1. . Metropolitan Hospital

2. Without intervention, a curve is likely to progressbetween the time of detection and the time ofskeletal maturity 3. The risk of progression increases as the degree ofcurvature increases increases with the magnitude ofthe curve at the time ofdetection decreases with increased ageat the time of detectionYounger girls (ten, eleven, or twelve years old) who had a curve of at least30o at the time of detection had the highest likelihood of progression,ranging from 90% to 100%.Nachemson et al, 1982 4. Curves that are 20oor less before the timeof skeletal maturityare considered mildand generally arere-evaluatedevery six months. 5. Curves that progress 5o to 10o in6 months that are more than30o at the time ofdiagnosisusually are treatedwith a brace, asearly and intensivebracing is believedto preclude the needfor an operation inmost instances. 6. Ideally, bracesshould be prescribedto patients withidiopathic scoliosiswith curves between30o and 40o, or withcurves less than 30owho have a historyof curve progressionwith a high risk forcontinuedprogressionEdgar et al, JBJS, 1985Kehl et al , Clin Orth, 1988Lonstien et al. JBJS(Am), 1994Nachemson et all, JBKS(Am), 1995 7. 1894DARK AGES 8. MANY TYPESOF BRACESMilwaukeeBostonStagnaraChenneauCharlestonMichelLyoneseDDBEtc. 9. 21 EXPERTS19 TLSO2 MILWAUKEE 10. Combination ofpressures applied tothe torsoover a prolongedperiod, bracetreatment attempts tomodify mechanicallythe scoliotic spinemorphologyand to controlprogression of spinalcurvaturePeterson et al, JBJS, 1995 11. The degree of spinalcorrection is related tomany parameters suchas The flexibility of the spinalcurves The shape and stiffnessof the brace shell The location, size andthickness of brace parts The strap tensionadjustment The biomechanicalproperties of truncaltissues to transmit thebrace forces to the spine The duration of braceforces applied on the torso 12. Pressuredistribution andforces generated bybraces on thescoliotic deformitieswere measured tocharacterizebracingbiomechanicalaction on the torso 13. A flexible tissue matrixwas developed,composed of thincircular sensors thatmeasure thepressures generatedat the entire skin-braceinterface.It was suggested that Boston brace action is limited mainly to specificregions of pressure 14. Measuring mean braceforces exerted locallyby the brace foundthat correction ofcurves was not solelydepended on the levelof force applied bythe braceThe patients with thegreatest curvesachieved littlecorrection despitesignificant levels ofapplied forceChase et al, Spine 1989 15. Measurement of magnitude, location and direction of pressuresgenerated by the braceand the forces present in thestraps while the pts assumeddifferent positions,proved that :posterior thoracic padsprovided scoliotic correctionand derotation and that braceinterface pressure werepresent in all positions. 16. Low strap forces hadscoliotic curves thatprogressed while in thebrace, whereas thosewith high strap forceshad a reduction incurvature.It was concluded thatalthough high strap forcesare necessary to ensurelateral and derotationalforces on the spine theyalso cause undesirableforces that inducelordosis. 17. An increase instrap tensionby 50%resulted in anincrease of 20%in the meanforce exertedthrough thecompressionpads 18. Therefore it would seem thatthe effectiveness of thebrace depends to a certainextend on how tightly it isadjusted and fastenedCurrently, there is nostandardized straptension at which the braceshould be fastened to obtainoptimal results 19. A great deal ofvariability in thestrap tension alsowas found thepatients weretaking differentpositionsregardless of howtightly the strapswere originallyfastened 20. Even when thepatients returned inthe standing positionafter havingperformed other tasksthese were alsosignificant decreasesin strap tension 21. Several authorsbelieve that theHeuter-Volkmannprinciple contributesto the developmentof adolescentidiopathic scoliosis(A.I.S.)Machida et al, Spione, 1999Dickson et al, JBJS, 1984Stokes et al, Spine, 1996 22. Briefly stated,asymmetricloading orcompression ofthe growth plateson the concaveside of the curvesinhibit growthleading towedging of thevertebral bodies 23. Bracing a scolioticcurve should, intheory, unload