Bracing for Scoliosis : Wheeless' Textbook of Orthopaedics

- See: Idiopathic Scoliosis:

- Discussion:
- bracing has been the mainstay of non operative treatment of significant curves which have a potential to progress;
- progression is related to size of curve, area of spine involved, & physiologic age of child;
- size of curve:
- larger curves progress to > deg than smaller curves (many curves less than 30 degrees don't progress);
- thoracic and double primary curves progress more than single lumbar or thoracolumbar curves.
- physiologic age (based on menarche & risser status);
- Risser stage 0-1: curves between 20-29 deg have > 65% risk of progression;
- Risser grade 2-4: curves between 20-29 deg have > 20% risk of progression;
- the major controversy surrounding bracing is whether or not it can influence the natural history of scoliosis;
- in the review article by Dickson RA and Weinstein SL (1999), the authors make several points;
- the authors note that the Cobb angle remains the main determinate of curve severity eventhough this is a two demensional
measurement of a three demensional deformity (it may not be the most optimal measurement of curve severity and correction);
- use of a brace in flexible curves may actually reduce the Cobb angle by flattening the lumbar lordosis which negatively affects
the saggital component of the scoliotic curve;
- hence ensure that use of a brace is not actually worsening thoracic lordosis (which is often the predominant aspect of scoliosis;
- authors note that there is some evidence that bracing is ineffective in treating scoliotic curves;
- reference: Bracing and screening - Yes or No?
                         - A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls.
                         - Brace compliance in adolescent idiopathic scoliosis.
                         - Use of the Milwaukee brace for progressive idiopathic scoliosis.

- Guidelines for Brace Use:
- less than 30 deg:
- curves < 20 deg are treated by observation alone;
- patients presenting w/ idiopathic spinal curves < 30 deg should be observed for progression ( > 5 deg change in 6 mo) before instituting bracing.
- ie, curves between 20 and 29 deg that show progression need to be treated w/ orthosis;
- greater than 30 deg;
- curves between 30 and 40 deg are treated w/ orthosis on first visit to office if they are less than Risser 3;
- hence, skeletally immature patients w/ significant curves (greater than 30 deg) require bracing even if there is no evidence of progression;
- greater than 45 deg;
- although some flexible curves between 40 and 45 deg can be treated successfully, bracing is not used for most curves > 45 deg;

- Vital Capacity: (see cardiopulmonary function in scoliosis)
- application of brace results in a significant reduction in vital capacity (14%), functional residual capacity (22%), & total lung capacity (12%);
- bracing will reduce lung function by 10 to 15%;

- Special Considerations:
- infantile scoliosis:
- bracing is the primary treatment for pts with infantile and juvenile idiopathic scoliosis;
- types of braces:
- curves w/ apices lower than T-8 or lower may be treated w/ underarm braces,
such as Wilmington brace (custom made) or Boston brace (prefabricated)
- these curves cannot be except to treat higher curves;
- high thoracic curves may require the Milwaukee Brace;
- how many hours per day is necessary?
- as noted by Rowe et al, probability of a successfull result was directly related to number of hours braces was worn per day;
- 23 hours was more effective than 16 hours which was more effective than 8 hrs;
- ref: A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis