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Medical Museum Home Wall Exhibits Home When the Spine Curves Home The Treatment of Scoliosis Home Forms of Treatment Estimating Progression Observation Bracing Alternatives to Bracing Surgery Untreated Scoliosis Patients The Experience of an Adolescent
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When the Spine Curves: Treatments for Scoliosis
The Treatment of Scoliosis
Bracing
Bracing was first used as an attempt to correct scoliosis in the time of Hippocrates (1 BCE). Throughout history, royalty and members of the wealthy classes used metal corsets to keep deforming curves from progressing. These early braces failed because they merely held the spine in place; no pressure was exerted on the curves of the spine. Today "pressure pads" have become a means for halting scoliotic curves in modern braces.
| Physicians now know more about effective bracing, and have more realistic goals for this treatment. The indications for bracing in adolescent idiopathic scoliosis are lack of skeletal maturity and a curve between thirty and forty degrees. A curve between twenty and thirty degrees can also indicate bracing, if five degrees of progression has been documented.
12. X-ray of a scoliotic spine that requires bracing
Thoracic curve of 31 degrees and lumbar of 38 degrees
1990
Courtesy of Stuart Weinstein, MD,
UIHC Department of Orthopaedics |
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Braces are most effective on curves of 40 degrees or less. Most braces are prescribed and fitted to each patient specifically. Other braces, like the Boston brace, are prefabricated and not custom fitted. However, the pads inside the brace are positioned according to the needs of each patient. Braces may be worn 23 hours or 16 hours a day; some physicians believe 16-hour braces are not effective, but with little evidence supporting the success of bracing, these less intrusive braces remain in use.
13. X-ray of spine while wearing brace
Thoracic curve of 15 degrees and lumbar of 23 degrees
1990
Courtesy of Stuart Weinstein, MD,
UIHC Department of Orthopaedics |
| Braces are used to prevent curve progression and are worn throughout puberty. The patient can stop wearing the brace when her physician determines that her bones have stopped growing. No brace is expected to correct a scoliotic curve, only to prevent progression. The most common result of bracing is halting curve progression. However, some curves continue to progress and may require additional treatment.
A brace's effectiveness depends on several factors. The patient's cooperation and continuous use of the brace is vital to halting curve progression. If the brace is not worn, the patient receives no treatment and the curve may progress to the point of requiring surgery. A brace that has been fitted specifically to the patient is also necessary. An ill-fitting brace will not be effective in preventing a curve from becoming worse.
14. X-ray of spine after bracing
Thoracic curve of 33 degrees and lumbar of 38 degrees
1997
Courtesy of Stuart Weinstein, MD,
UIHC Department of Orthopaedics |
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Braces
| The Milwaukee brace is the model for the underarm braces used by physicians today. It was originally designed by Blount and Schmidt in 1946 for postoperative care when surgery required long periods of postoperative immobilization. The Milwaukee brace consisted of a plaster pelvic girdle that attached to metal rods extending up to the shoulders. Fastened to this metal "superstructure" were pressure pads that applied force to the convex side of each curve. Pads were also placed within the girdle. Part of the brace surrounding the neck attempted to line up the pelvis and the neck bones. The Milwaukee brace was generally worn almost 24 hours a day for one year. With improvement, the patient would then wear the brace on a half-time basis, gradually decreasing the amount of time until the brace was worn only at night. When no improvement was seen after the first year of bracing, a patient continued to wear the brace full-time. These braces were usually worn for years at a time.
The Milwaukee was the most commonly worn brace until the development of the Boston brace in the 1970s. The Boston brace is one of the first underarm braces used for scoliosis treatment. The brace is made from polythene or polypropylene, as opposed to plaster, and can be removed with more ease than the Milwaukee. With a combination of pressure pads and pelvic stabilization, the brace usually prevents curve progression. Like the Milwaukee, the pads in a Boston brace are applied to the convex side of a curve with no pads directly opposed. This, coupled with stabilizing the pelvis, attempts to force the spine toward the "middle line" of the back. |
15. Adolescent wearing a Milwaukee brace
circa 1970
Courtesy of Weinstein, Stuart L., ed. The
Pediatric
Spine: Principles and Practice.
Vol. I. New York:
Raven Press, 1994. |
16. Adolescent wearing Wilmington brace
circa 1980
Courtesy of Weinstein, Stuart L., ed. The Pediatric
Spine: Principles and Practice. Vol. I. New York:
Raven Press, 1994. |
The Boston brace led to a series of underarm braces that lacked the metal superstructure of the Milwaukee, including the Rosenberger, Wilmington and Miami braces. These braces are widely used today and are less obtrusive in appearance. Patients find these braces more appealing because they can be worn under clothing, and patients can participate in sports and other activities with little difficulty. Underarm braces can be used for most types of scoliotic curves, unless the curve is extremely high on the spine.
Some physicians are now prescribing the Charleston bending brace. This brace attempts to halt curve progression by holding the patient in such a position that the spine bends in the direction opposite the curve while sleeping. For example, a patient with a left lumbar major curve would wear a brace that bends toward the right. Because of its bending action, the brace is worn only while sleeping. Since it is worn for only about 8 hours a day, some physicians believe this brace is not as effective as other underarm braces.
Although there is no evidence that exercise increases the effectiveness of bracing, it may be recommended to patients. General fitness is important to maintaining physical and mental health, which may benefit a self-conscious adolescent with scoliosis. |
| Braces cause few complications while being worn. Skin irritation is perhaps the most common problem. Compression of the superior mesenteric artery and sensory nerve compression may occur, but are extremely rare. All of these complications can be prevented with regular brace adjustments and frequent check-ups.
Although bracing is potentially the most effective non-operative treatment, and is widely used around the world, the effectiveness of bracing remains controversial. Some experts maintain that bracing does not improve upon the natural history of the disease, either in its ability to prevent progression or in decreasing the need for surgery. |
17. Adolescent wearing Rosenberger brace
circa 1980
Courtesy of Weinstein, Stuart L., ed. The Pediatric
Spine: Principles and Practice. Vol. II. New York:
Raven Press, 1994. |
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