Introduction

The treatment of any condition should take into account the short- and long-term outcomes as well as the complications of that treatment modality. The three generally accepted treatment options for scoliosis are observation, use of a brace, and surgical stabilization. Others have proposed that treatment modalities such as electrical muscle stimulation, postural exercises, chiropractic manipulation, nutritional supplementation, and magnet therapy have a role in the care of scoliosis, but evidence to support these modalities is lacking. Valid scientific evidence does indicate that bracing and surgery alter the outcome of scoliosis as compared with observation alone; this chapter will focus on these nonoperative modalities of treatment for scoliosis.

Screening

Early detection and school screening programs are widespread in North America. However, although these programs are mandated by many states and deeply rooted in tradition, recent studies have cast some controversy over their effectiveness. The objective of school screening is, ideally, to detect scoliosis in patients for whom brace treatment may alter the course of the disease at an early stage, rather than leave surgery as the only option.2 A valid screening program must have a screening tool that is valid, cost-effective, ethical, and acceptable to the subjects, and which provides a diagnosis of a disease about which there exist knowledge and appropriate treatment interventions.3

Currently, knowledge about scoliosis seems to be well accepted. For example, curve progression is known to be most likely for skeletally immature girls (Risser grades 0 and 1) with curves measuring 30 degrees or more.4 However, there is a paucity of data about small curves, including their progression potential and at what degree they constitute a serious health problem. The screening test used most widely for scoliosis is the Adams forward-bend test, which, when performed properly, is a sensitive method for identifying coronal-plane curvatures with concomitant axial-plane rotation. An inclinometer is frequently used in the forward-bend test to provide some objective measure of the rib prominence. A positive screen is applied to anyone with truncal asymmetry on this test, and such people are referred to a specialist. Vi-viani and colleagues tested the ability of trained nurses in the use of the Adams forward-bend test. They found the overall sensitivity of the test for curves >10 degrees to be 73.9%, the specificity 77.8%, and the positive predictive value 12.4%. The sensitivity for curves >20 degrees was 100%, with a specificity of 91%.5 Beauséjour et al studied a population of patients referred to a Canadian scoliosis clinic in a community without school screening and found that of the 489 suspected cases of AIS, 206 (42%) had no significant deformity (Cobb angle <10 degrees) and could be considered as inappropriate referrals. Among subjects with confirmed AIS, 91 patients (32%) were classified as late referrals with regard to indications for brace treatment.6

Opponents of school screening cite concerns about the low predictive value of screening and the cost-effectiveness of referral. Additional factors are the possibility of unnecessary treatment, including the use of a brace and the effects of exposure to X-radiation during screening and examination. Costs involved in screening for scoliosis are relatively low on a societal level, and may be justified by the avoidance of surgery in some adolescents with scoliosis.7 Patients without significant spinal deformity referred to specialists do not require X-radiography, and for those who do, it is important to note that current radiographic techniques involve significantly less radiation exposure than in the past.

Montgomery and coworkers, in 1993, supported school screening for scoliosis and demonstrated an 8-fold decrease in the relative risk of its progression into the surgical range. The authors concluded that screening decreased the demand for surgery, because smaller curves would be detected and braced at an earlier age, therefore having a better prognosis.8 Conversely, Yawn et al9 concluded that the positive predictive value of routine screening was low. Morais and colleagues10 stated that the prevalence of scoliosis was too low to benefit from screening, and expressed concerns about radiation exposure following clinical screening.

To date, no studies based on level-1 evidence have been done on school screening for scoliosis, and unfortunately, such a study is unlikely to be performed in the future. In addition, there are no studies based on level-1 evidence studies that show effectiveness of bracing. Therefore, the U.S. Preventive Services Task Force has recommended eliminating school screening for scoliosis.7 Definitive conclusions about the effectiveness of screening cannot be reached on the basis of the current body of literature. However, a study reported by Dolan et al in 2007 sought to examine professional opinion about the effectiveness of bracing relative to observation for AIS by polling experienced clinicians.11 Although there was variability of opinion among experts, the overall panel stance was that bracing would decrease the risk of progression in premenarchal patients by 20 to 30%. Thus, it appears that many of those who most commonly treat scoliosis, in addition to the major subspecialty societies, perceive a potential positive effect of bracing.7 Accordingly, it is important to identify patients with scoliosis at an early stage, either to begin bracing within a window of time when it is a viable option, or to allow surgical treatment at an earlier point in cases of severe deformity.

