Prognosis of brace-treated scoliosis. Comparison of the Boston and Milwaukee methods in 244 girls

Totally, 244 females with adolescent idiopathic scoliosis treated by brace were followed for at least 2 years after treatment. The initial curve magnitude correlated with failure, notably thoracic curves. The Boston brace was more successful than the Milwaukee brace irrespective of initial curve magnitude and skeletal maturity.     

Outcomes and predictors of brace treatment for girls with adolescent idiopathic scoliosis

Objective: To evaluate the effectiveness and to identify the predictive factors of standardized brace treatment for girls with adolescent idiopathic scoliosis (AIS). Methods: From July 2003 to July 2009, 142 girls with AIS completed standardized brace treatment. These patients had a mean age of (13.1 ± 1.5) years (range, 10.1–15.9 years), a mean main curve of 29.6°± 5.4° (range, 20°–40°), and a mean Risser grade of 2.0 ± 1.5 (range, 0–4) before brace treatment. Based on whether their scoliosis progressed or not, patients were divided into two groups: progressed (Group Pr, n = 27, 19%) and non‐progressed (Group NP, n = 115, 81%), and were then divided into a further two groups: surgery (Group Su, n = 18, 13%) and non‐surgery (Group NS, n = 124, 87%). χ² and logistic regression analyses were performed to investigate factors predicting outcomes of brace treatment. Results: The duration of brace treatment in all patients averaged 2.5 ± 1.0 years (range, 0.6–5.9). χ² analysis revealed that patients with progressive curves tended to be younger, with lower Risser grade, initial larger curve magnitude and a main thoracic curve pattern. Using stepwise logistic regression, pre‐menarche status (P= 0.00028) and a main thoracic curve pattern (P= 0.012) were found to be independent risk factors of curve progression despite brace treatment, while an initial Cobb angle >30° (P= 0.022) was an additional independent risk factor of curve requiring surgery due to progression. Conclusion: Brace treatment can prevent curve progression in most girls with AIS. The outcomes of brace treatment in these girls are influenced by growth status, curve pattern and curve magnitude. Less mature patients, and those with larger curves and thoracic curves are at risk of scoliosis progression despite brace treatment.     

Treatment of idiopathic scoliosis with the Wilmington brace. Results in patients with a twenty to thirty-nine-degree curve

The results in seventy-nine adolescent patients (ninety-five curves) who had idiopathic scoliosis treated with the Wilmington brace are reported. The average follow-up was two years and six months (range, one to nine years). Before treatment, all of the patients had a curve that measured 20 to 39 degrees and a Risser sign of zero or 1. Although the magnitude of the curve was generally reduced by about 50 per cent with the initial application of the brace, a gradual loss of this initial improvement was observed both during active treatment and after the patient was weaned from the brace. Although twenty-seven (28 per cent) of the curves had progressed more than 5 degrees at follow-up, Lonstein and Carlson reported that the projected probability of progression of untreated 20 to 29-degree curves is 68 per cent. Thirty-six per cent of the thoracic curves, 16 per cent of the thoracolumbar and lumbar curves, and 28 per cent of the double major curves had progression of more than 5 degrees. However, only 11 per cent of the patients had a curve that progressed sufficiently to warrant fusion. Our findings indicate that the Wilmington brace favorably alters the natural history of 20 to 39-degree idiopathic curves.     

初诊骨密度对女性青少年特发性脊柱侧凸患者早期支具治疗效果的预测价值

目的 探讨青少年特发性脊柱侧凸女性患者初诊时骨密度对短期支具治疗期间侧凸畸形进展的预测价值.方法 对接受规范化支具治疗1年以上的77例10～15岁龄的AIS女性患者,采用Logistic回归分析鉴定初诊骨密度与侧凸进展之间的关联,并运用多元回归分析探讨初诊骨密度状态是否是影响支具治疗期间侧凸进展的因素.结果 侧凸进展组16例(21%),非进展组61例(79%).进展组患者中以初潮未至、低Risser征、主胸弯、初诊大Cobb角者以及骨密度减低者居多.多元Logistic逐步回归分析表明,除了初潮未至(OR=4.606,P=0.020)、Cobb角31°～45°(OR=3.408,P=0.097)和主胸弯类型(OR=3.414,P=0.090)等因素外,骨密度减低(OR=5.362,P=0.022)也是支具治疗期间侧凸进展的危险因素.结论 初诊时较低的骨密度是独立影响特发性脊柱侧凸女性患者短期支具疗效的风险因素.分析支具治疗前患者的骨量状态有助于预测支具治疗效果.     

