Three-year results of bracing in scoliosis

We treated 107 patients with idiopathic scoliosis with the Boston brace. The primary correction was good in all the curve patterns. The follow-up time after weaning averaged 3 years. The best final result was achieved in thoracic and lumbar curves (mean 2 degrees). The final correction was worse in patients with an initial curve less than 30 degrees when compared with the patients with larger curves. Except the double major curves, there was a positive correlation between the primary correction, duration of the treatment, and the final result. The results in 14 patients with bracing for 12 hours daily did not differ from the remainder. Progression of the initial curve more than 5 degrees after the treatment was noted in 24 patients. Three patients were operated on later because of progression. We conclude that bracing can prevent progress of scoliosis.     

Operative Treatment of Scoliosis with the Harrington Instrumentation Technique

Preliminary results of treatment of scoliosis with the Harrington instrumentation technique in 80 patients are presented. The curve correction at operation averaged 43.4 per cent with the best results being achieved in idiopathic single curves (49.3 per cent). Most of the patients had been treated conservatively for a long time prior to operation, and the curves were rather stiff. The initial loss of correction was 3.2°, and the overall loss at 2 years postoperatively averaged 6.5° in 28 patients. Complications occurred in 22.5 per cent of the patients, most often at the upper hook site. Serious complications were rare. It is concluded that the Harrington instrumentation technique is an effective means of treatment of scoliosis.     

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.     

Nighttime bracing with the Providence brace in adolescent girls with idiopathic scoliosis

STUDY DESIGN: A prospective study was conducted of 102 consecutive female patients with adolescent idiopathic scoliosis. Those patients with Risser 0, 1, and 2 met the criteria for inclusion and were treated only with the Providence brace. OBJECTIVES: To report the authors' experience with a hypercorrective nighttime brace and to evaluate the results with respect to risk factors for progression. Second, the study compares results with expectations from the natural history as reported by others. SUMMARY OF BACKGROUND DATA: Compliance with full-time brace treatment for adolescent idiopathic scoliosis has been a problem. Since the introduction of the Milwaukee brace, alternatives such as low-profile braces, reduced wearing schedules, and nighttime only bracing have been tried. However, many factors influence the success or failure besides compliance. These include in-brace correction, brace design, and the orthotist's skills. This is the first report of the results of treatment with a new nighttime brace that is made with CAD/CAM technology that can achieve higher initial in-brace corrections than other reported methods. METHODS: Results were analyzed with respect to curve size, curve pattern, maturity, and level of the primary curve apex. Both compliant and noncompliant patients were included in the analysis. A univariate analysis was done on those factors thought to influence success with bracing using the Pearson chi2 test. RESULTS: The average initial in-brace correction with a supine radiograph was 96% for major curves and 98% for minor curves. Seventy-five patients (74%) did not progress >5 degrees and 27 patients (26%) progressed > or =6 degrees or went on to surgery. Twenty-nine percent of Risser 0 or 1 patients progressed and 17% of patients Risser 2 progressed. The risk of progression anticipated by natural history data, which included all curve patterns, was 68% for Risser 0 and 1 and 23% for Risser 2. Risser 3 and 4 patients were excluded from the study. Seventy-six percent of patients with curve apexes between T8 and L1 had successful outcomes using the Providence brace. This is compared with a 74% success rate in the prospective Scoliosis Research Society study of patients wearing a thoraco lumbar sacral orthosis for 16 hours per day with curve apexes between T8 and L1. With the Providence brace, 63% of thoracic curves and 65% of double curves were successful. Ninety-four percent of lumbar curves and 93% of thoracolumbar curves were successful. CONCLUSION: Excellent initial in-brace correction of adolescent idiopathic scoliosis was observed with this computer-designed and manufactured recumbent brace. Patients with high apex curves cephalad to T8 (n = 31) had a success rate of 61% compared with a success rate of 79% (n = 71) if the apex was at or below T9. Compared with previous natural history and the prospective study data, the Providence brace is effective in preventing progression of adolescent idiopathic scoliosis for curves <35 degrees. It was effective for larger curves with a low apex. The authors' experience with patients with curves >35 degrees (n = 8) is too small to validate its effectiveness for larger curves with a higher apex.     

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.     

