“Early, safe, painless mobilization”

Post-operative follow-up care with braces is a required standard for Professor Dr. med. Wolfgang Ertel from Berlin’s Charité Hospital. The benefits of external stabilization have convinced the Hospital Director and Head of the Spinal Surgery Department.

life: You and your team consisting of four attending physicians perform more than 800 procedures every year. What does this comprise?

Professor Dr. Wolfgang Ertel:  Our work includes the entire spine, from the atlas down to the sacral bone. Most often, we work on the fourth or fifth lumbar vertebra and the junction between the lumbar spine and the sacrum. We often see spinal stenoses and herniated discs here, both usually caused by wear and associated with a lot of pain. Fractures, malignancies and inflammation can also be reasons to indicate surgery. Many pathologies come together in the area of the spine. That makes this specialist field so exciting.

In emergency care, the spine is affected quite often. What type of trauma do you see a lot?

Professor Dr. Wolfgang Ertel: Vertebral body fractures make up at least 30 percent of cases in our hospital. Depending on the force exerted, we differentiate two types: what we call high-energy trauma occurs during serious accidents with a motorbike or bicycle, during accidents at work or falls from great heights, for example. Low-energy trauma usually affects older people with weak bone stock. Simply lifting a backpack weighing 5 kg may cause a vertebral body fracture. The number of these traumas is increasing rapidly because of demographic aging in Germany, in older women with osteoporosis in particular. 

Speaking of demographic change: what are the challenges in spinal medicine? 

Professor Dr. Wolfgang Ertel: The number and extent of degenerative changes as well as a diminishing immune system. Spinal conditions are closely linked to biomechanics but they’re also related to immunological processes. Degeneration is also an inflammatory process where the body’s own structures are destroyed and deformities develop. That doesn’t just affect older people but also immunosuppressed patients being treated with chemotherapeutics, MTX or cortisone as well as alcoholics and drug users.

How do you deal with patients who are afraid of surgery?  

Professor Dr. Wolfgang Ertel: We attach great value to comprehensive education. Many patients, whatever age, have a critical attitude toward spinal surgery and are worried about potential consequences. But if conservative methods are not an option or are no longer an option, and they can neither get up by themselves nor walk 100 meters in one go, the suffering will be too great at some point. We therefore take our time during the consultation, usually up to an hour, to explain everything and weigh the pros and cons together. Sometimes, we have a second or even third conversation with a patient. That’s the central aspect: We must convince our patients of the opportunities surgery can bring, and they have to trust the surgeon. But we don’t try to force them into anything. People need time. Some make up their mind and return after three months.

Do you have a current example?  

Professor Dr. Wolfgang Ertel: We recently corrected the spine of an 86-year-old patient in a highly complex surgical procedure lasting six hours. The spine was out of balance, meaning it no longer had its natural double S shape. The patient was an active woman with great vitality but significant osteoporosis which resulted in spontaneous vertebral fractures leading to severe misalignment of the spine. The anchoring of the screws, which are indispensable for the correction, also presented a major challenge. We discussed it for a long time and presented advantages and disadvantages. Eventually, we recommended surgery. We also advised her to talk to her family. She made her decision after that: she wanted to go forward with it. Now, she’s feeling really good.

“For an excellent outcome,
the post-operative management is as important
as the surgery itself.”

Professor Dr. med. Wolfgang Ertel

What importance do spinal braces have for you in follow-up care?  

Professor Dr. Wolfgang Ertel: Hardly any patient returns home without a brace. That’s our standard. After all, for an excellent outcome, the post-operative management is as important as the surgery itself. All our patients have to get up on the first day after surgery, take their first steps in their room on day two and make their way into the corridor on day three. Whether supported by crutches, a walking frame or a rolling walker. That’s our standard approach, and we demand it. In our specialist discipline, the outcome hinges on the patients’ motivation and how they treat their bodies. And to provide early, safe and painless mobilization, we need medical products like braces. External stabilization not only offers protection, it also has other important benefits.

What benefits are those?  

Professor Dr. Wolfgang Ertel: First of all, quicker healing of the wound and fewer infections because movement is a little restricted with braces, meaning stitches won’t open up and pain is avoided. Secondly, there’s the psychological aspect that reminds patients who have undergone surgery to be a little more careful. In particular younger patients are a little euphoric after herniated disk surgery because the pain has gone. So they want to get back to action quickly. Thirdly, in my opinion, the supporting effect also results in faster reduction of pain medication, which we can identify using the pain scale from 0 to 10.

What criteria do you apply to decide on treatment using a spinal brace?  