Curve progression after treatment with the Wilmington brace for idiopathic scoliosis

We evaluated curve progression after completion of Wilmington brace treatment for adolescent idiopathic scoliosis in 67 patients. Follow-up ranged from 5 to 13 years. Pretreatment curve magnitudes ranged from 20 to 39 degrees, with a Risser sign of 0 or 1. Sixteen patients (21%) experienced 5-16 degrees of curve progression after brace treatment was discontinued. For nine of these patients, the final curve magnitude was within 5 degrees of the pretreatment Cobb angle, reflecting a loss of correction achieved during brace treatment. The remaining seven patients had final curve magnitudes measuring 8-32 degrees greater than the pretreatment Cobb angle.     

Advances in scoliosis brace treatment for adolescent idiopathic scoliosis

Orthotic treatment with a brace remains the treatment of choice for adolescent idiopathic scoliosis in the immature patient with documented progression or a curve magnitude of 25 degrees to 40 degrees . Studies of natural history and bracing consistently show high rates of curve progression and surgery with observation and significantly less so with brace treatment. Brace treatment is difficult in overweight patients and challenging in males. Many of the variations in brace study results may be attributable to differing rates of compliance with brace wear, a parameter that is becoming easier to measure.     

The biomechanical effectiveness of the Boston brace in the management of adolescent idiopathic scoliosis

The present study assesses the biomechanical effectiveness of the Boston brace on a group of 14 patients with adolescent scoliosis. Interface pressure measurements were performed at the appropriate compression pads within the brace when it was first applied and on two further sessions within the 6-month period of brace treatment. A corresponding series of Cobb angle measurements also were performed. Mean values of total force exerted through the brace of 58 +/- 18 N were associated with an initial curve correction of 37 +/- 21%. This mean force level was maintained throughout the study, although the mean curve correction at 6 months had reduced to 15 +/- 14%. In addition to biomechanical parameters, factors relating to the nature of the individual curve were important in determining the overall effectiveness of the Boston brace system.     

Application of a lumbar brace for thoracic and double thoracic lumbar scoliosis: a comparative study

A pilot study was performed to determine if thoracic and double thoracic lumbar scolioses can successfully be treated by applying a lumbar brace. In some of the patients application of a thoracic brace yielded insufficient correction of the lumbar curve. As the response of a curve to application of a brace is said to be the best guideline for prediction of the results of brace treatment, it was thought important to focus more attention on the behaviour of the lumbar curve. It was assumed that a lumbar brace would result in a better fit and might lead to better correction of the lumbar curve. In total 21 patients were treated according to the above-described method. Three patients were omitted from the study because of incomplete radiographic data. Thus, 18 patients treated with a thoracic brace, who showed insufficient correction of the lumbar curve, were subsequently treated with a lumbar brace. Radiographs taken in the thoracic brace patients showed a mean decrease of the thoracic curve of 9 degrees (27%) and a mean decrease of the lumbar curve of 5 degrees (16%). In the lumbar brace group the mean decrease of the thoracic curve was 7 degrees (21%) and the mean decrease of the lumbar curve was 12 degrees (38%). Brace treatment was successful (<6 degrees progression of the major curve) in 13 patients (70%). In this selection of patients with thoracic and double thoracic lumbar scoliosis a lumbar brace clearly led to a better initial correction of the lumbar curve; follow-up results seem to be comparable to those in literature.     

Scoliosis in-brace curve correction and patient preference of CAD/CAM versus plaster molded TLSOs

Purpose CAD/CAM technology is a newer technique for creating spinal orthoses than standard plaster molded methods. To our knowledge there has been only one previous study of CAD/CAM braces. The purpose of our study was to compare patient preference and in-brace correction of Cobb angle between plaster molded thoracolumbosacral orthoses (TLSO) and CAD/CAM designed TLSOs in a series of patients with scoliosis. Methods Ten patients with an average initial Cobb angle of 30.8° (range 18°–46°) had both a plaster molded TLSO and a CAD/CAM TLSO fabricated for them. In each case, the decision to brace was made by the treating surgeon based on curve magnitude and skeletal maturity. After 3 weeks of 23 h a day wear, in-brace correction of the Cobb angle was measured for each brace based on standard PA spine radiographs. After 3 months of use, patients were asked which brace they preferred. Results For the CAD/CAM brace, the mean curve correction after 3 months was 51% compared to 44% in the plaster molded TLSO cohort. (p = 0.46). Seven out of nine patients preferred the CAD/CAM TLSO over the plaster molded TLSO. There were no brace complications in either group. Conclusion In our matched cohort study, CAD/CAM TLSOs had at least equivalent if not superior correction of the Cobb angle compared to standard plaster molded TLSOs; 78% of our patients preferred the CAD/CAM brace over the standard TLSO.     

