When it comes to bracing, in the past
we used to brace everybody.
Now, bracing has been moved towards those
in the early phases of growth
who still have a lot of growth to go.
Those who have a disease
serious enough to where you think that in
the future they're going to need surgery;
or you see a progression that's going
more rapid than you would like.
Those are times when you consider bracing
for the potentially pushing back
of the worst thing of the disease. Again,
it does not correct the curvature.
It is something that is time limiting.
We don't do in patients who have reached
skeletal maturity because your
benefit is going to be minimal.
So if the Riser score shows that there is
a 4 or a 5 and growth is complete,
bracing is no longer going to be of benefit.
If the angle is severe
and they've already reached
the need for surgery,
bracing is not going to have a benefit.
It's contraindicated in patients
who have a thoracic lordosis.
The other thing is with bracing,
if you don't have a compliant patient, it's not
something you should look at doing.
The underarm orthoses are what's used,
underarm down to the pelvic area.
It does stabilize motion as well as
work on straightening the back.
There are other braces out there
like the Charleston brace
or the Wilmington jacket that have metal
inserts to keep the back stable.
That's how the benefit
The Milwaukee brace was the most
common and the most studied
but it's rarely used now.
That's a flared brace
that has the stabilization
on the top and bottom.
Data shows that its benefit is present
when it's used for 23 hours a day.
If you're using it less
than 16 ½ or 17 hours,
you're not going to get
the benefit you want.
But the other nice thing about
the brace is within six months,
you'll see a slowing
Then it does have some benefit as long as
you're using it for 23 hours a day.
So, a bracing has
There are some good studies
out there that will tell you
what to think about bracing. The NIH
had the BrAIST study going on,
which is the bracing in adolescent
idiopathic scoliosis trial.
It's a five-year, multi-center,
prospective, randomized trial
that compares bracing with
observation in a young patient
whose skeletal hasn't
fully fused yet.
It's been for patients with a Cobb
angle between 25 to 40 degrees.
What that does show is
that bracing treatment
is effective when used
greater than 23 hours a day.
The proportion of success in
those patients was 0.93.
When the brace was used
less than 16 hours,
the effect was much lower at 0.62 and
much less effective at 8 hours as well.
So, you see bracing is effective when used
constantly and paid attention to.
If you don't have a patient
who's going to use the brace
for 23 hours a day, your benefit is not going to be as great.
We also know that most
patients will use a brace
65% of the time that they
are told to use the brace.
So, if they're told to use it
for 20 hours a day,
you may only get 13 to 14
hours’ worth of bracing.
This was done with the study with a
temperature monitor in the brace
so that people weren't asked,
they were monitored.
So it is more accurate information
than if were self-reported.
The patient may need to wear
the brace during sports
or they’re going to
refrain from sports.
It can only be removed
for short periods of time.
The other issue with the brace is it needs
to be monitored routinely for proper fit.
If a person is growing, they need
to return more frequently
to make sure that the fit is appropriate and
that it's not going to be causing
chafing or discomfort
in other ways.
It's also worn under or over the clothes
which are decisions and choices
that can affect the look and how a person
feels about their own health.
With the brace, you want to continually
monitor how it's affecting the curvature.
If the goal is a 20% reduction
when the brace is being worn,
that's the goal you're going to use
to see if you have a success.
The bracing should continue until
the end of the growth period.
For girls, it's two years after menarche
or when their Risser score is 4 or 5.
For boys, it's a Risser score of 5 when
there’s complete termination of growth
because they've grown
to their full height.
With the bracing, you can
either stop completely
or you can just wean it down
to using the brace at night.
That is when people feel that they
have a limitation of symptoms,
or they feel better with the brace,
or more comfortable.
Sometimes people start
using the brace as a crutch,
feeling they need it or they're
not going to be comfortable.
You should generally have a follow-up
six months post-bracing
and make sure you know
what is happening to the curve.
Sometimes people do report a rapid
deterioration or worsening of the curve
after they stopped bracing.
That's something you need to measure
to have a good answer
to know what's going on.
You need to monitor the brace
treatment every 6 to 8 months
both clinically and with
When you get the radiographs
after the bracing,
you want to check for any
curve progression and note
whether it's speeding up
or slowing down.
