Adolesecent idiopathic Scoliosis Kyphoscoliosis, Spine deformity,

1. Role of Spinal Orthosis in Management of
Adolescent Idiopathic Scoliosis (AIS): Brief Insight
Dr Bhaskar Borgohain. MS. DNB
Faculty I/C Orthopaedics
NEIGRIHMS
Shillong
With contribution from
Balaphrang Marbaniang, NEIGRIHMS

2. BACKGROUND
• Bracing is widely prescribed across the world for AIS
• Blanket bracing is unscientific in AIS
• Current literature lacks consistency for both
inclusion criteria and the definitions of brace
effectiveness
• The decision to brace for AIS is often difficult for
both clinicians and families.
Adolescent Idiopathic Scoliosis (AIS

3. The SPECTRUM OF VIEWS & BELIEFS
•
•
•
•
Brace Definitely Works
Brace or No brace: Doesn‟t Really matter!
Surgery is the gold standard
Surgery is the best conservative approach!
• Efficacy
• Safety issues
• Convenience: Patient acceptance & Satisfaction
Possibly there is a scientific middle path

4. Surgical rates after observation and bracing for AIS :
An Evidence-Based Review.
• One cannot recommend one approach over the other to
prevent the need for surgery
• The use of bracing relative to observation is supported by
"troublingly inconsistent or inconclusive studies of any
level."

5. The aim of this paper
• Sum up current practices
• Brief Insight of AIS Literature
• Evidence : Understand the emerging bottom line
recommendation on evidence base.
• Nihilism of skeptics to cautious expectancy
• Cautious optimism: Growing amount of literature has
tested and endorses conservative treatments for AIS
with brace

6. Definitions
• Infantile scoliosis is classically defined as scoliosis that is first
diagnosed in a child between birth and 3 yrs old: boys > girls
: left> Rt. Curves
• Juvenile scoliosis: classically defined as scoliosis that is first
diagnosed between 4 &10 yrs of age: boys > girls : left> Rt.
Curves
• Idiopathic : Curve between 10 & 18 yrs of age is termed
adolescent scoliosis (AIS)

7. AGE IS IMPORTANT
•
•
•
•
Infantile:
Juvenile:
Adolescent:
Adult:
0-3 years old (0.5%)
4-11 years old (10.5%)
10-18 years old (89%)
>18 years old

8. AIS affects about 2–3% of
adolescent females aged 10-16 yrs.
• 90% are Female
• Body image issues
• Scoliosis is a deformity:
Characteristic lateral
curvature of spine > 10°
• Measured by the Cobb‟s
method on standing
upright spine
radiographs.

9. Cobb‟s method
Upper End Vertebra
End plates
Apical vertebra
Lower End Vertebra

10. The overall goal of Rx:
Prevent the curve from worsening over time.
• The vast majority: Require No Rx other than regular
check-ups: Only curves are monitored.
• Generally, patients are followed every 6 months until
growth is complete.
• In general, bracing is initiated when the curve
measures 200-250 in skeletally immature
• > 50 Curve Progression over 6 months is considered
risk for further progression

11. Risk assessment
• Research shows that once a curve reaches 20-25
degrees, there is a good chance that the curve will
progress during growth
• Therefore, bracing treatment is continued until the
end of growth.

12. Viewed in three dimensions:
Constellation of deformities
• The lateral deviation of the
spine in the frontal plane
• The rotational and
• The rib cage deformity in
the transverse plane and
• Restore the sagittal plane
NASH & MOE
•
•
•
•
Lordosis
Scoliosis
Rotation
Rib cage defects

13. Any conservative management like bracing of
scoliosis should ideally aim at
• correcting all
• Technically
components of the
deformity
simultaneously
• Theoretically possible
challenging
• Practically
cumbersome
• Less predictable cf
modern surgical
corrections

14. The strategy for the treatment :AIS
• Depends essentially : the
magnitude and pattern of the
deformity and
• Its potential for progression.
• To prevent curve progression
during high risk period of
skeletal growth.

15. Treatment options in AIS : 3 „O‟ s
• Observation
• Orthosis &
• Operation
PT is an adjunct
Corrective surgery is
the final common
pathway in cases of
failures
Operation
Orthosis
Observation

16. The 3 O’s of Rx options
ORTHOSIS

17. Principle: Three point fixation
MILWAUKEE BRACE
To prevent curve progression during high risk period of skeletal growth.

