Clinical Surface Anatomy and Spinal Orthotic Management

Posted on Nov 7, 2025 in Physical Education

Anterior Trunk Surface Landmarks

Thoracic Region (Chest)

Clavicles: Easily palpable, running horizontally at the root of the neck.
Jugular (Suprasternal) Notch: Midline depression at the superior border of the manubrium sterni.
Sternal Angle (Angle of Louis): At the junction of the manubrium and body of the sternum; corresponds to the 2nd costal cartilage and T4–T5 vertebrae.
Sternum: Palpable midline bone; the body lies vertically down from the sternal angle.
Ribs and Intercostal Spaces: Ribs 1–7 are palpable anteriorly; ribs 8–10 form the costal margin; ribs 11–12 are palpable at the sides.
Nipples: In males and children, usually at the level of the 4th intercostal space; variable in females.
Xiphisternal Junction: Where the body of the sternum meets the xiphoid process; corresponds to the T9 vertebra.

Abdominal Region

Xiphoid Process: Palpable small projection at the lower end of the sternum.
Costal Margin: Lower border formed by the costal cartilages of ribs 7–10.
Umbilicus (Navel): Usually at the L3–L4 vertebral level, varies with body build.
Linea Alba: Vertical fibrous line in the midline from the xiphoid process to the pubic symphysis.
Linea Semilunaris: Curved line marking the lateral border of the rectus abdominis muscle.
Inguinal Ligament: Runs from the Anterior Superior Iliac Spine (ASIS) to the pubic tubercle.
Pubic Symphysis: Midline bony prominence above the genitalia.

Posterior Trunk Surface Landmarks (Back)

Bony Landmarks

Vertebral Column:
- C7 Spine: Most prominent cervical vertebra (the “Vertebra Prominens”).
- T3 Spine: Level of the medial end of the spine of the scapula.
- T7 Spine: Level of the inferior angle of the scapula.
- T12 Spine: Midpoint between the costal margin and the iliac crest.
- L4 Spine: Level of the iliac crests (important for lumbar puncture).
- S2 Spine: Level of the Posterior Superior Iliac Spines (PSIS).
Scapula: The spine of the scapula is palpable at the back of the shoulder. The inferior angle lies opposite T7.
Iliac Crest: Palpable lateral hip border, highest point at L4.
Posterior Superior Iliac Spine (PSIS): Palpable dimples in the lower back.

Muscular Landmarks

Trapezius: Forms a diamond shape on the upper back.
Latissimus Dorsi: Covers the lower half of the back laterally.
Erector Spinae: Vertical muscular mass along the vertebral column.

Gluteal Region

Iliac crest superiorly, gluteal fold inferiorly.
Greater trochanter palpable laterally.

Lateral Trunk Surface Landmarks

Axilla (Armpit)

Anterior Wall: Pectoralis major.
Posterior Wall: Latissimus dorsi and teres major.
Apex: Between the clavicle and scapula.
Midaxillary Line: Vertical line through the axilla, important for chest tube insertion.

Other lateral landmarks include the Costal Margin (easily felt on the side) and the Iliac Crest and ASIS (palpable laterally).

Clinical Relevance of Surface Anatomy

Chest Wall Examination: Used for heart and lung auscultation (using intercostal spaces as guides).
Abdominal Quadrants/Regions: Surface landmarks used to localize organs (e.g., liver, stomach, appendix).
Lumbar Puncture: Done at the L3–L4 or L4–L5 level using the iliac crest as a landmark.
Scapular Landmarks: Guide for thoracic vertebral level identification.
Surface Projection of Organs:
- Heart: Behind the sternum from the 2nd to 6th rib.
- Lungs: Extend from the clavicle to the 6th rib (anteriorly), 8th rib (laterally), and 10th rib (posteriorly).
- Liver: Beneath the right costal margin.
- Stomach: Left hypochondrium below the costal margin.

