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Retrospective cohort study.
To determine which of TLSO, Charleston, or Milwaukee bracing best prevents curve progression and surgery in adolescent idiopathic scoliosis.
Bracing has been shown to prevent curve progression in idiopathic scoliosis, when compared with no treatment. However, there is little literature available comparing the effectiveness of different brace designs.
One hundred seventy patients who completed brace treatment for adolescent idiopathic scoliosis between 1988 and 1995 were studied. Forty-five thoracolumbosacral orthoses, 95 Charleston braces, and 35 Milwaukee braces were used. Thoracolumbosacral orthoses and Charleston braces were used on comparable curves, whereas Milwaukee braces were used in a subgroup in which the other brace designs were considered inappropriate. Evaluated were the absolute increase in curve severity, the percentage of curves that progressed beyond 6 degrees and 10 degrees thresholds, and the percentage of patients who underwent surgery.
Age, Risser stage, curve size, and time braced and observed did not differ among groups. Mean progression of the curve during bracing was 1.1 degrees with thoracolumbosacral orthosis, 6.5 degrees with the Charleston brace, and 6.3 degrees with the Milwaukee brace (P = 0.012; analysis of variance). Proportion of patients with more than 10 degrees of curve progression was 14% with thoracolumbosacral orthosis, 28% with the Charleston brace, and 43% with the Milwaukee brace (P = 0.017; chi-square). The proportion of patients who underwent surgery was 18% with thoracolumbosacral orthosis, 31% with the Charleston brace, and 23% with the Milwaukee brace (P = 0.26; chi-square).
The thoracolumbosacral orthosis was superior at preventing curve progression in adolescent idiopathic scoliosis.
Prospective study.
To document immediate and late changes in shape and balance of the thoracic and lumbar spine and lower rib cage on the frontal plane induced by treatment with a thoracolumbosacral orthosis (TLSO).
The effect of TLSO on lateral plane of spinal deformity, frontal lower rib cage, trunk balance, and natural history are poorly understood.
Twenty-four female adolescents with major thoracic and/or lumbar scoliosis, averaging 30 degrees and 26 degrees, respectively, were treated with a full-time TLSO program. Scoliosis, kyphosis, convex, and concave rib-vertebral angles T7 to T12, frontal trunk balance, frontal vertebral inclination, rotation and translation from T7 to L4-vertebrae were measured before bracing, 1 month after bracing, and biannually thereafter in brace and without brace for a 4-year period and reevaluated at the age of 20 years, at an average of 3.5 years after termination of bracing to measure any permanent changes.
Thoracolumbosacral orthosis treatment corrected both thoracic and lumbar scoliosis and reduced lateral trunk shift at the expense of significant, although temporary reduced physiological thoracic kyphosis, increased lateral displacement of T7 to T10, increased frontal inclination of L2 to L4, and elevation of the apical concave rib in favor of reduction of lateral displacement of T11 to L4; decreased frontal inclination of T7, T9, and T11; and derotated L1 and L2 and thoracic apical vertebra without affecting drooping of the 7th to 12th ribs. In this series, there was marked inconsistency in the obtained changes in several of the roentgenographic parameters in the different evaluations, which is probably because of the empiric application of the TLSO during different periods of treatment. 3.5 years after termination of TLSO-wearing, all roentgenographic parameters remained to the prebrace values.
Thoracolumbosacral orthosis program maintained the measured roentgenographic parameters at the prebrace levels in progressive adolescent idiopathic scoliosis, but it had no effect on the droop of the seven lower ribs. The TLSO treatment stopped progression of scoliosis and reduced the number of patients requiring surgery. Thus, it changed the natural history of scoliosis.
In a prospective study by the Scoliosis Research Society, 286 girls who had adolescent idiopathic scoliosis, a thoracic or thoracolumbar curve of 25 to 35 degrees, and a mean age of twelve years and seven months (range, ten to fifteen years) were followed to determine the effect of treatment with observation only (129 patients), an underarm plastic brace (111 patients), and nighttime surface electrical stimulation (forty-six patients). Thirty- nine patients were lost to follow-up, leaving 247 (86 per cent) who were followed until maturity or who were dropped from the study because of failure of the assigned treatment. The end point of failure of treatment was defined as an increase in the curve of at least 6 degrees, from the time of the first roentgenogram, on two consecutive roentgenograms. As determined with use of this end point, treatment with a brace failed in seventeen of the 111 patients; observation only, in fifty-eight of the 129 patients; and electrical stimulation, in twenty-two of the forty-six patients. According to survivorship analysis, treatment with a brace was associated with a success rate of 74 per cent (95 per cent confidence interval, 52 to 84) at four years; observation only, with a success rate of 34 per cent (95 per cent confidence interval, 16 to 49); and electrical stimulation, with a success rate of 33 per cent (95 per cent confidence interval, 12 to 60). The thirty- nine patients who were lost to follow-up were included in the survivorship analysis for the time-period that they were in the study. Treatment with a brace was successful (p < 0.0001) in preventing 6 degrees of increase or more until the patients were sixteen years old. Even a worst-case analysis, in which the twenty-three patients who were dropped from the study after management with a brace were considered to have had failed treatment, showed that the brace prevented progression and that this effect was significant (p = 0.0005). There was no difference in the degree of increase in the curve between the patients who were managed with observation only and those who were managed with electrical stimulation.