18. THE CONTROVERSIES
• Brace is the most
common method to
treat AIS : 250-400
• In common practice
worldwide >30 years
• Several studies
questioned the very role
of brace for controlling
curve
• Evidence level is fair to
poor

19. SURGERY VS ORTHOSIS
Restlessness with tubular vision syndrome !
Balance
Inborn Nihilism in Conservatism
Breathless expectancy

20. Brace related stress & lifestyle issue
• Braces in Adolescent Idiopathic Scoliosis (AIS)
treatment seem to produce stress
• Controversy whether health related quality of
life issues of brace treated adolescents are
affected negatively
• Body image perception issue of mentally &
socially growing adolescent leading to
alterations in lifestyle.

21. VARIABLES
Scoliotic curve is a half known potential enemy
“Change is the only constant”
• Natural history of scoliosis ?
• Depending on Age/sex/growth pattern, curve
type etc
• Evidence alone is not enough
• Level of evidence ?

22. The goal of surgical treatment
Two-fold:
• First: to prevent curve progression &
• Secondly : to obtain some curve correction
• Risks: Yes
• Patient satisfaction: abstract
• Posterior approach is utilized most often and
can be utilized for all curve types

23. SURGEON VS ORTHOTIS
Restlessness with
Tubular vision syndrome !
Over-enthusiastic
Proponent of Brace
EVIDENCE
BASED
MEDICINE
PRAGMATISM
Balance
Inborn Nihilism in Conservatism ?
UNREALISTIC
Breathless expectancy on Braces
UNREALISTIC

24. EXTENT AND SEVERITY ASSESSMENT:
King classification of idiopathic scoliosis
Defines 5 types of idiopathic scoliosis: the severity is based on
· Cobb‟S angle based on x-ray image
· Determined flexibility index based on bending radiographs

25. PRIMARY AND COMPENSATORY SECONDARY CURVE
BALANCED CURVES

26. TYPES OF CURVES
Prognostications
Risk stratification
Objectivity
Implications: Best Rx
Orthosis type & extent

27. During the past decade
• Several studies have
demonstrated the True
natural history of AIS
• Appears: AIS is positively
affected by non-operative
treatment, especially
bracing.
• Physiotherapy, traction
• Muscle stimulations etc
• Various combinations
• Unclear role

28. Indications for brace treatment
• Age: skeletal maturity
• A growing child presenting
with a curve of 25°- 40° or
• A curve <25° but with
documented progression.
• A curve >200 may also
indicate bracing, if 50
progression has been
documented: 6 months
• Girls vs. Boys

29. Natural history : Risk of progression
Data generated by the Scoliosis Research Society, Chicago, Illinois, USA

30. High Risk group identification
Objective: To determine what radiographic or clinical
observations may be predictive of outcome.
• Patients with a double curve with thoracic curve >35 degrees
and the LPR angle is >12 degrees are significantly more likely
to demonstrate curve progression. ( LPR angle : LumbarPelvic Relationship Angle)
• In-brace correction for double curves of at least 25% and a
patient's ability to wear the orthosis >18 hours/day
significantly increased the likelihood of success.
- Katz DE, Durrani AA. Spine. 2001 Nov 1; 26(21):2354-61

31. Contraindications for bracing do exist !
• Child who has completed
growth
• Growing child with a curve
> 45°
• Growing child with < 25°
without documented
progression.
RISSER‟S SIGN

32. Poor compliance to brace wearing is an
important issue
• Linked to failure of braces.
• Brace Duration: 24 Hours !!
• Interestingly the results of 12
hours per day of bracing were
similar to the results of 23
hours per day of bracing.
• Pressure Points/Discomfort
• Boys
• Milwaukee Brace

33. The Boston TLSO
• Fits under the arms and
around the rib cage,
lower back, and hips.
• Four Point Fixation
• Minimum limitations
of activities
• 18-23 hours Wearing
• Maximum Available
studies

34. Milwaukee Brace: Overkill-Obsolete
• Consisting of a Leather
Girdle &
• Neck Ring
• Connected By Metal
Struts: Superstructure
Prolonged use may induce or
complicate malocclusion
unless the teeth and jaws
are supported with
retaining appliances.

35. Wilmington & Rosenberger brace
The Boston brace led to a
series of under-arm
braces that lacked the
metal superstructure of
the Milwaukee,
including
Lyon, Rosenberger,
Wilmington & Miami
braces.
Wilmington
Rosenberger

36. Lyon brace
• Modified braces
• Similar principles
• Better tolerated than
Milwaukee

37. Brace-weaning
• Begins when the patient
reaches skeletal maturity
• Determined as the finding
of a Risser sign of 4
• Risser 4: > 12 months
post-menarche and lack of
growth in height.