Physiological Basis of Orthotic Methods

Orthoses are external devices applied to the body to support, align, prevent, or correct deformities and to improve the function of movable parts of the body. Their design and application are deeply rooted in physiology and biomechanics.

1. Principles of Orthotic Function

a) Force Application

Orthoses act on the body by applying controlled external forces. These forces can:

Support weakened muscles.
Prevent excessive or abnormal movement.
Correct deformities through gradual remodeling.

Physiological Basis: The body responds to controlled mechanical stresses through Wolff’s law (bone adapts to stress) and Davis’s law (soft tissues adapt to tension), making gradual correction possible.

b) Pressure Distribution

Orthoses spread forces over larger surface areas to avoid localized tissue damage.

Pressure = Force ÷ Area → increasing contact area reduces pressure on skin and soft tissues.

Physiological Basis: Maintains circulation, prevents ischemia and ulcers, and reduces pain.

c) Three-Point Pressure System

Used to control unwanted joint motion or deformity. One main corrective force is applied opposite to the deformity, while two counterforces stabilize above and below.

Physiological Basis: This mimics natural muscle balance by creating an artificial equilibrium of forces when normal muscle control is absent.

2. Neuromuscular Physiology

a) Muscle Substitution

When certain muscles are weak or paralyzed, orthoses substitute their function (e.g., an ankle-foot orthosis prevents foot drop in peroneal nerve palsy).

Basis: The orthosis provides passive support until muscles recover or permanently replaces lost function.

b) Stretch and Inhibition

Orthoses can hold muscles and soft tissues in elongated positions, preventing contractures and spasticity (e.g., night splints in cerebral palsy).

Physiological Basis: Sustained stretch reduces gamma motor neuron activity, decreasing muscle tone.

c) Proprioceptive Feedback

Contact of orthoses with skin, tendons, and joints enhances proprioceptive input. This stabilizes posture and gait by improving neuromuscular control. Example: Knee-ankle-foot orthosis improves stance stability by enhancing joint position awareness.

3. Biomechanical & Physiological Effects on Movement

a) Energy Conservation

Orthoses optimize joint alignment and reduce abnormal motion, leading to a lower metabolic cost of walking. Example: Hip-knee-ankle-foot orthosis in paraplegia improves upright posture with less energy demand.

b) Joint Protection

In arthritis or ligament injury, orthoses limit painful or destructive movements.

Physiological Basis: Prevents microtrauma, reduces inflammatory stress, and promotes healing.

c) Functional Positioning

Orthoses maintain joints in a position where muscles are at the optimal length-tension relationship for contraction. Example: Wrist-hand orthosis holds the wrist in extension, improving grip strength.

4. Circulatory and Respiratory Considerations

Proper orthotic fit must not obstruct venous return or lymphatic drainage. Orthoses (like spinal braces) may influence respiratory mechanics, so ventilation must be considered. Compression orthoses (stockings) use external pressure to improve venous return in varicose veins.

5. Psychological and Functional Basis

Orthoses not only provide physical support but also improve confidence and independence. The feeling of stability promotes more active use of limbs, which in turn prevents disuse atrophy.

Summary of Physiological Basis

The physiological basis of orthotic methods relies on:

Force application principles (three-point pressure, pressure distribution).
Muscle physiology (substitution, stretch, inhibition).
Proprioception and neuromuscular feedback.
Energy conservation and joint protection.
Circulatory and respiratory considerations.

In short, orthoses act as external aids to mimic, supplement, or correct normal physiological functions, allowing patients to move, work, and live with less pain and disability.

Orthotic Treatment of Lumbar and Thoracic Spine

Orthoses applied to the lumbar and thoracic spine aim to control motion, stabilize structures, correct deformity, relieve pain, and promote healing. Choice of orthosis depends on the pathology, severity, and treatment goals.