Results of brace treatment of scoliosis in Marfan syndrome

STUDY DESIGN: Retrospective review of a defined Marfan population with traditional indications for bracing. OBJECTIVES: To determine the success rate of brace treatment in keeping curves from progressing by more than 5 degrees or exceeding 45 degrees. SUMMARY OF BACKGROUND DATA: Few studies exist regarding brace treatment of Marfan syndrome, and they include many patients with curves of more than 45 degrees, as well as some who are near maturity. All of the prior studies risk the possibility of some selection bias. METHODS: Patients were selected from support groups and several institutions. Inclusion criteria were: Definite diagnosis of Marfan syndrome, curve of 45 degrees or less, Risser sign 2, 1, or 0 at inception of bracing, recommended wear of 18 hours or more per day, and follow-up until maturity or surgery (minimum, 2 years). Success was defined as curve progression of 5 degrees or less and final curve remaining 45 degrees or less. Failure was a final curve of more than 45 degrees. Twenty-four patients met the criteria. There were 15 girls and 9 boys. Twenty-two patients wore a brace as recommended. Two additional patients were unable to tolerate it. RESULTS: Mean age at inception of bracing was 8.7 years (range, 4-12 years). There were 14 double major, 6 thoracic, and 4 thoracolumbar curves with a mean size of 29 degrees at the beginning of bracing. The stated wearing time averaged 21 hours per day. Five patients had significant pain over bony prominences. Although correction of the curve in brace was good (45%), only 4 of the patients had success, and in 20 of the 24 treatment was considered a failure. Mean progression was 6 degrees +/- 8 degrees per year, for a final mean curve of 49 degrees. Sixteen of the patients had, or were advised to have, surgical correction. The difference in age and degree of curvature were not statistically significant between the success and nonsuccess groups. CONCLUSIONS: The success rate for brace treatment of Marfan scoliosis is 17%, which is lower than that reported for idiopathic scoliosis. Possible reasons include increased progressive forces, altered transmission of corrective pressure to the spine, and younger age at inception of bracing. Because there was no control group, it is unknown whether bracing slowed curve progression. Physicians should understand that most patients with Marfan syndrome who have a curve of more than 25 degrees and a Risser sign of 2 or less will reach the surgical range, even with brace treatment.     

Effectiveness of the Providence nighttime bracing in adolescent idiopathic scoliosis: a comparative study of 36 female patients

The aim of the study was to assess the results of treatment of adolescent idiopathic scoliosis (AIS) with the Providence nighttime brace at 1.8 years after discontinuation of bracing. A total of 36 consecutive female patients with an average Cobb angle of 28.4° and an apex below T 10 were studied prospectively. For comparisons, 36 matched patients treated with the Boston full-time brace were studied retrospectively. With the Providence night brace an average of 92% for brace correction of the primary curve was achieved and during follow-up progression of the curve >5° occurred in 27% of the patients. In the control group of the Boston full-time brace patients, brace correction was 50% and the progression of the major curve occurred in 22% of the patients. We conclude that the Providence night brace may be recommended for the treatment of AIS with curves less than 35° in lumbar and thoracolumbar cases.     

Operative Treatment of Scoliosis with Harrington Instrumentation Technique

Thirty-five patients with scoliosis were treated with posterior fusion including the Harrington instrumentation technique. The operation was followed by a 1-year period of treatment in a Milwaukee brace. The patients had a thoracic or a thoracolumbar curve averaging 74°. The mean initial correction was 45 per cent, and the mean final correction 33 per cent, after 2 3/4 years. There were no cases of pseudarthrosis and only one case of transient paresis. There were no deaths. It is concluded that these results are satisfactory and that the method is a safe one in experienced hands.     

A large adolescent idiopathic scoliosis curve in a skeletally immature patient: is early surgery the correct approach? Overview of available evidence

The goal of this study was to determine whether the available studies provide enough evidence that, in a borderline case of adolescent idiopathic scoliosis with a large (35 to 50 degrees) curve in a skeletally immature patient (Risser 0 to 2) with significant growth potential left, a conservative line of management in the form of bracing can be considered, rather than to rush into a potentially unnecessary major spinal surgery. We reviewed the literature spanning the last 20 years for the results of bracing in this specific group of patients. From the 9 studies selected, a group-specific data extraction was carried out. Three hundred and five patients with a 36 to 50 degrees scoliosis curve and Risser stages 0 to 2 were treated by bracing and the treatment was termed successful in 160 patients. Thus, more than half (52.5%) of the patients were successfully managed with a brace and were spared surgery. The current trend for management of these curves is early surgical intervention, the rationale being the ineffectiveness of bracing in preventing the progression of such a large curve and the difficulty in obtaining satisfactory correction by postponing surgery to a later date. On the basis of our results, we propose a conservative line of management for these curves, in contrast with current views, rather than to rush into a major spine surgery, expecting a favorable outcome with a well-supervised bracing program. If the curve progresses, surgery can always be considered later, keeping in mind the excellent correction obtained with the pedicle screw systems even for large curves of 70 to 100 degrees.     

