POINT: Bracing Is the Proper Choice
Mark A. Erickson, MD

To brace or not to brace” has been a long-standing area of controversy and debate in the field of scoliosis treatment. I believe that orthopaedic surgeons should use the evidence in guiding decision making.

The 1984 landmark manuscript authored by Lonstein and Carlson provides the necessary information on the natural history of scoliosis, finding that 68 percent of curves measuring 20° to 29° progress in patients who are at Risser 0–1. This information creates a clinical indication to define options for managing this daunting expected course in these patients. With these data, the obvious question becomes: Can bracing effectively alter this natural history?

Some recent additions to the literature can help frame this decision. A recently published study conducted by Katz et al supports the efficacy of bracing with Level 2 evidence. This high-quality study revealed a “dose–response” effect of bracing: the more time the patient spends wearing the brace, the lower the risk of curvature progression. According to these data, among patients with curves measuring 20° to 29° who were at Risser 0–1 and who wore the brace more than 12 hours per day, just 8 percent had curve progression.

More recently, Sanders et al presented a follow-up study of this same cohort. Their analysis demonstrated that, to prevent one spinal fusion surgery, the number of patients who needed to be treated with bracing ranged from four (compliant brace wearers) to nine (less compliant brace wearers).

Certainly the quality of brace fabrication and compliance in wearing the brace are variables that are difficult to manage at many institutions. These studies were performed at an institution with a long-standing history and tradition of excellence and consistency in the profession of orthotics. Nonetheless, the evidence is compelling because it shifts the question from “to brace or not to brace?” to “how do we enhance brace wear compliance?”

Indeed, the evidence is strong enough to warrant the exploration of methods to improve compliance and brace construction quality at all institutions providing care for this group of patients. Additionally, some evidence supports improved compliance with different styles of bracing, including nighttime braces (such as the Charleston bending brace) and the SpineCor system (The SpineCorporation, Chesterfield, United Kingdom). More rigorous scientific evaluation is needed in this area to determine if the efficacy is similar with these bracing types, but the outlook appears promising.

The ultimate scientific challenge is whether Level 1 evidence can be generated in this area with a randomized controlled trial. These recent additions to the literature make it difficult to present a clear case for clinical equipoise in this setting. Hence, this remains an ongoing debate in treating adolescent idiopathic scoliosis.

At the end of the day, when a patient who meets these criteria is sitting in front of you with his or her family, asking for your expertise, you have to guide them to the best of your ability. Can the challenges associated with bracing be overcome by the real opportunity to diminish the risk for progression and prevent the need for surgery? At this point, the answer seems obvious: Yes, bracing is the proper choice!

Mark A. Erickson, MD, is an associate professor in the department of orthopaedics at the University of Colorado School of Medicine. He can be reached at mark.erickson@childrenscolorado.org

Disclosure information: Dr. Erickson—no conflicts.

COUNTERPOINT: The Jury Is Still Out!
Stuart L. Weinstein, MD

Over the last 30 years many advances have taken place in the surgical management of adolescent idiopathic scoliosis (AIS) that have made surgery safer, while at the same time improving correction of coronal and sagittal plane deformity. With respect to nonsurgical management, however, little has changed since the time of Hippocrates.

Braces theoretically work by applying distraction and lateral pressure to reduce the spinal deformity until the patient reaches skeletal maturity. The expectation of both the parents and the patient is that the brace will prevent progression of the curve until the risk of progression greatly diminishes.

Many controversies exist with respect to orthotic management of AIS, including the following:

• the type of orthotic
• the duration of wear each day
• adherence to recommended wear regimens by adolescent patients
• interplay among these factors and the variable natural history of the disease

Although many studies on bracing in AIS have been conducted, careful analysis of these studies demonstrates inadequate evidence concerning the effect of bracing on curve progression, rate of surgery, and the burden of suffering associated with AIS. A literature review shows that surgical rates postbracing range from 0 percent to76 percent. A recent evidence-based review showed no difference between AIS patients who wore a brace and those who did not with respect to rates of surgery. Hence, the literature supporting bracing to prevent the need for surgery in these patients is inconclusive and inadequate.

Although the literature and personal experience have led some clinicians to conclude that bracing is a valuable treatment for AIS, they have led others to conclude the opposite. Bracing has remained the standard of care since the introduction of the Milwaukee Brace in the late 1940s, but it has never been subjected to a rigorous evaluation of either its efficacy or its effectiveness.

In addition, the expected benefit of bracing varies greatly within the community of physicians who counsel patients and help them make decisions concerning this treatment option. To answer this important question— Do braces (specifically a thoracolumbosacral orthosis, or TLSO) lower the risk of curve progression in patients with AIS relative to observation alone?—a multicenter, prospective, partially randomized effectiveness clinical trial is in its final stages.

The BrAIST (Bracing in Adolescent Idiopathic Scoliosis Trial) is sponsored by the National Institutes of Health (specifically, the National Institute for Arthritis, Musculoskeletal, and Skin Diseases), the Canadian Institute of Health Research, Shriners Hospital for Children, Children’s Mercy Hospital Kansas City, and the University of Rochester (N.Y.). When complete, the study will not only answer the question of whether braces work in AIS, but also address the best dosing and duration schedule, and the impact of bracing on quality of life, functioning, and psychosocial adjustment among study participants. The trial should be complete in about 18 months.

Stuart B. Weinstein, MD, is the Ignacio V. Ponseti Chair and professor of orthopaedic surgery in the department of orthopaedic surgery at the University of Iowa, and the principal investigator of the BrAIST study. He can be reached at stuart-weinstein@uiowa.edu

Disclosure information: Dr. Weinstein— Wolters Kluwer Health–Lippincott Williams & Wilkins; Journal of Bone and Joint Surgery–American

References

1. Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am 1984;66(7):1061-1071.
2. Katz DE, Herring JA, Browne RH, Kelly DM, Birch JG: Brace wear control of curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg Am 2010;92(6):1343-1352.
3. Sanders JO, Newton PO, Browne RH, Herring JA: Bracing for Idiopathic Scoliosis: How Many Patients Require Treatment to Prevent One Surgery? POSNA award paper, May 2012.