1. Lumbar Spine Conditions

a) Low Back Pain (Mechanical / Muscular / Degenerative)

Orthoses Used: Soft lumbosacral corset or belt (elastic or canvas).
Functions: Provides proprioceptive feedback → discourages harmful movements. Increases intra-abdominal pressure → reduces compressive load on lumbar vertebrae. Gives mild warmth and compression → relaxes muscles and reduces spasm.
Indications: Acute/subacute low back pain, degenerative disc disease, lumbosacral strain.

b) Lumbar Disc Prolapse / Herniation

Orthoses Used: Rigid Lumbosacral Orthosis (LSO): Chairback brace, Williams brace.
Functions: Restricts flexion (which aggravates disc prolapse). Provides stability and reduces micromotion at the affected disc level. Promotes healing after discectomy.
Indications: Acute disc herniation, sciatica, post-surgical stabilization.

c) Lumbar Instability / Spondylolisthesis

Orthoses Used: Rigid overlap brace (Boston overlap brace), Chairback orthosis.
Functions: Reduces shearing forces at the unstable segment. Limits extension and flexion → prevents worsening of slip. Relieves back pain by stabilizing alignment.
Indications: Isthmic or degenerative spondylolisthesis.

d) Lumbar Fractures / Trauma

Orthoses Used: Thoracolumbosacral Orthosis (TLSO): Jewett brace (3-point hyperextension system, limits flexion); Knight-Taylor brace (limits flexion/extension, lateral flexion); Rigid body jackets (Boston TLSO, plastic body jacket).
Functions: Immobilizes the fracture site. Prevents flexion (common mechanism of compression fracture). Allows healing and prevents neurological compromise.
Indications: Stable compression fractures, post-operative fixation.

2. Thoracic Spine Conditions

a) Scoliosis

Orthoses Used: Milwaukee brace (CTLSO – Cervicothoracolumbosacral orthosis); Boston brace (TLSO – low-profile, underarm design); Chêneau brace, Wilmington brace.
Functions: Applies a 3-point pressure system to correct the lateral curve. Provides axial elongation and derotation. Prevents progression of the curve during growth.
Indications: Idiopathic scoliosis (Cobb angle 20°–40° in growing children).

b) Kyphosis

Orthoses Used: Milwaukee brace (for high thoracic kyphosis); Jewett hyperextension orthosis (for Scheuermann’s kyphosis, postural kyphosis).
Functions: Prevents forward bending (hyperflexion). Applies corrective forces to reduce kyphotic angulation.
Indications: Scheuermann’s disease, postural kyphosis, osteoporotic kyphotic deformities.

c) Thoracic Fractures

Orthoses Used: TLSO (body jacket, Jewett brace, Knight-Taylor brace).
Functions: Restrict motion at the fracture site. Prevent excessive kyphotic collapse. Allow controlled mobility during healing.
Indications: Stable thoracic compression fractures, post-operative stabilization.

d) Post-operative / Post-trauma Thoracic Stabilization

Orthoses Used: Plastic TLSO body jackets (custom-molded).
Functions: Provide maximum immobilization. Maintain spinal alignment after internal fixation or fusion.

3. Combined Thoracolumbar Conditions

Osteoporosis with Compression Fractures: Jewett brace or TLSO body jacket to prevent flexion collapse.
Post-polio Spinal Deformities / Neuromuscular Scoliosis: CTLSO / TLSO braces to support the trunk and balance posture.
Post-spinal Surgery (laminectomy, fusion, fixation): Custom-molded TLSO body jacket for stabilization during healing.

4. Key Orthoses Summary Table

Low Back Pain: Soft lumbosacral corset → Support, compression.
Lumbar Disc Prolapse: Rigid LSO (Williams, Chairback) → Limit flexion, stabilize.
Spondylolisthesis: Boston overlap brace → Limit motion, stabilize.
Lumbar Fracture: Jewett, Knight-Taylor, TLSO body jacket → Immobilization.
Scoliosis: Milwaukee, Boston brace → 3-point correction.
Kyphosis: Milwaukee, Jewett → Prevent flexion.
Thoracic Fracture: TLSO (body jacket) → Immobilization.