Lenke 5型脊柱侧凸前路选择性融合术后胸弯的转归及其影响因素

目的 探讨Lenke 5型脊柱侧凸前路选择性融合术后胸弯的转归及其可能的影响因素.方法 回顾性分析伴有胸弯的29例女性Lenke 5型脊柱侧凸患者,年龄12～20岁,平均(15.3±2.0)岁;Risser征0～5级,平均(3.8±0.8)级.所有患者均行前路选择性融合术,随访24～58个月,平均33个月,分析术后胸弯的转归及其与术前相关指标的关系.结果所有患者行前路选择性融合术后,主弯Cobb角减小至11.9°±7.3°(矫正率为74.7%±15.3%),胸弯Cobb角减小至16.7°±7.5°(矫正率为40.4%±21.8%).胸弯Cobb角矫正丢失2°以上的9例患者术前胸弯Bending相矫正率较低(F=5.408,P=0.028).在发生显著胸弯矫正丢失的3例患者中,2例术前胸弯Cobb角均达35°以上,2例胸弯柔软度低于50%,1例主弯和胸弯Cobb角比值低于1.25,1例Risser征为0级.末次随访时,胸弯Cobb角与术前胸弯Cobb角、胸弯Bending相Cobb角以及胸弯和主弯Cobb角比值均正相关(分别为r=0.664,19<0.001;r=0.555,P=0.001;r=0.515,P=0.002).而末次随访时胸弯矫正率则与术前胸弯Bending相矫正率正相关(r=0.495,P=0.006).结论 Lenke 5型患者行前路选择性融合术后胸弯的自发性矫正可能与术前胸弯Cobb角、柔软度以及生长潜能等密切相关,但术前胸弯柔软度小能完全反映术后自发性矫正的程度.     

The Boston bracing system for idiopathic scoliosis. Follow-up results in 295 patients

A total of 295 patients treated with the Boston bracing system with follow-up of at least 1 year after completion of bracing are reviewed. Pre-brace curves ranged from 20-59 degrees Cobb. Mean age at brace initiation was 13.2 years with a mean treatment time of 2.9 years and mean follow-up of 1.4 years. Mean best in-brace correction averaged 50% with correction averaging 23% at the initiation of weaning from the brace. By the time of brace discontinuance, average curve correction was 15%. At follow-up, average correction was 11%. A comparison of follow-up with pre-brace values of major curves showed that 49% were unchanged +/- 5 degree, 39% achieved final correction of 5-15 degrees, 4% achieved final correction of 15 degrees or more, 4% of patients lost 5-15 degrees, and 3% lost more than 15 degrees by the time of follow-up. Eleven percent of patients underwent surgery during the period of bracing; 1% had surgery during follow-up period. Correction and control of major curves with apexes below T8 and above L2 were best. A strong correlation between best, or initial in-brace correction, and follow-up correction was noted. Young age at the initiation of bracing and higher degrees of pre-brace curvature increased the incidence of surgery. Those curves that had corrected most at the end of bracing were most at risk for loss of correction after bracing. Partial compliance with brace wear appeared as effective as full-time wear. Boston braces without superstructure appeared to be as effective as braces with superstructure for curves with apexes below T7.     

Idiopathic scoliosis. An 11-year follow-up study of the role of the Milwaukee brace in curve control and trunco-pelvic alignment

One hundred and fifty-two patients with idiopathic scoliosis were treated at the Alfred I. duPont Institute with the Milwaukee brace between 1961 and 1972. This study includes 94 patients and was undertaken to evaluate the effectiveness of Milwaukee brace treatment in managing various sequelae associated with idiopathic scoliosis, such as degree of curvature and trunco-pelvic alignment, and to assess the degree of spinal stability after treatment. Good results were obtained in patients with curves less 30 degrees; in addition, there was improvement in trunco-pelvic alignment and curve correction. However, results varied considerably among patients and were unpredictable. Double major curve patterns were found to have a poor response to bracing. After bracing is stopped, rate of curve progression appears to decrease with time.     

