Orthopaedic Surgery Essentials: Spine by Bono Christopher M.;Schoenfeld Andrew J.;

Author:Bono, Christopher M.;Schoenfeld, Andrew J.; [Bono, Christopher M.; Schoenfeld, Andrew J.]
Language: eng
Format: epub
ISBN: 5122318
Publisher: Wolters Kluwer
Published: 2017-09-15T00:00:00+00:00

Figure 22.5 Boston style thoracolumbosacral orthosis for scoliosis management.

Figure 22.6 Milwaukee style cervicothoracolumbosacral orthosis for scoliosis management.

Bracing should be considered for skeletally immature patients with curves that have reached a Cobb angle of 25 degrees or, in some centers, measure 20 degrees and have shown to be progressive. Brace wear is not offered to patients who are skeletally mature because, although, braces prevent progression of scoliosis, they do not correct scoliosis in the mature patient. Several types of braces have been described and prescribed, but the most commonly used current brace is a TLSO with small variations based on their place of origin (Boston, Wilmington, Miami) (Fig. 22.5). This style of brace can prevent progression of curves with an apex below the T7 vertebral level. Curves with a more proximal apex are better managed by a cervicothoracolumbosacral orthosis (CTLSO) like the Milwaukee brace (Fig. 22.6) designed by Walter Blount in 1946. This style of brace is rarely prescribed as compliance is quite poor with modern adolescents. Most comparative studies between full-time bracing and nighttime bracing (Providence, Charleston) have demonstrated inferior results of nighttime bracing, although these studies generally are not high quality investigations.

Newer fabrication methods and materials have led to thinner, more breathable braces that can often be worn under than patient’s clothing. There are many opinions on the prescriptive hours of brace wear that should be encouraged. Data from the BrAIST study exhibit a considerable increase in efficacy with brace wear greater than 13 hours per day. Ideally, a brace is worn as much as possible.

Bracing should be continued until the patient has reached skeletal maturity clinically and radiographically. During treatment with a brace, patients should be evaluated every 4 to 6 months with clinical and radiographic examination. In patients who have curve progression to 50 degrees despite brace wear, surgical stabilization should be considered.

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