Summary: Orthotic treatment of lumbar and thoracic conditions is based on biomechanical control (three-point pressure, motion restriction, load reduction) and physiological effects (pain relief, muscle relaxation, proprioception, deformity correction).

Orthotic Treatment of Cervical Conditions

The cervical spine is highly mobile and vulnerable to trauma, degenerative changes, and deformity. Orthoses are prescribed to support, immobilize, protect, or correct cervical alignment.

1. Objectives of Cervical Orthoses

Restrict cervical spine motion (flexion, extension, rotation, lateral bending).
Relieve pain by reducing strain on muscles, ligaments, and discs.
Provide external stabilization in fractures, dislocations, or post-surgery.
Prevent or correct deformity (e.g., torticollis).
Reduce nerve root irritation (e.g., radiculopathy).
Offer proprioceptive feedback → discourages harmful movements.

2. Types of Cervical Orthoses and Applications

A. Soft Cervical Collar

Material: Foam with fabric cover.
Functions: Provides mild restriction of cervical motion. Supports weight of the head partially. Provides warmth → reduces muscle spasm. Acts as a kinesthetic reminder to limit movement.
Indications: Acute cervical strain (whiplash); cervical spondylosis (pain relief); early stages of rehabilitation after minor trauma.

B. Semi-Rigid / Rigid Cervical Collars

Examples: Philadelphia collar, Aspen collar, Miami J collar.
Functions: Restricts flexion, extension, lateral bending, and rotation (more than a soft collar). Provides firm support to the cervical spine. Allows some anterior-posterior adjustments for jaw and occipital support.
Indications: Stable cervical fractures; post-operative stabilization (after fusion, discectomy); severe cervical spondylosis with instability; radiculopathy or myelopathy requiring rest.

C. Cervicothoracic Orthoses (CTO)

Examples: SOMI brace (Sterno-Occipital-Mandibular Immobilizer), Minerva orthosis.
Functions: Provides more rigid immobilization than collars. Controls cervical flexion, extension, rotation, and lateral bending. Distributes load to the thoracic region for stronger control.
Indications: Unstable cervical spine injuries; post-operative fusion extending to the upper thoracic spine; severe trauma where collar support is insufficient.

D. Halo Vest Orthosis

Structure: Metal ring (halo) fixed to the skull with pins, connected to a rigid vest.
Functions: Provides maximum immobilization (restricts nearly 100% of cervical motion). Maintains cervical alignment during fracture healing. Allows patient mobilization without risk of displacement.
Indications: Unstable cervical fractures (e.g., odontoid fracture, C2 hangman’s fracture); post-operative stabilization after cervical fusion; correction of severe deformities.

3. Cervical Conditions and Management

Acute Neck Pain / Strain (Whiplash): Use: Soft cervical collar. Purpose: Rest, muscle relaxation, proprioceptive feedback.
Cervical Spondylosis / Disc Disease: Use: Soft or rigid collar. Purpose: Pain relief, motion restriction, reduce nerve irritation.
Cervical Instability (Degenerative or Trauma): Use: Rigid collar / CTO. Purpose: Segmental stabilization.
Cervical Fractures (Stable): Use: Rigid collar (Philadelphia, Miami J). Purpose: Immobilization, healing.
Cervical Fractures (Unstable): Use: CTO (SOMI, Minerva) / Halo vest. Purpose: Maximum immobilization, fracture healing.
Post-operative Cervical Fusion / Laminectomy: Use: Rigid collar, CTO, or Halo vest (depending on surgery). Purpose: Protects surgical site, promotes healing.
Torticollis (Congenital or Acquired): Use: Soft collar / custom orthosis. Purpose: Corrects alignment, prevents contracture.