Progression of the Cobb angle
more than 5 degrees
during bracing treatment
is a poor sign and says
that the person is not going to do
well and surgery may be needed.
With surgery, the primary goal
in spinal fusion is to prevent
curve progression because of
potential damage to the organs.
You want to protect their functioning and
protect cardiac and pulmonary functioning.
The secondary goal
is curve correction.
What you're doing is straightening out
the curvature and putting rods in place.
So it is going to
correct the curve.
The indication is for skeletally
At diagnosis, the patient should have
a Cobb angle of greater than
or equal to 50 degrees. That's when
you know that damage is occurring.
Sometimes a skeletally immature
patient with a Cobb angle
of between 40 to 50 degrees
may need surgery.
That should be determined
on a case-by-case basis.
The surgical procedure done for
adolescent idiopathic scoliosis
is a posterior spinal fusion.
That's bone grafting and rodding.
The rod is put in the spine
to straighten it out.
Bone grafting is put
to cement it in place.
Instrumentation has evolved
from the Harrington rods
which were full-body corrections to the
more modern segmental instrumentation,
which are hooks, screws,
wires, and much shorter.
So there's much less metal going much fewer
segments in order to stabilize the back.
The modern instrumentation provides
your orthopedic surgeon
with control of positioning so they
can fix the specific vertebrae
and help maintain the angle that's
needed for proper functioning.
The other important part of the surgery
is the bony fusion with grafts
or allografts that allow the bones to heal
so that the issue of infection
isn't there and the person can
go on in a functional manner.
Postoperatively for 9 to 12 months, this
person is not supposed to participate
in sports because the risk
of injury is much greater.
Once the spine has fused and
we know that each canaliculus
takes about three months, and
it's usually about a year
before you have full fusion
of the bone around this area,
once it's fused, you can go
ahead and start sports.
Long-term follow up data on these
procedures is still being collected.
So we don't have the answers
we would like to have for you.
We do know that untreated curves may
continue to progress after skeletal maturity.
This occurs in two-thirds
When the curves even are less than
30 degrees, you're going to see
some progression even though it's
less likely than the larger curves.
One 50-year follow up showed
patients had little impairment
other than back pain and cosmetic
concerns with the smaller curves
which is why we do not
suggest surgery for them.
Curves treated with bracing and
surgery can also progress.
There are studies showing bracing
patients followed for 22 years
and they had an average curve
progression of about 8 degrees.
So while it does progress, it doesn't progress
to the point of causing organ damage.
In the surgical treatment in patients
who followed for 23 years,
we saw an average progression
of about 3.5 degrees.
So these are important concepts to keep
in mind when patients bring up
whether or not they should
get surgery earlier
or when they don't meet criteria
for surgical intervention.
The back pain from scoliosis can be treated
to make the patient more comfortable.
Untreated, there's no evidence that there's
going to be a greater occurrence
of progression or change.
There may be a correlation between
the initial magnitude of the curve and
later back pain but that's a different issue.
Patients with adolescent idiopathic scoliosis
who are treated with bracing or surgery
may have an increased risk of degenerative
joint disease, osteoarthritis later on in life.
When patients who have
scoliosis get pregnant,
they do need increased
monitoring and awareness.
It's important to note the number of pregnancies
and the age of the first pregnancy
because these could affect curve
stability and curve progression.
The scoliotic curve itself does not seem
to affect the outcome of the pregnancy.
The patient is still able to get
pregnant and carry to term.
There is no increase in cesarean
section or other complications
in patients with scoliosis
who had pregnancy.
So to summarize, scoliosis treatment for
patients with a 20 to 30 degree curve
is generally orthotics, fixing the area
around, and documenting progression
to see if things are going to change.
In children with a 30-40 degree curve,
again you're going to treat with orthotics.
You're going to continue monitoring
with particular attention to
people in a growth phase
and in children who are
continuing to grow.
That's when you monitor
If a scoliosis has a
40-50 degree curve,
you do know that there's going
to be some organ involvement
and surgical intervention should be
looked at and prepared for.
You also may consider orthotics particularly
if there's a double major curve in the spine.
In patients with a curvature of greater than
50 degrees, surgery is going to be needed.
That's our talk on scoliosis.
I hope you found it useful.