Professor Dr. Wolfgang Ertel: We recommend braces after almost all spinal surgeries because, these days, there is a differentiated selection when it comes to length and circumference so they can be adjusted. Treatment is agreed in coordination with orthotists and patients. In most cases, the SofTec Dorso, LumboLoc Forte or SacroLoc are used. The decision is based on the spine-related pathology, the area and type of procedure. After extensive corrections on the lumbar and thoracic spine, we use the SofTec Dorso to provide stabilization from the shoulder girdle to the sacrum and to straighten the upper body using reclination in order to relieve the anterior part of the vertebral bodies. That’s what we did for the 86-year-old osteoporosis patient, for example. After minor, minimally invasive intervertebral disk or lumbar spine surgery, a shorter brace, such as the LumboLoc Forte, is useful for post-operative protection because the lumbar vertebrae have the greatest range of motion. We use the SacroLoc after sacral bone fractures to cover the sacroiliac joints. It’s important that stabilization doesn’t stop where surgery stops. The brace must always cover an area a little above and below where surgery took place. Otherwise, shear forces caused by the patient moving would start exactly where the screw and rod system starts.

Following extensive procedures, do you limit rotational movements using braces which can then be allowed over the course of treatment?  

Professor Dr. Wolfgang Ertel: Yes, because we neither want our patients to make sideways or rotational movements nor bend forward during the first months after surgery. That’s why we use the SofTec Dorso for overall stabilization. Following lengthy fusion surgery, which often affects the thoracic and lumbar spine, it usually takes four to six months to achieve the desired stiffening of the segments. We also wait about three months after surgery before we send patients to rehabilitation, when they can be subjected to more strain, feel more motivated and the wound has healed. But they’ll do gentle physiotherapy until then. They need to learn how to move without damaging their spine. After six to twelve weeks, after six months and twelve months, we will arrange a follow-up appointment where we decide whether rotational movements can be allowed or if the brace can be removed. The timing is different for each patient. After all, no two patients are the same. Progress is different, the mentality, compliance as well as the condition of the muscles, age and the social surroundings. Motivation is the key! 

How did the SofTec Dorso and the other Bauerfeind braces win you over?  

Professor Dr. Wolfgang Ertel: By offering versatility and different adjustment options. My colleagues and I had our orthotists show us various spinal braces. We tried the models, put them on ourselves and then decided which of them we wanted to include in specific cases during follow-up care.

Do you also use braces in non-surgical care?  

Professor Dr. Wolfgang Ertel: Most patients benefit from conservative treatment, except in cases of paralysis or incontinence. But not many suffer from that. We actually only operate on about 20 percent of patients. The other 80 percent are treated non-surgically. We also recommend wearing a stabilizing, specially fitted brace for two to three months.

How does the cooperation with orthotists work when providing braces? 

Professor Dr. Wolfgang Ertel: After surgery, we develop a protocol. The physical therapist will discuss it with the orthotists who provide inpatient care. 48 hours after surgery, they will visit the patient’s bed, fit the brace, set the movement limitations and decide on details, such as an optional back pad in the LumboLoc Forte. The patient will wear the brace after three days at the latest. There are clear, transparent guidelines as to which brace is suitable for which patient. Our role as surgeons also includes checking the brace within 24 hours as well as asking patients how they’re getting on with it, and whether they feel it’s helping. We will repeat this process just before patients are discharged and give advice on what they need to do at home. After all, the brace shouldn’t just lie in the drawer.

What about patient compliance regarding spinal braces?  

Professor Dr. Wolfgang Ertel: Patients who are eager to get moving again quickly will get actively involved and use the brace, at least three to six months for recovery or longer. Modern braces are quite high-tech these days and can be adapted precisely to each individual patient. That’s what people love, and the colors, by the way. It’s more difficult with patients who are overweight or who do no exercise whatsoever. The outcome is generally less successful, they are often in pain for longer, and their muscles are overall weaker. They will benefit from braces just as much but they have more difficulties with mobilizing measures. Trying to prescribe braces to patients with severe dementia or obesity doesn’t make any sense. That’s where we reach the limits of medicine.

Stability for the spine

The SofTec Dorso spinal brace straightens the lumbar and thoracic spine and stabilizes from the pelvis up to T8. The tension-stable knitted fabric around the pelvis and the torso, in combination with the dorsal reclinator and special tensioning strap system, corrects the patient’s posture. Force is applied from the shoulders and can be adjusted by the patient as required. A stabilizing cross that can also be attached helps restrict painful rotation movements in the upper body.

Relieving the lumbar area

The LumboLoc Forte lumbar brace provides the lumbar spine and lumbosacral junction with greater stabilization to reduce pain in that area. Its adjustable functional strap enables individual adjustment of the pressure distribution, with respect to location and intensity.

Straightening the sacrum

The SacroLoc pelvic brace stabilizes the pelvis and relieves pressure on the sacroiliac joints. The circular compression provided by its elastic mesh material and tensioning straps straightens the sacrum and is proven to relieve the local ligaments.

Bilder: Bauerfeind, Thomas Lebie