4. Physiological Basis of Cervical Orthotic Treatment

Pain Relief: By limiting movement and reducing muscle spasm.
Immobilization: Allows fracture or soft tissue healing.
Load Sharing: Orthoses help bear the head’s weight (~4–5 kg), reducing stress on cervical muscles/discs.
Proprioceptive Input: Acts as a reminder to restrict harmful movements.
Correction/Prevention of Deformity: Sustained external forces remodel soft tissues and stabilize alignment.

Summary: Orthotic treatment of cervical conditions ranges from soft collars (mild support, pain relief) to rigid collars (motion restriction), to CTOs and Halo vests (maximum immobilization). The choice depends on whether the condition is painful but stable (soft/rigid collar), unstable fracture/instability (CTO/Halo), or post-operative (rigid/CTO/Halo).

Spinal Orthotic Prescription Details

A spinal orthosis is an external device designed to control motion, support spinal segments, correct or prevent deformities, reduce pain, and protect the spine during healing. Prescription must be individualized, based on pathology, biomechanics, patient needs, and rehabilitation goals.

1. General Principles of Prescription

Diagnosis-Specific: Orthosis should match the pathology (fracture, scoliosis, kyphosis, instability, post-op, etc.).
Biomechanical Control: Based on the three-point pressure system, motion restriction, and load sharing.
Patient Factors: Age, activity level, body habitus, compliance, skin condition.
Comfort & Function: Must allow mobility for daily living while giving necessary support.
Duration of Use: Temporary (acute injury) versus long-term (deformity control).

2. Indications for Spinal Orthoses

Pain relief (low back pain, cervical spondylosis).
Immobilization (fractures, post-operative stabilization).
Deformity correction or prevention (scoliosis, kyphosis, lordosis).
Functional support (neuromuscular weakness, post-polio, cerebral palsy).
Protection (after surgery, trauma, instability).

3. Types and Prescription Guidelines

A. Cervical Orthoses

Soft Collar: For neck strain, whiplash, mild cervical spondylosis.
Rigid Collars (Philadelphia, Miami J, Aspen): For disc disease, stable cervical fractures, post-op support.
CTO (SOMI, Minerva): For unstable cervical spine, high thoracic involvement.
Halo Vest: Gold standard for unstable cervical fractures, maximum immobilization.

B. Thoracic Orthoses

TLSO (Thoracolumbosacral Orthosis):
- Jewett Hyperextension Brace: Compression fractures, osteoporosis, kyphosis (flexion restriction).
- Knight-Taylor Brace: Restricts flexion, extension, lateral bending.
- Boston Brace (TLSO): Scoliosis correction (underarm).
CTLSO (Milwaukee Brace): Scoliosis (high thoracic curves, kyphosis).

C. Lumbar Orthoses

Soft Lumbosacral Corset: For low back pain, mild spondylosis, muscle spasm.
Rigid LSO (Chairback, Williams brace, Boston overlap brace): For spondylolisthesis, lumbar disc disease, instability.
Custom Molded TLSO Body Jacket: Post-trauma/post-op stabilization, fractures.

D. Combined Thoracolumbar Conditions

Body Jacket TLSO (plastic molded): For unstable fractures, post-operative spinal fusion.
Dynamic Braces (rare): To allow some controlled motion in rehabilitation.

4. Factors to Consider in Prescription

Pathology: Stable vs. unstable fracture. Painful vs. painless deformity. Progressive vs. static deformity.
Biomechanical Needs: Which motion to restrict (flexion, extension, lateral bending, rotation). How much correction is needed (partial vs. complete).
Patient Characteristics: Age, growth potential (important in scoliosis). Activity level (worker, student, elderly). Skin condition (avoid pressure sores). Compliance (cosmetic acceptability, ease of donning/doffing).
Duration of Use: Short-term (fractures, acute injuries) or long-term (scoliosis, neuromuscular deformities).
Follow-up & Monitoring: Adjustments for growth, weight changes. Regular X-rays (for scoliosis, fracture healing).
Key Points in Writing a Prescription: When prescribing a spinal orthosis, always specify:
- Type of orthosis (Soft, Rigid LSO, TLSO, CTLSO, Halo).
- Region of application (Cervical, Thoracic, Lumbar, Thoracolumbar).
- Motion restriction desired (flexion, extension, rotation, lateral bending).
- Special modifications (padding, cutouts, openings for hygiene, cosmetic concerns).
- Duration of use (hours per day, total months/years).
- Follow-up schedule (for adjustment and monitoring).