Pelvic tilt and trunk inclination: new predictive factors in curve progression during the Milwaukee bracing for adolescent idiopathic scoliosis

Introduction

Previous studies had shown that sagittal spinal and pelvic morphology may be associated with the development and progression of adolescent idiopathic scoliosis, but the predictive value of initial spinal and pelvic morphology on the curve progression during brace treatment is unknown. The objective of this study was to evaluate the relation between initial spinopelvic morphology and the risk of curve progression of adolescent idiopathic scoliosis with the Milwaukee brace.

Materials and methods

From 2002 to 2007, adolescent idiopathic scoliosis (single thoracic curve with apex at or above T8) was treated with the Milwaukee brace in 60 girls. Initial standing, full-length lateral radiographs were made and seven sagittal radiographic parameters of spinal and pelvic alignment were measured. Patients were followed until skeletal maturity or progression of Cobb angle >45°. The progression of curve was defined as an increase of Cobb angle ≥6° at final follow-up or progression to surgery during brace treatment.

Results

The 45 patients (75.0 %) who had successful control of curve progression were initially significantly more skeletally mature (higher mean Risser sign) than the 15 patients (25.0 %) who had curve progression. The initial mean Cobb angle was similar between the stable and progressed groups. The mean pelvic tilt, T1-spinopelvic inclination and T9-spinopelvic inclination angles were significantly greater in the stable group than in the progressed group and these three angles were independent predictors for curve progression during brace treatment. There were no significant differences between the stable and progressed groups in initial mean pelvic incidence, sacral slope, thoracic kyphosis or lumbar lordosis angles. Pre-bracing pelvic tilt ≤?0.5° was strongly predictive and T1-spinopelvic inclination ≤3.5° was moderately predictive of curve progression during the Milwaukee brace treatment.

Conclusions

Initial pelvic tilt and spinopelvic inclination angles may predict the curve progression and treatment outcome of adolescent idiopathic scoliosis with the Milwaukee brace.     

Role of exercises in the Milwaukee brace treatment of scoliosis

Specific exercises designed to strengthen trunk muscles are an integral part of most Milwaukee brace treatment protocols. To assess the effectiveness of these exercises, we established a prospective study evaluating a closely monitored exercise program coordinated with the use of a Milwaukee brace. Between 1973 and 1979, 24 girls treated with a Milwaukee brace for documented progression of primary right thoracic idiopathic scoliosis were selected for the study. All patients were instructed to perform a standard set of exercises based on the program of Blount and Moe (The Milwaukee Brace [Williams and Wilkins, 1973]). Twelve patients who were regular exercisers constituted the exercise group; 12 patients noncompliant in performing regular exercises composed the control group. Both groups remained faithful brace wearers. No significant difference was found between the two groups regarding age at onset, initial curve degree, skeletal maturity, total time in brace, or general activity level. There was no statistically significant difference in curve improvement between the two groups (p = 0.95). This preliminary study suggests that the Milwaukee brace alone is as effective in halting curve progression as a Milwaukee brace plus standard prescribed exercises.     

Prospective evaluation of braces as treatment in idiopathic scoliosis

AIM: To prospectively evaluate the results of brace treatment in idiopathic scoliosis and to define risk factors of treatment failure. METHOD: Fifty-two patients with a Cobb angle of between 25 and 40 degrees were included in the study. Prior to initiation of brace treatment with the Chêneau-Toulouse-Muenster orthesis, skeletal age and flexibility of the curve (bending films) were evaluated. The average follow-up after weaning of the brace was 42 months (36-78 months). RESULTS: An average initial Cobb angle of 31 degrees was corrected to 18 degrees (43 %) under brace treatment with a flexibility to 6 degrees Cobb angle on bending films. Three years after weaning there was an overall increase of the Cobb angle to 37 degrees on average. The apical vertebral rotation was corrected from 16 degrees to 11 degrees (31 %) and increased to 20 degrees during follow-up. Thoracic kyphosis changed from 24 degrees to 18 degrees during treatment. At the latest follow-up kyphosis had returned to the pre-treatment angle again. Twenty-two patients had a curve progression during or after brace treatment of more than 5 degrees. In 14 patients surgical correction and fusion have been indicated. There was a positive correlation between flexibility and Cobb angle correction during brace treatment and a negative correlation between Cobb angle correction during brace treatment and curve progression (p < 0.05). CONCLUSIONS: Curve progression was prevented in 58 %. Prognostic risk factors are a young age at initiation of brace treatment, a thoracic curve, unsatisfactory curve correction in the brace and a male gender.     

