Oxford Textbook of Trauma and Orthopaedics (2 edn)
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Summary points
Brace treatment has best chance of success in younger children and those with smaller curves
In most cases it can be expected to stop the curve becoming worse.
Introduction
To brace or not to brace is still a matter of debate. A large number of studies of this question are still being presented, with no less than 459 papers reported in Medline between 1966 and 1995. Most of these papers are retrospective and are open to criticism on various points. A meta-analysis has been published by Rowe and colleagues (1997). A recent cochrane review states that there is very low quality evidence in favor of using braces, making generalization very difficult. It suggests further prospective studies following Scoliosis Research Society Guidelines.
History
The first effective brace module for idiopathic scoliosis was the Milwaukee brace (Figure 3.14.1). This was molded individually. Module braces, such as the Boston brace (Figure 3.14.2), which are made from prefabricated plastic were then developed. The module is trimmed to the needs of the individual patient and fitted with pads to correct the curvature.
The Milwaukee brace.
The Boston brace.
Indications
The indication for conservative treatment of idiopathic scoliosis is the possibility of influencing the natural history. This means that we must predict what will happen if the individual case is or is not treated. The natural development of idiopathic scoliosis is influenced by age, sex, stage of pubertal development, skeletal development (Risser sign), and the pattern and progression of the curves.
Bracing is ineffective in curves with a Cobb angle in excess of 50 degrees. To be effective, bracing should reduce the incidence of surgical treatment.
One study compared the effectiveness of brace treatment in adolescent idiopathic scoliosis with non-treated scoliosis cases, all with Cobb angles between 25–35 degrees. This supported the use of brace treatment in this subset of patients. Brace treatment is also supported by a meta-analysis which suggests that the 23-h regimen is better than shorter regimens.
The cosmetic appearance of the trunk is important. Another study showed a 41% improvement of the surface shape during brace treatment, although only a 9% improvement was seen radiographically. Brace treatment probably prevents progression of the Cobb angle, but some have reported improvement. Premenarchal children may have an increased risk of failure compared with older children.
Today, the indications generally suggested are as follows:
A Cobb angle between 25–45 degrees
A visible progression of 5 degrees observed during the previous 6 months
At least 1 year of growth remaining
Risser sign, 0–3.
Effectiveness depends on compliance; full parental support and cooperation with the orthopedic surgeon, the physiotherapist, and the orthotist is essential. A sufficient number of cases must be treated annually to obtain optimum results. Many new non-rigid braces have entered the market place but the results are no more or less encouraging at this stage than the more traditional rigid braces.
Results of brace treatment
Brace treatment should prevent further progression of the curvature. Usually an improvement of 10–20% is reported. In rare cases the curvatures are almost completely corrected. The Boston brace is more successful than the Milwaukee brace.
The best results are obtained when the initial correction of the scoliosis in the brace is at least 50%. The poorest results are obtained when there is a hypokyphosis of the thoracic area of less than 20 degrees. The brace must be used for at least 20h a day. It is taken off for sporting activities. Brace treatment must continue until skeletal maturity is reached (Risser 4).
Weaning from the brace treatment must be carried out slowly over a period of 4–6 months. A slow correction loss is often seen after cessation of treatment. The end result is usually a few degrees less than the degree of the scoliosis seen before the start of the treatment. The maximal correction loss is observed within 2 years of the end of the weaning. A follow-up of 2 years has been found to be enough to predict failure.
The failure rates ranges up to 30%. The reasons for these variations are mainly different indications for bracing.
Conclusion
Brace treatment of idiopathic scoliosis may influence the natural history in some individuals and may reduce the number of patients requiring surgical treatment. Close monitoring is required.