Summary: Spinal orthotic prescription must be condition-specific, considering pathology, biomechanics, patient needs, and compliance. It ranges from soft supports (for pain relief) → rigid braces (for stabilization) → full-contact body jackets or halo vests (for maximum immobilization and deformity control).

Specific Spinal Braces: Milwaukee and Boston

1. Milwaukee Brace (CTLSO)

Description: A Cervicothoracolumbosacral Orthosis (CTLSO). One of the earliest and most effective braces for scoliosis and kyphosis.

Structure:
- Pelvic Girdle (Pelvic Section): Custom-molded, provides base support.
- Vertical Uprights (Metal/Plastic Bars): Extend from the pelvis to the neck.
- Neck Ring: With throat mold and occipital pads, applies traction and alignment.
- Corrective Pads: Apply 3-point pressure to scoliotic curves.
Indications: Idiopathic scoliosis (especially high thoracic curves, apex above T8); kyphotic deformities (Scheuermann’s kyphosis); post-operative spinal stabilization (less common now).
Biomechanical Action: 3-point pressure system → corrects lateral curvature. Axial elongation via the neck ring → encourages spinal alignment. Rotational control via corrective pads.

2. Exercises for Milwaukee Brace Users

Wearing the Milwaukee brace can weaken muscles due to support and restriction. Exercises are essential to maintain spinal mobility, muscle strength, and compliance.

Exercise Goals

Strengthen spinal extensor and abdominal muscles.
Improve posture and breathing capacity.
Maintain flexibility of the spine and chest wall.
Prevent dependency on the brace.

Recommended Exercises

Spinal Extension Exercises: Prone lying → lifting head, shoulders, and arms (“superman” exercise). Strengthens erector spinae and counteracts kyphosis.
Abdominal Strengthening: Supine lying → straight leg raises. Partial sit-ups / crunches (with brace removed).
Breathing Exercises: Deep breathing, diaphragmatic breathing. Incentive spirometry to counteract restricted chest expansion from the brace.
Postural Training: Wall-standing exercises (heels, buttocks, shoulders, head touching the wall). Teaches upright posture awareness.
Flexibility & Mobility: Gentle stretching of hamstrings, hip flexors, and shoulders.

Note: Exercises are usually done without the brace, under physiotherapist supervision, to avoid over-restriction.

3. Boston Brace (TLSO)

Description: A Thoracolumbosacral Orthosis (TLSO). Low-profile, underarm brace (does not include a neck ring). Made of molded thermoplastic (lightweight and more cosmetic than the Milwaukee brace).

Indications: Idiopathic scoliosis (especially thoracic, thoracolumbar, lumbar curves with apex at/below T8). Preferred in adolescents for cosmetic acceptability.
Biomechanical Action: Uses a 3-point pressure system with pads inside the brace to push against the curve. Open spaces opposite pads → allow the body to shift into corrected alignment. Provides derotation and stabilization of the curve.

4. Milwaukee vs. Boston Brace Comparison

Type: Milwaukee Brace (M.W.): CTLSO (with neck ring). Boston Brace: TLSO (underarm, no neck ring).
Curve Location: M.W.: High thoracic & cervical scoliosis (apex above T8). Boston: Thoracic, thoracolumbar, lumbar scoliosis (apex at/below T8).
Appearance: M.W.: Bulky, visible. Boston: Low-profile, worn under clothes.
Biomechanics: M.W.: Axial elongation + pads. Boston: 3-point pressure + pads.
Compliance: M.W.: Lower (less cosmetic, bulky). Boston: Higher (cosmetically acceptable).
Use in Kyphosis: M.W.: Yes (especially Scheuermann’s). Boston: Rarely used.