A pilot study of ten individuals with adolescent-onset idiopathic scoliosis demonstrated that a week of Cotrel traction and exercises did not improve curve correction obtained by the application of an elongation, derotation, flexion (EDF) cast. There was, however, a significant improvement on lateral bending correction during this period. A prospective, randomized, controlled clinical trial showed that the exercise programme and not the traction was responsible for rendering the spine less rigid.
Forty-four patients with fifty-five scoliotic curves were studied to determine the efficacy of part-time bracing. All patients were skeletally immature at the initiation of treatment with the brace. All but one of the patients had a curve of at least 25 degrees that had shown 5 degrees of documented progression. Each patient wore the brace for sixteen hours a day, most patients preferring not to wear it during school hours. The patients all completed the course of treatment. Because of the margin of error in radiographic measurements, a change in the magnitude of the curve of 5 degrees or more was considered significant. Twenty-five patients, with twenty-seven curves, showed a change of less than 5 degrees from the initiation of brace treatment to final follow-up. The other nineteen patients (twenty-eight curves) showed a change of more than 5 degrees in at least one of the curves, with four of them showing worsening and the other fifteen showing improvement.
We reviewed the cases of 727 patients with idiopathic scoliosis in whom the initial curve measured from 5 to 29 degrees. The patients were followed either to the end of skeletal growth or until the curve progressed. One hundred and sixty-nine patients (23.2 per cent) showed progression of the curve. The incidence of curve progression was found to be related to the pattern and magnitude of the curve, the patient's age at presentation, the Risser sign, and the patient's menarchal status. We found no correlation between progression of the curve and the patient's sex, Harrington factor, rotational prominence, family history, or radiographic measurements. A progression factor was calculated using the three strongest correlations available at initial examination: the magnitude of the curve, the Risser sign, and the patient's chronological age. A graph and nomogram are presented that can serve as a guide for advising patients' families and for planning continuing care.
In a prospective study by the Scoliosis Research Society, 286 girls who had adolescent idiopathic scoliosis, a thoracic or thoracolumbar curve of 25 to 35 degrees, and a mean age of twelve years and seven months (range, ten to fifteen years) were followed to determine the effect of treatment with observation only (129 patients), an underarm plastic brace (111 patients), and nighttime surface electrical stimulation (forty-six patients). Thirty-nine patients were lost to follow-up, leaving 247 (86 per cent) who were followed until maturity or who were dropped from the study because of failure of the assigned treatment. The end point of failure of treatment was defined as an increase in the curve of at least 6 degrees, from the time of the first roentgenogram, on two consecutive roentgenograms. As determined with use of this end point, treatment with a brace failed in seventeen of the 111 patients; observation only, in fifty-eight of the 129 patients; and electrical stimulation, in twenty-two of the forty-six patients. According to survivorship analysis, treatment with a brace was associated with a success rate of 74 per cent (95 per cent confidence interval, 52 to 84) at four years; observation only, with a success rate of 34 per cent (95 per cent confidence interval, 16 to 49); and electrical stimulation, with a success rate of 33 per cent (95 per cent confidence interval, 12 to 60).(ABSTRACT TRUNCATED AT 250 WORDS)
We reviewed the medical records and roentgenograms of 1020 patients who had been managed for adolescent idiopathic scoliosis, between January 1954 and December 1979, with a Milwaukee brace; we wished to determine whether use of the brace had effectively altered the natural history of the disease. The findings were considered with respect to a previous study of 727 children who had had comparable curves and had not initially been managed with the brace but had been followed for progression of the curve, during the same time-span as that in the current study. Of those 727 patients, 558 (77 percent) had no progression of the curve. The average age of the 1020 patients at the time that treatment with the brace was begun was thirteen and one-half years (range, ten to seventeen years). None of the patients had received any other treatment, and all had been managed only by the physicians participating in this study. In both the current and the earlier series, the outcome was considered a failure if the curve had increased 5 degrees or more; in the patients in the current study, who were managed with the brace, the outcome was also considered a failure if operative intervention had been needed. Of the 1020 patients in the current series, 229 (22 percent) had operative intervention; this rate was higher in the patients who had a curve of more than 30 degrees at the time of bracing and in those who had a Risser sign of 0 or 1. The 791 remaining patients, who were managed with the brace only, had a mild improvement of 1 to 4 degrees at the time that use of the brace was discontinued (the difference being within the margin of error of measurement). With respect to curves of between 20 and 39 degrees, the rate of failure was lower in the current series of patients who had been managed with the brace than in the earlier series of patients who had not been thus managed but had been followed for progression. Progression of the curve was found to be related to the pattern and magnitude of the curve; the age of the patient at the time of presentation; the Risser sign; and, in girls, the menarchal status. We recommend that immature adolescents who have a curve of more than 25 degrees and a Risser sign of 0 be managed with a brace immediately, rather than after progression has been documented.