The Use of Bracing

The goal of brace treatment of moderate scoliosis in growing children is to limit its further progression and, ideally, to avoid surgery. Spinal curves of 20 degrees or less before skeletal maturity are considered mild and are re-evaluated at 6-month intervals. Curves that progress by 5 to 10 degrees or curves of 30 degrees at presentation are moderate and are usually recommended for treatment with a brace because early, full-time bracing is considered to prevent curve progression and obviate the need for surgical intervention in most cases. Curves of less than 30 degrees rarely progress after maturity, but larger curves, especially in the thoracolumbar or lumbar region can increase during the life of the patient.12 Fusion with instrumentation is indicated for curves >45 degrees in growing children, for curves >50 degrees at maturity, and for those curves that continue to progress after the cessation of brace treatment.

It is thought that brace correction of spinal curves occurs through molding of the spine, trunk, and rib cage during growth, specifically through the use of transverse forces to correct such curves with endpoint control. The application of transverse force and curve correction has an additive effect in improving critical load and stabilizing a curve.13 Full-time bracing instituted early and with a well-fitting brace may reduce the size of a curve during the treatment period, but this correction rarely persists long after bracing is discontinued at skeletal maturity. The consensus among centers with a long track record of bracing is that the best outcome of bracing is the prevention of further deformity.

The Milwaukee brace was developed by Blount and Moe in the late 1940s as a substitute for postoperative casting in scoliosis and was then adapted for use in the nonoperative treatment of neuromuscular and idiopathic scoliosis. This CTLSO (cervical-thoracic-lumbar-sacral orthosis) consisted of a molded pelvic girdle that was attached to a metal superstructure, which supported lateral pads, trapezial pads, and axillary slings (for curves with an apex above T7). An occipital attachment and throat mold was used to stabilize the head and create traction forces; however, effectiveness of this component was later disproven.14

The Boston brace system was developed at Children’s Hospital, Boston, in the 1970s and consisted of six standard prefabricated polypropylene pelvic and thoracolumbar modules, lined with polyethylene foam. The pelvic module is trimmed on the basis of X-ray findings and) pressure pads are added at the apex of the curve(s).6 Lumbar lordosis is reduced by flexing the lumbar spine. For curves with a high apex, an axillary support can be added on the concave side with lateral pressure from a pad on the convex side. Today the Boston brace is the most commonly used brace for AIS worldwide, with more than 16 prefabricated modules available. Advantages of the Boston brace include its rapid fabrication time, curve correction of 50% in the brace, and better patient acceptance than the Milwaukee brace.15

The Wilmington brace was developed by Bunnell and colleagues at the Alfred I. duPont Hospital for Children in Wilmington, Delaware, also as an alternative to the Milwaukee brace.16 Fashioned from Orthoplast, the total-contact custom jacket of this brace is made from a custom mold of the patient with the patient’s scoliotic curve corrected on a Risser table with transverse, derotation, and traction forces. In the mold, transverse forces are applied at the apices of the curves, spinal balance is sought, and curve correction of 50% is attempted. Trim lines are cut high in the axilla and low over the pelvis, but still allow the patient to sit. An opening is cut in the front of the brace with an overlap that allows the patient to don and doff the brace over a cotton or synthetic-fiber undergarment with Velcro straps. Because of the intimate fit of the brace, convenience of its wear, and thinner material (3.2 mm) of which it is made, its acceptance by patients was superior to that of the Milwaukee brace. The breakdown of the Orthoplast material was, however, seen as a relative disadvantage of the Wilmington brace, although this deterioration of the brace documents compliance in its use. Patients who wear the brace full-time need an average of three fabrications.17

Other TLSO types of braces, constructed from more durable polypropylene include the Miami brace, Rosenberger brace, Providence brace, and Charleston bending brace. The Charleston brace was originally developed as an alternative to full-time brace wear for single thoracolumbar or lumbar curves. During production of this brace the orthotist maintains pressure over the apex of the patient’s scoliotic curve while applying an unbending force above the curve, More than 75% curve correction is considered adequate. The Wilmington brace is intended for night-time wear only because of the awkward positioning of the patient in the brace.