女性青少年特发性脊柱侧凸支具治疗效果和影响因素评估

目的 评估女性青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者支具治疗效果及影响因素.方法 2003年7月至2009年7月,完成支具治疗或因侧凸进展而行手术治疗的女性AIS患者142例,初诊时平均年龄为(13.1±1.5)岁,平均主弯Cobb角29.6°±5.4°,平均Risser征为(2.0±1.5)级.定义侧凸畸形进展为末次随访Cobb角大于初诊6°以上或治疗期间建议行矫形手术(Cobb 角＞45°),其余为非进展.根据侧凸进展或需手术治疗的比率来评估支具治疗效果.运用卡方检验和Logistic回归分析探讨影响支具治疗效果的因素.结果 平均支具治疗时间为(2.5±1.0)年.按照侧凸进展的定义,进展组为27例(19%),非进展组115例(81%);手术组病例18例(13%),因支具治疗而避免手术病例124例(87%).卡方检验发现侧凸进展组和手术组中以初诊年龄10.0～12.9岁、月经初潮未至、Risser征0～1级、初诊Cobb角＞30°以及胸弯型居多.Logistic回归分析发现月经初潮未至(P=0.000)和胸弯型(P=0.012)是支具治疗后侧凸进展的独立预测因素,而初诊Cobb角＞30°(P=0.022)是支具治疗期间因侧凸进展而需手术治疗的另一独立预测因素.结论 支具治疗可有效控制多数AIS患者的侧凸进展,而生长发育状态、侧凸严重程度和侧凸类型是影响支具疗效的重要因素.

Abstract：

Objective To analyze the outcomes of bracing treatment for girls with adolescent idiopathic scoliosis (AIS), and to investigate the predictive factors of the protocol. Methods This study included 142 girls with AIS who finished standardized bracing treatment from July 2003 to July 2009. These patients had a mean age of 13.1±1.5 years, a mean main curve of 29.6°±5.4°, and a mean Risser grade of 2.0±1.5 before bracing treatment. Curve progression was defined that Cobb angle was greater than 6° compared to bracing initiation or was aggravated to more than 45° (indicative for surgery). The outcomes of bracing treatment were assessed based on the ratio of curves of progression or indicative for surgery. Chi-square and Logistic regression Analyses were performed to investigate the predictive factors of bracing treatment. Results The duration of bracing treatment averaged 2.5±1.0 years. Twenty-seven girls with curve progression (19%)and 115 girls (81%) with non-progression were found. Final curve which was greater than 45° was found in 18 girls (13%) who need a correction surgery, the remaining 124 girls (87%) had completed bracing treatment and avoided surgery. Chi-square analyses revealed that curve progression were more common in younger girls with lower Risser grade, with initial larger Cobb angle and with a main thoracic curve pattern.Logistic regression analyses found that premenarchal status and a main thoracic curve pattern were the independent risk factors of curve progression despite bracing. While initial Cobb angle which was greater than 30° was the additional independent risk factor of progression requiring surgery. Conclusion Bracing treatment could effectively prevent curve progression in most girls with AIS. The degree of growth maturity, the pattern and grade of curve are the influencing factor for bracing treatment.     

Results of Charleston bracing in skeletally immature patients with idiopathic scoliosis

Previous studies have reported varying success rates with the use of the Charleston brace in idiopathic scoliosis. However, these studies have included patients from multiple centers, those with double curves, and those still undergoing treatment. This article presents the results of Charleston bracing in 42 skeletally immature patients (Risser 0/1) treated at one institution and followed up for a mean of 3.3 years after brace discontinuation. Selection criteria included a diagnosis of idiopathic scoliosis, Risser stage 0 or 1, at least 10 years of age at the time of bracing, female gender, a single curve between 25 degrees and 40 degrees, and no prior treatment. The average age at the time of bracing was 12.5 years (range 10-15) and the average curve was 30.3 degrees (range 25 degrees -40 degrees ). Outcome was considered a failure if the curve had increased more than 5 degrees at last follow-up, if surgical intervention was required, or if there was a change of orthosis during treatment (e.g., Charleston to Boston). In 25 of the 42 patients (60%), the brace was successful in preventing progression of the curve (mean follow-up 3.4 years; range 1.1-11.7). Thoracic curves had the same success as thoracolumbar and lumbar curves. Based on these results, the authors conclude that the Charleston brace is effective in preventing progression of curve. Proper patient selection is important.     

Lateral electrical surface stimulation for the treatment of progressive idiopathic scoliosis

Transcutaneous lateral electrical muscle stimulation is demonstrated to be a reasonable alternative to bracing in the treatment of progressive, mild-to-moderate idiopathic scoliosis. Stimulation is applied nightly during sleep, through surface electrodes, on the convex side of the curve, evoking muscle contractions which cause correction of the curvature. Arrest of progression or curve correction in 90 patients treated up to four years (average 15 months) was observed in 84% of 61 patients with single primary curves and 83% of 29 patients with double primary curves. If only the patients who complied totally with the program are considered, the above rates improve to 97% and 93%, respectively. Post-treatment observations of skeletally mature curves for up to two years in 13 patients show no increase in curvature.     