Three-dimensional reconstructions of the spine and rib cage were done and compared just before and 1 month after initiation of treatment with a Boston brace in a group of adolescents with idiopathic scoliosis.
To document the immediate changes in shape of the thoracic spine and rib cage induced by the original Boston brace design.
The effect of the Boston brace has been well documented in the frontal plane but is poorly understood in the other planes of deformity.
Three-dimensional reconstructions were obtained with and without the brace using a stereoradiographic technique in a group of 40 adolescents with idiopathic scoliosis. Several geometric indices of the spine and rib cage were compared using Student t tests.
The brace produced significant curve correction of the spinal deformity in the frontal plane at the expense of a significant reduction of thoracic kyphosis in the sagittal plane, as well as in the plane of minimum deformity. No significant effect on rotation of the thoracic apical vertebra, on the rib hump, or on frontal balance could be documented, but changes were noted in the sagittal orientation of the rib cage and in the sagittal balance of the spine.
The original Boston brace does not completely correct the three-dimensional deformities associated with thoracic idiopathic scoliosis, although it reduces Cobb angles in the frontal plane.
With use of data culled from twenty studies, members of the Prevalence and Natural History Committee of the Scoliosis Research Society conducted a meta-analysis of 1910 patients who had been managed with bracing (1459 patients), lateral electrical surface stimulation (322 patients), or observation (129 patients) because of idiopathic scoliosis. Three variables - the type of treatment, the level of maturity, and the criterion for failure - were analyzed to determine which had the greatest impact on the outcome. We also examined the effect of the type of brace that was used and the duration of bracing on the success of treatment. The number of failures of treatment in each study was determined by calculating the total number of patients who had unacceptable progression of the curve (as defined in the study), who could not comply with or tolerate treatment, or who had an operation. The percentage of patients who completed a given course of treatment without failure, adjusted for the sample sizes of the studies in which that treatment was used, yielded the weighted mean proportion of success for that treatment. The weighted mean proportion of success was 0.39 for lateral electrical surface stimulation, 0.49 for observation only, 0.60 for bracing for eight hours per day, 0.62 for bracing for sixteen hours per day, and 0.93 for bracing for twenty-three hours per day. The twenty-three-hour regimens were significantly more successful than any other treatment (p < 0.0001). The difference between the eight and sixteen-hour regimens was not significant, with the numbers available. Although lateral electrical surface stimulation was associated with a lower weighted mean proportion of success than observation only, the difference was not significant, with the numbers available. This meta-analysis demonstrates the effectiveness of bracing for the treatment of idiopathic scoliosis. The weighted mean proportion of success for the six types of braces included in this review was 0.92, with the highest proportion (0.99) achieved with the Milwaukee brace. We found that use of the Milwaukee brace or another thoracolumbosacral orthosis for twenty-three hours per day effectively halted progression of the curve. Bracing for eight or sixteen hours per day was found to be significantly less effective than bracing for twenty-three hours per day (p < 0.0001).
We report long-term experience with the Charleston Bending Brace for treatment of adolescent idiopathic scoliosis. This brace holds the patient in maximal side-bending correction and is worn at nighttime only. Patients included in this prospective multicenter study met all of the following criteria: skeletal immaturity (Risser 0, 1, or 2), curvature >25 degrees before bracing, no prior treatment, and >1-year follow-up since completion of bracing (skeletal maturity or progression to surgery). All curves were monitored and reported. There were 149 structural curves in 98 patients. Sixty-five (66%) patients showed improvement or <5 degrees change in curvature. Seventeen (17%) patients progressed to the point of requiring surgery for their scoliosis. Based on these long-term results and improvement of the natural history of adolescent idiopathic scoliosis, continued use of the Charleston Bending Brace is justified.
