The treatment of scoliosis is fairly straightforward, as there are only 3 options: observation, bracing and surgery. Observation is best for mild curves that are not progressing, surgery is for severe curves. The question is which curves are treated with a brace. This is not an easy question to answer because there are many factors that are considered in the decision to brace a patient with scoliosis.
A key point to understand about bracing is that its purpose is to prevent further curve progression during a patient’s adolescent growth spurt and avoid surgery. Braces do NOT correct scoliosis. Braces used for scoliosis are not like orthodontic braces that are very effective in correcting crooked teeth. In scoliosis, the best one can hope for is that size of the scoliosis curve remains the same size while the patient completes growth. For example, if a 12 year old girl has a 30 degree scoliosis and is braced, a “successful” outcome after, say, 2 years of bracing is for that patient to have avoided surgery. At age 14 or 15, that curve is very unlikely to be less than 30 degrees. In fact, it is likely that the curve will be somewhere between 30-40 degrees, and this is considered a successful outcome of bracing. The “best case scenario” is for the curve to be 30 degrees after 2 years of bracing, which means there was no progression whatsoever.
Bracing is initiated in “skeletally immature patients” (i.e. those with growth remaining) with curves between 25 and 40 degrees. The upper limit of curve magnitude that is amenable to bracing is about 45 degrees. Patients who have reached skeletal maturity (or are close to it) are not candidates for a brace because these patients have a low risk of progression. Bracing is only considered when substantial spinal growth is anticipated.
There are several methods of assessing skeletal maturity in an adolescent. None of them are perfect, and surgeons frequently use a combination of these parameters to gauge the amount of remaining growth a patient has:
- Menarche – in girls, this is an easy and reliable method of assessing skeletal maturity. Premenarchal girls are skeletally immature and are in the rapid phase of their growth. Skeletal maturity is reached when girls are roughly 18-24 months postmenarchal.
- Looking at various growth plates. Common growth plates to evaluate are the pelvis (Risser sign and triradiate cartilage) fingers (hand xrays) and elbow.
- 3. Peak height velocity – calculated from changes in a patient’s height over time. If 2 measurements (a few months apart) do not show a gain in height, growth is likely to be complete.
- Bone age – determined from hand xrays. Very little growth occurs after a bone age of 13 in a girl, and 15 in a boy.
A common question is whether bracing is effective or not. In some patients, bracing is effective and does halt curve progression. However, some curves continue to progress to the point of needing surgery despite brace treatment. Recent studies have been done on the effectiveness of bracing, but the results will not be known for another few years. At this time, experts do not know for certain how effective brace treatment is, and which patients are most likely to benefit from it. Bracing has been a “standard of care” for decades despite this lack of scientific evidence supporting its use.
If your child is deemed to be a good candidate for a brace, these are the general steps involved in brace treatment:
- Fitting the brace – these braces are called TLSOs, short for Thoraco-Lumbo-Sacral Orthosis. They are custom-fitted, which means the brace is made specifically to fit the contours of your child’s body. You will receive a prescription for the brace, make an appointment with the brace shop and they will make the brace. This process takes 1-2 weeks.
- After your child has worn the brace for 2-3 weeks, you will come in for a visit and get X-rays in the brace. The purpose of this x-ray is to determine whether the brace is doing what it is supposed to be doing: we like to see as much improvement in the size of the curve as possible with the brace on. For flexible curves, this may be as much as 50% improvement, but frequently 25-40% improvement is seen and this is acceptable.
- Increase the number of hours in the brace over the course of a couple of weeks. Goal is to wear the brace for 21 hours a day.
- Patients are encouraged to be active in sports and allowed to be out of the brace if the sport cannot be performed in the brace.
- After the initial xray, the next x-ray will be obtained 6 months later. For the duration of brace treatment, xrays will be obtained about every 6 months to check for any progression of the curve.
Starting brace treatment in an adolescent is a decision that is not entered into lightly. Although bracing is not physically invasive like surgery, it can be psychologically invasive in an adolescent who is in the most psychologically sensitive period of life. There is great variability in adolescents’ response and tolerance of a brace. Some patients do extremely well and are compliant with wearing their brace as prescribed, and the best results are seen in this group of patients. However, brace treatment does not always lead to a successful result, and some patients end up needing surgery despite wearing their brace for an extended period of time. This can be a difficult realization in an adolescent who has been compliant with the brace and still faces the prospect of surgery.
If bracing is initiated, it is important for patients to remain active and participate in sports that they enjoy.