whereas others use straps for adjusting.
Indications are pelvic fractures or symphysis pubis fractures
or strains. It is useful to control motion and for pain control.
Contraindications are unstable fractures, as well as fractures
or conditions in the lumbar region.
and loop or hook and eye fasteners or snaps. Many different
styles are available in prefabricated sizes, usually in 2-in.
increments, and are designed to t the body circumference at
14.10 Specialized Orthosis
the level of the hips. Indications are low back pain, herniated
discs and lumbar muscle strain and to control gross trunk
motion for pain control after single-column compression
fractures with one-third or less anterior height loss.
Specic indication points must be observed when dealing
with scoliosis and/or kyphosis, as well as with osteoporotic
fractures. Some of these have already been described.
Contraindications are unstable fractures.
14.10.1 Scoliosis [4, 7]
14.9 Sacral Orthosis (SO)
Idiopathic (infantile, juvenile, adolescent), congenital and
The biomechanics of sacroiliac orthosis or sacral orthosis are
to provide anterior and lateral trunk containment and to assist
in the restriction of some pelvic exion and extension. It also
neuromuscular scolioses have different aetiologies, treatment approaches and outcomes. With idiopathic scoliosis,
the evaluation should reveal no anomalous vertebrae, spinal
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