Retrospective review of a defined Marfan population with traditional indications for bracing.
To determine the success rate of brace treatment in keeping curves from progressing by more than 5 degrees or exceeding 45 degrees.
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.
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.
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.
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.
Retrospective analysis of outcome in terms of incidence of surgery for adolescent idiopathic scoliosis during a period when bracing was not practiced.
To determine whether centers with an active bracing policy have lower numbers undergoing surgery for adolescent idiopathic scoliosis than a center where nonintervention is the practice.
Two major recent publications have claimed that bracing significantly improves the outcome in adolescent idiopathic scoliosis. However, one had no control subjects and the other did not examine the final status of the subjects under review. While statistically significant differences in progression have been observed, what will convince patients to submit to an onerous treatment is the conviction that it will make a substantial difference, such as the avoidance of surgery.
Since 1991, bracing has not been recommended for children with adolescent idiopathic scoliosis at this center. The scoliosis database was searched for patients with adolescent idiopathic scoliosis who were at least 15 years of age at last review and who had adequate documentation of curve parameters. The incidence of surgery was compared with that of published data from other centers.
A total of 153 children, 11 boys and 142 girls, fitted the criteria. Forty-three of these (28.1%) have undergone surgery. This was not statistically different from the surgery rate reported from an active bracing center.
If bracing does not reduce the proportion of children with adolescent idiopathic scoliosis who require surgery for cosmetic improvement of their deformity, it cannot be said to provide a meaningful advantage to the patient or the community. Recent studies notwithstanding, the question of the efficacy of orthoses in idiopathic scoliosis remains unresolved.
A review of a clinical series was performed.
To assess the effectiveness of orthotic treatment in male patients with idiopathic scoliosis and to compare with published data on female patients.
Although males have been included in bracing studies, the number of males has been small, and there have been no studies of exclusively male braced patients.
The medical records of 112 males with idiopathic scoliosis age > or =10 years who were prescribed orthoses were reviewed to confirm idiopathic etiology, determine the brace prescribed, and estimate compliance. Cobb angles and Risser signs were measured from radiographs at presentation, brace prescription, brace discontinuation, and final follow-up. Progression was defined as an increase in curve magnitude of 6 degrees. Surgical progression was defined as progression to 50 degrees and/or arthrodesis. The average age at brace prescription was 13.9 years, and 66% were Risser 0. Duration of treatment averaged 3.1 years. Curve magnitude at brace prescription averaged 33.1 degrees. The patients were observed an average of 1.2 years after the brace was discontinued.
Progression of 6 degrees occurred in 74% of boys, and 46% reached surgical thresholds. Curve progression was related to immature Risser status but not to age or curve magnitude. Progression to surgery was related to immature Risser status and initial curve magnitude. Curves measuring > or =30 degrees progressed to surgical magnitudes in >50% of patients. Compliance was good in only 38% of patients.
Bracing of male patients with idiopathic scoliosis is ineffective. Curves measuring > or =30 degrees are very likely to progress to surgery, especially in immature patients.
Since 1986, the authors have been conducting conservative treatment for idiopathic scoliosis with the combination of brace treatment and physical treatment (side shift exercise and hitch exercise). A total of 328 female patients with adolescent idiopathic scoliosis who were at least 10 years of age at the first visit, with Cobb angle of 10 degrees at the minimum and followed until after 15 years of age or skeletal maturity were included. The average Cobb angle was 32.4 degrees and the average age was 13.8 years at the first visit. Surgery was recommended when curvature progressed to >50 degrees. Twenty of 328 patients (6.1%) with more severe curves to begin with (mean Cobb angle at admission of 48.5 +/- 9.3 degrees ) progressed to 62.2 +/- 8.5 degrees and were treated with spinal fusion by the age of 16.0 +/- 2.6 years. The remaining 308 patients, of comparable age at inception of treatment but with a smaller original mean Cobb angle (32.4 +/- 11.1 degrees ), showed no significant increase in magnitude of curvature (mean 33.6 +/- 11.5 degrees ) by the time of discharge (18.6 +/- 3.1 years). The fact that curvature magnitude was maintained at <35 degrees means that these patients will have a good prognosis for avoiding dramatic progression during adulthood.
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