Adolescent idiopathic scoliosis, bracing, and the Hueter-Volkmann principle.

BACKGROUND CONTEXT: Evidence demonstrating the biomechanical effects of the Hueter-Volkmann principle on vertebral body growth in spinal deformities is lacking. Bracing a scoliotic curve should, in theory, unload the growth plates on the concave side of the vertebral bodies near the curve's apex. Growth stimulation, leading to structural remodeling of the vertebral bodies, on the curve's concave side may explain the improvement or lack of curve progression, as measured by Cobb angles, reported with successful brace management of adolescent idiopathic scoliosis (AIS). PURPOSE: To determine whether brace treatment stimulated asymmetric chondrogenesis in the apical three vertebral bodies. STUDY DESIGN: A prospective cohort of patients with AIS receiving brace treatment were followed from the initiation of brace treatment until skeletal maturity. Patients were then retrospectively divided into those with and without radiographic progression. This post hoc analysis was included to determine risk factors for curve progression. PATIENT SAMPLE: Forty-one skeletally immature patients with AIS meeting criteria for brace treatment were followed until skeletal maturity. All patients were treated with thoracolumbosacral orthotics (TLSOs). OUTCOME MEASURES: The positional derotation of the TLSO on the spine was measured by comparing the initial radiograph with the first radiograph in a brace. The long-term structural changes of the vertebral bodies were determined by comparing the initial and final radiographs. Differences in initial radiographic parameters between the groups of patients with AIS with and without curve progression indicated predictive factors for successful brace treatment. METHODS: Initial radiographic measurements were compared with those observed in a brace and those observed at final follow-up. The same analysis was retrospectively repeated comparing patients with AIS with and without radiographic progression. RESULTS: Cobb measurements (p=.0001) and concave-to-convex height ratios of the apical three vertebral bodies improved when the brace was initially applied (p=.0035). Structural remodeling or a rotational correction of the apical three vertebral bodies was appreciated only in patients with flexible curves (p=.01). CONCLUSION: Brace application results in immediate positional derotations of the spine in patients with AIS. These positional derotations were maintained only in patients with flexible curves, at final follow-up. Brace treatment was not recommended in patients whose curves did not correct at least 20% in a TLSO.     

Changes in curve pattern after brace treatment for idiopathic scoliosis

We studied whether thoracic Boston brace treatment changes the King type of scoliotic curves in a group of 50 patients with adolescent idiopathic scoliosis. Bending radiographs showed more flexibility of the lumbar curves than that of the thoracic curves. However, after initial application of the brace, the mean lumbar correction in degrees was less than the mean thoracic correction. After brace treatment we found a slight statistically significant increase in the mean lumbar curve, but no significant change in the mean thoracic curve. In 7 of our patients, we found a change in the King classification which seemed to be related to insufficient lumbar correction at the start of brace treatment. When classifying idiopathic scoliosis, one should bear in mind that the result may be temporary because scoliosis is a dynamic process. A change in curve type can occur during brace treatment.     

Does brace treatment impact upon the flexibility and the correctability of idiopathic scoliosis in adolescents?

Purpose

Brace treatment has served as a vital non-surgical procedure for immature adolescent idiopathic scoliosis (AIS) patients with a mild or moderate curve. For the patients who fail in bracing and resort to surgery, it is unclear whether prior full-time brace treatment significantly influences outcomes. This study aims to investigate whether prior brace treatment has a negative impact upon the flexibility and correctability of the main curve in patients with AIS.

Methods

The participants were collected from female AIS patients who underwent posterior correction surgery with pedicle screw instrumentation from August 2006 to December 2010, with or without prior brace treatment. Patients included in Group A had prior brace treatment over a 1-year period, and underwent surgery within 6 months after cessation of bracing; those in Group B received no prior treatment and were randomly selected from our database. Curve flexibility pre-surgery and curve correctability post-surgery were computed and compared between both groups and subgroups according to the curve location.