Components of Spinal Braces (Orthoses)

Spinal braces (orthoses) are external devices designed to support, immobilize, correct, or assist the spine in various conditions. Although design varies, most spinal orthoses share basic components:

1. Base / Foundation

Pelvic Section: The foundation for thoracic and lumbar braces. Custom-molded around the pelvis and iliac crests for stability. Example: Pelvic girdle in the Milwaukee brace, pelvic band in the Knight-Taylor.
Thoracic / Chest Section: Provides contact on the thoracic cage. Distributes corrective and stabilizing forces. Example: Anterior chest plate in TLSO, thoracic band in Knight-Taylor.

2. Uprights / Bars

Vertical metal/plastic bars connecting the pelvic section to the thoracic/cervical section. They provide longitudinal stability and transmit corrective forces. May be posterior (paraspinal uprights), anterior, or lateral depending on the design. Example: Uprights in the Milwaukee brace, Knight-Taylor orthosis.

3. Bands / Shells / Jackets

Pelvic Band: Anchors the brace around the pelvis.
Thoracic Band: Contacts the posterior thorax, controls flexion/extension.
Shoulder Straps / Axillary Straps: Prevent upward migration, improve posture.
Abdominal Apron/Corset: Provides abdominal compression and increases intra-abdominal pressure (reducing load on the lumbar spine).
Plastic Body Jacket (TLSO/CTLSO): Encloses the trunk, custom molded for maximum immobilization (used in Boston, Wilmington, and body jacket braces).

4. Pads and Pressure Components

Corrective Pads: Apply the 3-point pressure system to correct deformities. Example: Lateral pads in scoliosis braces.
Counterforce Pads: Placed opposite corrective pads to balance forces.
Liners / Padding: Prevent skin breakdown and improve comfort.

5. Cervical / Head Control Components

(If included in the orthosis):

Neck Ring (Milwaukee brace): Encircles the neck, attached to uprights.
Throat Mold (Anterior): Supports the mandible.
Occipital Pad (Posterior): Supports the occiput.
Halo Ring (Halo Orthosis): Metal ring fixed to the skull with pins, attached to the vest via uprights for maximum immobilization.

6. Fastening Systems

Straps and Buckles: Allow tightening/loosening for donning, doffing, and adjustment.
Velcro Closures: Common in modern plastic braces (Boston, Wilmington).
Laces: Seen in corsets and some traditional braces.

7. Additional Features

Cut-outs / Relief Areas: For comfort, ventilation, and to allow movement in non-critical areas.
Openings: For hygiene, abdominal expansion (breathing), and cosmetic acceptability.
Materials: Rigid parts → thermoplastic, metal uprights. Soft parts → foam, leather, fabric. Hybrid designs → soft corsets with rigid stays.

Examples of Component Arrangements

Milwaukee Brace (CTLSO): Pelvic girdle (foundation), uprights (posterior and anterior), cervical ring (with throat mold + occipital pad), corrective pads for scoliosis curves.
Boston Brace (TLSO): Thermoplastic body shell (pelvic + thoracic section), Velcro straps for closure, corrective pads inside the brace, relief areas opposite pads.
Knight-Taylor Brace (Rigid LSO/TLSO): Pelvic band + thoracic band, two posterior uprights + two lateral uprights, axillary straps, abdominal apron.
Halo Vest: Halo ring fixed to the skull, uprights connecting the halo to the chest vest, thoracic vest (foundation).

Summary: The main components of spinal braces are: 1. Base/Foundation; 2. Uprights; 3. Bands/Shells/Jackets; 4. Pads; 5. Cervical/Head control; 6. Fastening systems; and 7. Additional features.