38. The main purpose of scoliosis surgery
• Is to fuse the affected bones of curve.
• The fusion keeps the spine straight.

39. Favouring a brace: Evidence ?
• Bracing to slow down
curve progression in
patients with AIS has been
the standard of care in the
United States > 30 years,
• But the treatment‟s
effectiveness remains
unclear !

40. ADVANTAGES & CHALLENGES of Brace
• A scoliosis brace does not have decided mechanical
advantages unlike a dental brace
• But in suitable candidates who are compliant with
optimal brace wearing in a bracing program: the
success rate is in the order of 80 percent in various
reported case series
• So in these patients an operation is potentially
avoided.

41. Widespread General agreements
currently are
• There is no universally accepted standard approach to
bracing for AIS.
• Not all cases of AIS need bracing
• Before bracing: x-ray documented progression of > 5 0 is
recommended
• Skeletally immature patient: Bracing may be purposefully
undertaken with curves 300-400
The reason for this Selective bracing is that 1/3 of AIS curves > 30 degrees
do not progress despite no Rx

42. Literature evidence !
Online survey : July-Nov 2008 to 30 Pediatric spine
surgeons of the Canadian Pediatric Spinal Deformities Study
Group. The response rate was 70% representing 12
Canadian spine centres.
Douglas L Hill, Eric C Parent , Edmond Lou et al: 7th
International Conference on Conservative Management of
Spinal Deformities. Montreal, Canada. May 2010

43. Surgeons had >80% agreement on bracing
• “Only in cases of progressive pre-menarchal females with
25-35 degree curves or
• 250 - 300 curves within 1 year of menarche had >80%
agreement on bracing.
• Detection of curve progression increased the likelihood of
recommending bracing by surgeons for curves < 35
Degrees”
Douglas L Hill, Eric C Parent , Edmond Lou et al

44. Bottom line of this study
“In spite of SRS guidelines and general agreement that
braces are effective, there is little agreement among
surgeons on Protocol or Methodology of treatment
with a brace in AIS.
The likelihood that a girl with AIS will be prescribed a
brace primarily depends on surgeon, brace
prescription patterns, rather than spine curvature.”
Douglas L Hill, Eric C Parent , Edmond Lou et al

45. Patient satisfaction
• Patient satisfaction is an abstract & multidimensional
concept
• Recognized & important component of evidencebased health care.
• Although there have been limited attempts
to develop/use standardized, patient-reported
outcome (PRO) measures

46. MILD CURVE: MORE COUNSELING
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
Kenneth M. C. Cheung, Elaine Y. L. Cheng et al. INTERNATIONAL ORTHOPAEDICS
31(4): 507-511

47. Blanket surgery: Role?
2007
• Nonrandomized prospective comparative cohort of
Operative versus Observational management of AIS
• Scoliosis surgery results in a small increase in spinerelated quality of life at 2 years compared to brace gr.
• This increase is of questionable clinical significance.
• Decisions to operate on adolescents with scoliosis should
acknowledge only modest expectations about short-term
gains in quality of life.
Howard Andrew , Donaldson Sandra Hedden Douglas et al
Spine:2007 32 (24):2715-2718

48. Observation Versus Bracing
2007: Spine
• 16-year follow-up of original SRS brace study /Sweden
• Original study: Brace treatment was superior to electrical
muscle stimulation, as well as observation alone, in the
original study
• 2007: The curves of AIS with a moderate or smaller size at
maturity did not deteriorate beyond their original curve
Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL. Spine . 2007
15;32(20):2198-207.

49. Curve progression was related to
immaturity
• No patients treated primarily with a brace had
surgery, whereas 6 patients (10%) in the
observation group required surgery during
adolescence compared with none after maturity.
• In patients with observation alone as the
intention to treat, 20% were braced during
adolescence due to progression and another 10%
underwent surgery
Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL.
Spine . 2007 15;32(20):2198-207.

