Scoliosis, a condition marked by a spine curvature in the shape of an “S” (sideways) or a “C” (forward and backward), ranges in severity from mild to debilitating, affecting not only posture but sometimes also respiratory function. Children and adolescents who develop scoliosis may be monitored with X-rays to measure the degree of curvature and can be prescribed exercises, encouraged to wear a stiff brace around the torso or even undergo corrective surgery.
In the current issue of the New England Journal of Medicine, Eugene Carragee, MD, a professor of orthopaedic medicine at Stanford, co-authored an editorial titled “Spinal Bracing in Adolescent Idiopathic Scoliosis.” The piece considers whether spinal bracing – previously a problematic form of treatment for post-polio paralysis – is an effective solution for young people with adolescent idiopathic scoliosis (AIS) who have spinal curvature of 50 degree or greater. Carragee and his co-author, Ronald Lehman, MD, professor of orthopaedic surgery and neurological surgery at Walter Reed National Military Medical Center, review a multicenter study from the same NEJM issue measuring the effectiveness of bracing as means of preventing AIS progression.
Carragee and Lehman write that the study authors found bracing for AIS patients to be effective, and that longer times of wearing the brace each day was associated with greater effectiveness. Also noted in the editorial were challenges to the 242-subject study: difficulty with participant enrollment and compliance meant that much of the data was drawn from a non-randomized cohort.
From the editorial:
The decision to commit a12 or 13 year-old to several years of brace wear requires careful consideration of both the benefits and downsides. Although brace-wear in AIS does not have the serious physiological side effects apparent in polio-related scoliosis, it carries financial, emotional and social burdens to consider.
As the authors appropriately point out, 48% of the untreated subjects had a successful outcome, as did 42% of the braced subjects with little to no time in treatment. In retrospect, the bracing indications described are likely too broad, resulting in what may be unnecessary treatment for many patients. We agree with the authors that the equally important finding of this study is that so many growing children with AIS seem to do just fine with no treatment at all; the challenge for the field going forward is to identify those children who are most likely and those who are unlikely to benefit from bracing.