Curve progression in scoliosis associated with Chiari I malformation following suboccipital decompression

Nine children with scoliosis and Chiari I malformations were followed 1-11 years after suboccipital decompression. Eight also had syringomyelia. Despite initial curve stabilization, at final follow-up eight curves were of the magnitude to require spinal fusion. Neither bracing nor secondary neurosurgical procedures arrested progressive curves.     

Effectiveness of braces in mild idiopathic scoliosis

Despite the wide use of bracing for the treatment of idiopathic scoliosis, controlled studies apparently have not been performed to examine whether bracing, in fact, alters the natural history of spine lateral curves. We studied 255 female patients, ages 8-17 years, with idiopathic scoliosis who had curves with initial Cobb measures from 15-30 degrees. They were divided into two groups: one group consisted of 144 patients who had received a Milwaukee or Boston brace; and the other, a control group, consisted of 111 patients who remained untreated through a mean period of 1.9 years. The groups had similar mean ages, ages of menarche and curve severities. The results showed a slight but nonsignificant trend, suggesting that bracing reduced the overall probability of progression in the braced curves. However, noting that nearly 75% of the control group curves were nonprogressive, it is possible that a similar proportion of the braced curves need not have been braced. Moreover, bracing failed to prevent eight curves in seven patients (5%) from progressing. These curves progressed at a mean rate of 8 degrees per year. Our retrospective results suggest that bracing probably is not necessary in a large proportion of patients who meet current, clinical criteria for bracing. Given the limitations of retrospective studies like this one, a controlled prospective trial of bracing effectiveness in idiopathic scoliosis seems warranted.     

Scoliosis elasticity assessed by manual traction:49 juvenile and adolescent idiopathic cases

We assessed preoperative curve elasticity in 49 consecutive patients with juvenile or adolescent idiopathic scoliosis who were operated on with Harrington distraction rods. Preoperatively, the curve was determined from posteroanterior radiographs taken in the standing position and in the supine position, with traction. In the latter, the radiographs were taken at the moment of maximal traction when one technician applied traction to the ankles and another to the wrists. The scoliotic curve in the 10 patients with juvenile scoliosis averaged 59° and 32° in the standing and supine positions with traction, respectively. Immediately postoperatively, the curve averaged 19°. 39 patients with adolescent scoliosis had a scoliotic curve which averaged 58° in the standing position and 32° in the supine position with traction. The mean postoperative measurement was 21°. These findings suggest that manual traction is a simple and reliable means of predicting the minimal correction of the scoliotic curve to be expected, using Harrington distraction rods.     

Effectiveness of the boston brace in treatment of large curves in adolescent idiopathic scoliosis

STUDY DESIGN: This is a retrospective study of 50 patients with adolescent idiopathic scoliosis with curves measuring 35 degrees to 45 degrees who were treated with a Boston brace. OBJECTIVES: The purpose of this study was to determine whether the Boston brace could effectively halt long-term progression in skeletally immature adolescents with idiopathic scoliosis who had a curve between 35 degrees and 45 degrees. SUMMARY OF BACKGROUND DATA: The Boston brace has been shown to be effective in preventing curve progression in adolescent idiopathic scoliosis, but its efficacy in large curves has not been fully studied. METHODS: Fifty adolescents were treated with a Boston brace for idiopathic scoliosis curves of 35-45 degrees (mean, 38.55 degrees ). All were judged to be skeletally immature based on menarcheal status (mean, 2.6 months before menarche), Risser sign (mean, 0.90; range, 0-2), and chronologic age (mean, 13 +/- 1 years). Patients were recalled for long-term follow-up at a mean of 9.7 years (range, 6.23-13.22 years) after brace discontinuation. Three well-matched patient subsets were then identified based on compliance. Group 1 (n = 24) consisted of patients who were compliant with the brace program and wore the brace 18 or more hours per day, Group 2 (n = 14) contained patients who wore the brace 12-18 hours per day, and Group 3 (n = 12) contained patients who wore the brace 0-12 hours per day. RESULTS: There was a significant difference in the amount of initial correction seen in the brace between the groups: 49%, 45%, and 33% curve correction in the brace for Groups 1, 2, and 3, respectively (P < 0.05). At long-term follow-up there was a statistically significant difference between Groups 1, 2, and 3 in the percentage of patients in whom the curve had progressed to more than 45 degrees (P < 0.001), who had more than 5 degrees of curve progression (P < 0. 05), or who had undergone posterior spinal fusion (P < 0.001). CONCLUSIONS: These long-term data confirm that the Boston brace when used 18 or more hours per day is effective in preventing progression of large curves at a mean of 9.8 years after bracing is discontinued.