50. Observation Versus Bracing: Web based review
2007: Spine
• Multiple electronic databases were searched: limited to the
English language: Eighteen studies were included
(observation = 3, bracing = 15).
• Comparing the pooled rates for these two interventions shows
no clear advantage of either approach.
• An evidence-based estimate of the risk of surgery will
provide additional information to use as Option & weigh the
costs and benefits of bracing.
Dolan Lori A.; Weinstein Stuart L.: Surgical Rates After Observation and Bracing for
Adolescent Idiopathic Scoliosis: An Evidence-Based Review. SPINE 2007 : 32(19)S 91-100

51. Nighttime bracing
• Prospective study: 102 consecutive female patients
• Providence Night Brace
• This is the first report of results of treatment with nighttime
brace made with CAD/CAM technology
• Risser 0, 1, and 2- criteria for inclusion
• High apex curves cephalad to T8 (n=31) success rate of 61%
• Success rate of 79% (n = 71) if the apex was at or below T9.
• Providence brace effective in preventing progression of
AIS for curves <35 degrees. It was effective for larger
curves with a low apex.
D'Amato CR, Griggs S, McCoy B. Spine. 2001: 15;26(18):2006-12.

52. Comparison of Brace versus Surgical Treatment:
2001
• „Radiologic Findings and Curve Progression 22 Years After
Treatment for Adolescent Idiopathic Scoliosis: Comparison of
Brace and Surgical Treatment With Matching Control Group
of Straight Individuals‟
• Although more than 20 years had passed since
completion of the treatment, most of the curves did
not increase. The surgical complication rate was low
• Degenerative disc changes were more common in both
patient groups than in the control group.
Aina J.Danielsson, L. Nachemson, Alf et al Spine 2001: 26(5): 516-525

53. Standardization in study to avoid flaws:
Optimal inclusion criteria
Future AIS brace studies should consist of:
•
•
•
•
Age : 10 years or older when brace is prescribed
Risser 0-2, primary curve angles 25 degrees -40 degrees
No prior treatment &
If female, either premenarchal or < 1 year postmenarche
SRS Committee on Bracing and Non-operative Management. 2005
Richards BS, Bernstein RM, D'Amato CR, Thompson GH. Spine.
2005 5;30(18):2068-77. Review.

54. Assessment of brace effectiveness should
include:
1) The % of patients who have < 50 curve progression and the % of
patients who have > 60 progression at maturity
2) The % of patients with curves > 450 at maturity and the % who have
had surgery recommended or undertaken
3) 2 year follow-up beyond maturity to determine the % of patients
who subsequently undergo surgery.
-All patients, regardless of compliance, should be included in the
results (intent to treat).
-Every study should provide results stratified by curve type and size
grouping
Richards BS, Bernstein RM, D'Amato CR, Thompson GH. Spine. 2005 5;30(18):206877. Review.
SRS Committee on Bracing and Non-operative Management. 2005

55. BrAIST Trial
2009
• Bracing in Adolescent
Idiopathic Scoliosis
Trial (BrAIST),
• One of the first clinical
trials in pediatric
orthopedics
• Funded by the National
Institutes of Health.
• 6 monthly follow up
• Anticipate to discover that
bracing works for certain
types of curves
• Much more selective in
prescribing braces as a
treatment

56. BrAIST Trial: INCLUSION CRITERIA
• Physical & Mental
ability to adhere to
bracing treatment
• BOYS /GIRLS
• Pre/post menarche no
more than one year
• Outcome expected next
year
• Washington University
School of Medicine, St.
Louis, Missouri
• The medical center is one
of 25 sites across the
United States and Canada
participating in the trial

57. SURGEON VS ORTHOTIS
Restlessness with
Tubular vision syndrome !
Over-enthusiastic
Proponent of Brace
EVIDENCE
BASED
MEDICINE
PRAGMATISM
TEAM
Balance
Inborn Nihilism in Conservatism ?
UNREALISTIC
Breathless expectancy on Braces
UNREALISTIC

58. NO EBM: INTUITION
Source: Wheeless' Textbook of Orthopaedics

59. Rx Algorithm

60. Consensus
• Only progressive pre-menarchal females with 25-35 degree
curves or 250 - 3 00 curves within 1 year of menarche had
>80% agreement on bracing.
• Braces in Adolescent Idiopathic Scoliosis (AIS) treatment
seem to produce stress; however there is controversy
whether health related quality of life issues of brace
treated adolescents are affected negatively
Aina J.Danielsson, L. Nachemson, Alf et al. Spine:2007 – 32
(19): S91-S100

61. Surgery
•
•
•
•
Failed bracing
Curves >45 degrees
Unbalanced curves >40 degrees
Surgery is fusion with instrumentation

62. The future of AIS is with EBM
Controversies are Reducing and bottom lines are just
evolving.
More recently, inclusion criteria have narrowed
considerably to include primarily those most at risk
for curve progression
Multi-centric randomized control trails are underway
internationally for identifying Practices based on
EBM
“Medicine is a science of uncertainty & an art of probability”