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      Retrospective analysis of immediate in-brace correction of scoliosis attainable in patients with AIS: a SOSORT initiative

      abstract
      1 , , 2 , 3 , 1 , 1 , 1 , 1 , 2
      Scoliosis
      BioMed Central
      9th International Conference on Conservative Management of Spinal Deformities - SOSORT 2012 Annual Meeting
      10-12 May 2012

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          Abstract

          Background The effectiveness of bracing in AIS has been debated for years, and there are few studies that can provide a clear picture of how a brace influences curve magnitude, rate of progression, or reduction in surgery. A 2007 review article found no clear advantage to bracing, over observation, in reducing the need for surgery [1]. However, the article highlighted the lack of uniformity in the studies it reviewed, and the high variability in the outcomes that it pooled. A 2010 Cochrane Systematic Review also found that there was only low-quality evidence in favor of using braces [2]. One must first be able to distinguish effective from ineffective bracing, as there is no reason to evaluate the outcome of ineffective braces. A standard must be set as to the amount of immediate curve correction that a brace should deliver, before any brace treatment is labeled as effective or ineffective. Other authors have outlined the appropriate criteria for evaluating brace effectiveness, but have not included immediate in-brace correction of the curve in their list of outcome measures [3]. This study was developed as a SOSORT board initiative, and will attempt to develop that standard. Aim The aim of this study is to evaluate the radiographs of patients who have just had a brace applied, and to determine the amount of correction that is routinely achieved. Methods For this study, a group of European physicians, skilled at scoliosis bracing, were recruited to submit sequential pre- and post-bracing radiographs of their patients for a specified period of time. American physicians, experienced in scoliosis evaluation, measured the Cobb angles in the two sets of radiographs. The percent correction was calculated using these two measurements. Results The results were stratified according to age, gender, initial curve magnitude, and brace type. Average curve corrections were calculated for each group. Conclusions Although there is variation among the subgroups evaluated, an effective brace should be able to achieve 50% correction of the curve magnitude, immediately after application. Research that includes patients whose curves has significantly less than 50% correction in-brace are not studies of “effective” bracing.

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          Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management.

          Literature review. To establish consistent parameters for future adolescent idiopathic scoliosis bracing studies so that valid and reliable comparisons can be made. Current bracing literature lacks consistency for both inclusion criteria and the definitions of brace effectiveness. A total of 32 brace treatment studies and the current bracing in adolescent idiopathic scoliosis proposal were analyzed to: (1) determine inclusion criteria that will best identify those patients most at risk for progression, (2) determine the most appropriate definitions for bracing effectiveness, and (3) identify additional variables that would provide valuable information. Early brace studies lacked clarity in their inclusion criteria. In more recent studies, inclusion criteria have narrowed considerably to include primarily those patients most at risk for curve progression who may benefit from the use of a brace. Brace effectiveness was usually defined by various degrees of curve progression at maturity. Less frequently, it was defined by the resultant curve magnitude at maturity, whether or not surgical intervention was needed, or if there was change to another brace. Optimal inclusion criteria for future adolescent idiopathic scoliosis brace studies consist of: age is 10 years or older when brace is prescribed, Risser 0-2, primary curve angles 25 degrees -40 degrees , no prior treatment, and, if female, either premenarchal or less than 1 year postmenarchal. Assessment of brace effectiveness should include: (1) the percentage of patients who have or =6 degrees progression at maturity, (2) the percentage of patients with curves exceeding 45 degrees at maturity and the percentage who have had surgery recommended/undertaken, and (3) 2-year follow-up beyond maturity to determine the percentage of patients who subsequently undergo surgery. All patients, regardless of subjective reports on compliance, should be included in the results (intent to treat). Every study should provide results stratified by curve type and size grouping.
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            Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review.

            : Systematic review of clinical studies. : To develop a pooled estimate of the prevalence of surgery after observation and after brace treatment in patients with adolescent idiopathic scoliosis (AIS). : Critical analysis of the studies evaluating bracing in AIS yields limited evidence concerning the effect of TLSOs on curve progression, rate of surgery, and the burden of suffering associated with AIS. Many patients choose bracing without an evidence-based estimate of their risk of surgery relative to no treatment. Therefore, such an estimate is needed to promote informed decision-making. : Multiple electronic databases were searched using the key words "adolescent idiopathic scoliosis," "observation," "orthotics," "surgery," and "bracing." The search was limited to the English language. Studies were included if observation or a TLSO was evaluated and if the sample closely matched the current indications for bracing (skeletal immaturity, age <15 years, Cobb angle between 20 degrees and 45 degrees ). One reviewer (L.A.D) selected the articles and abstracted the data, including research design, type of brace, minimum follow-up, and surgical rate. Additional data concerning inclusion criteria and risk factors for surgery included gender, Risser, age and Cobb angle at brace initiation, curve type, and dose (hours of recommended brace wear). : Eighteen studies were included (observation = 3, bracing = 15). All were Level III or IV clinical series. Despite some uniformity in surgical indications, the surgical rates were extremely variable, ranging from 1 surgery of 72 patients (1%) to 51 of 120 patients (43%) after bracing, and from 2 surgeries of 15 patients (13%) to 18 of 47 patients (28%) after observation. When pooled, the bracing surgical rate was 23% compared with 22% in the observation group. Pooled estimates for surgical rate by type of brace, curve type, Cobb angle, Risser sign, and dose were also calculated. : Comparing the pooled rates for these two interventions shows no clear advantage of either approach. Based on the evidence presented here, one cannot recommend one approach over the other to prevent the need for surgery in AIS. This recommendation carries a grade of D, indicating that the use of bracing relative to observation is supported by "troublingly inconsistent or inconclusive studies of any level." The decision to brace for AIS is often difficult for clinicians and families. An evidence-based estimate of the risk of surgery will provide additional information to use as they weigh the costs and benefits of bracing.
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              Author and article information

              Conference
              Scoliosis
              Scoliosis
              Scoliosis
              BioMed Central
              1748-7161
              2013
              3 June 2013
              : 8
              : Suppl 1
              : O49
              Affiliations
              [1 ]Rosalind Franklin University, Chicago, IL, USA
              [2 ]Illinois Bone and Joint Institute, Chicago, IL, USA
              [3 ]3T Imaging
              Article
              1748-7161-8-S1-O49
              10.1186/1748-7161-8-S1-O49
              3675390
              5c8553d4-e199-4845-94ee-18e2e61068e1
              Copyright ©2013 Knott et al; licensee BioMed Central Ltd.

              This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

              9th International Conference on Conservative Management of Spinal Deformities - SOSORT 2012 Annual Meeting
              Milan, Italy
              10-12 May 2012
              History
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              Oral Presentation

              Orthopedics
              Orthopedics

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