Results

Each group consisted of 35 patients. Age, curve magnitude and location were comparable between the two groups. Before surgery, patients in Group A had a slightly lower curve flexibility than those in Group B (52 vs. 60 %, P = 0.036). After surgery, satisfactory correction results were observed in both groups, but the average post-operative main curve magnitude of patients in Group B was 4° less than that of Group A (10° vs. 14°, P = 0.010). The curve correctability in Group B was significantly higher than that in Group A (80 vs. 74 %, P = 0.002). No matter what curve pattern the patient had, having a prior history of brace treatment resulted in a trend of lower flexibility and correctability of their scoliosis.

Conclusions

Good surgical correction can be achieved in AIS patients who have been unsuccessful with prior brace treatment. However, a history of prior brace treatment leads to a trend of lowering the curve flexibility, and in turn, negatively impacts upon the curve correctability.     

Changes in curve pattern after brace treatment for idiopathic scoliosis

We studied whether thoracic Boston brace treatment changes the King type of scoliotic curves in a group of 50 patients with adolescent idiopathic scoliosis. Bending radiographs showed more flexibility of the lumbar curves than that of the thoracic curves. However, after initial application of the brace, the mean lumbar correction in degrees was less than the mean thoracic correction. After brace treatment we found a slight statistically significant increase in the mean lumbar curve, but no significant change in the mean thoracic curve. In 7 of our patients, we found a change in the King classification which seemed to be related to insufficient lumbar correction at the start of brace treatment. When classifying idiopathic scoliosis, one should bear in mind that the result may be temporary because scoliosis is a dynamic process. A change in curve type can occur during brace treatment.     

Efficacy of a new computer-aided design/computer-aided manufacture orthosis in the treatment of adolescent idiopathic scoliosis

To report on the initial experience with the Los Angeles brace, a new computer-aided design/computer-aided manufacture brace used in the treatment of idiopathic scoliosis. This was a retrospective review of 40 idiopathic scoliosis patients who completed treatment with this new computer-aided design/computer-aided manufacture brace. In-brace correction averaged 51% for the primary curves, with corrections of 53 and 22% for girls and boys, respectively. Only six patients (15%) had curve progression at brace completion. This preliminary study suggests that the new Los Angeles brace is effective in the treatment of scoliosis in girls, while avoiding some obstacles involved in traditional bracing.     

Outcome assessment of bracing in adolescent idiopathic scoliosis by the use of the SRS-22 questionnaire

The SRS-22 questionnaire is specifically designed for the assessment of quality of life in spinal deformity patients. This study is the first to use it to assess the quality of life of adolescent idiopathic scoliosis patients under brace treatment and compares the results with an observational group matched by age and curve magnitude. Forty-six patients were enrolled into each group. Overall, it was found that patients under observation had a significantly better quality of life than braced patients. Specifically, the domains for function/activity and self-image were most affected. This effect was most apparent in those with a curve magnitude of under 20 degrees . The scores did not improve significantly with the duration of brace wear, suggesting little adaptation. This study has implications for treatment, and more attention will need to be given to those with mild but progressive curves to help improve patients' understanding of their treatment and hence their compliance and satisfaction.     

Results of brace treatment of adolescent idiopathic scoliosis in boys compared with girls: a retrospective study of 102 patients treated with the Boston brace

The aim of the study was to compare the results of brace treatment of adolescent idiopathic scoliosis (AIS) in male patients with matched female patients and to assess the effectiveness of bracing of boys in AIS and to discuss the results with published data. Between 1987 and 1995, 51 consecutive male patients with AIS were treated with the Boston brace. The patients were advised to wear the brace 23 h/day. The medical records of all patients were reviewed. Cobb angles and Risser signs were measured before bracing, in brace, at brace discontinuation and at final follow-up. Everyone of 51 male patients was compared with a female patient who was treated by the same method and matched by Risser sign, curve pattern, curve magnitude and duration of treatment and follow-up time. Compliance with brace was noted at every visit. Fourteen boys had worn the brace only during nighttime or occasionally and were considered non-compliant. Only compliant patients with treatment period > 1 year and follow-up > 1 year after treatment were accepted for the analyses of effectiveness of brace treatment and its prognostic factors. Thirty-three boys met these inclusion criteria. Bracing was considered to have a failure if > 5° progression occurred or if surgery was performed. At the final follow-up study progression > 5° was found in 16/51 (31.4%) of male patients. Corresponding figures of female patients were 11/51 (21.6%), respectively. In compliant boys progression > 5° occurred in 6/33 boys compared with 9/33 girls. The association between risk of progression and correction% in brace was statistically significant. The overall results of brace treatment of idiopathic scoliosis in male patients were inferior compared with matched females. One reason for inferior overall results in boys was poor compliance with brace wear. However, brace treatment in AIS may be recommended with the same principles in both genders.