thegrowth plates on theconcave side of thevertebral bodiesnear the curvesapex 24. Growth stimulationleading to structuralremodelingof the vertebral bodies,on the curves concaveside may explain theimprovementor lack of curveprogression,as measured by Cobbangles, reported withsuccessful bracemanagement of A.I.S. 25. Evidencedemonstratingthe biomechanicaleffects of the Hueter-Volkmann on thevertebral body growth inspinal deformitiesis lackingThe threshold and limitof the force magnitudesnecessary for theHueter-Volkmannprinciple to apply inA.I.S. have not beendelineated 26. Frank et al Spine Journal, 2003The purpose of thisinvestigation was todetermine whetherlong-term bracetreatment stimulatedasymmetricchondrogenesis in theapical three vertebrae 27. Curve flexibility is animportant predictorof successful braceoutcome. 28. Brace applicationwas a successfultreatment whenthe initialvertebral bodyderotations weremaintained untilskeletal maturity 29. The efficacy ofbrace treatmentin patients withrigid curves wasstronglyquestioned 30. The Prevalence andNatural HistoryCommittee of theScoliosis ResearchSociety decided tocompare, with use ofmeta-analysis, theresults of non-operativetreatment ofidiopathic scoliosis 31. The type of bracehad a significanteffect on theoutcomealthough this effectwas small comparedwith the effects ofother variables 32. The daily duration forwhich the brace wasworn also had asignificant effect on theoutcome 33. Bracing for twenty-threehours per daywas associated withthe highest rates ofsuccess 34. The goal of brace treatment is toprevent progression of thescoliosis by:1. Correcting the lateral curve2. Correcting the malrotation3. Returning the torso to a balancedposition over the sacrum4. Properly aligning the spine in the sagittalplane 35. Lumbar Pad Trochanter PadA trochanter pad isused to correct a stifflumbo-sacral curve andto act as a lever arm forthe lumbar pad and/orthe axilla extension.It is usually placed onthe same side that L5tilts toward.The length and position of the lumbar pressure pad is determined by applyingpressure to the paraspinal muscle at the level of the lumbar apex of the curve andevery vertebral body with a segmental vertrebral tilt towards the curve.Added length must be estimated for patients with increased lumbar lordosis as thisresults in an apparently shorter lumbar spine.If L4 and L5 are to be included in the lumbar pad, the pad thickness should betapered in this area so that a bridging effect between the gluteus and the upperlumbar region do not occur 36. Thoracic PadThe length and position of the thoracicpressure pad is determined from theribs which project downward from thethoracic curve.The pad is positioned from the mid-illiaccrest roll level and extends superiorly toinclude the rib of the apex vertebra.The pad should not extend above therib of the apex vertebra.The thickness of the pad should notextend to the posterior verticaltrim line to avoid worsening thoracichypokyphosis.The thickness of the thoracic pressurepad is determined by the severity of thethoracic curve and the extent to which thethorax is displaced from the center line.The pad should provide superior medial liftto the ribs under the apex, thus the pad isthicker at the bottom than at the top (atriangle in cross section). 37. Derotation PadAxial rotation is most efficiently corrected by using forcecouples, that is using a pair of forces directed in oppositedirections working on opposite sides of the axismajority of derotational corrective forces are built-in tothe brace.Anterior LumbarDerotation PadJust as the lateral forces require a relief areaopposite the correcting force, rotationalforces require an area of relief so that thespine can migrate axially to derotate.These relief areas can be created by anadjacent pad which draws the brace awayfrom the body as seen anteriorly or bybending the brace away from the body asseen posteriorly on the right 38. ASIS Derotation PadIn order to keep the brace from twisting on thepelvis, pads may be needed, in a force-couplearrangement,opposite to the ones used forderotation of the lumbar spine.This can be accomplished by a pad anterior to theASIS on one side and by bending inward thelower margin of the module posteriorlyBecause the ribs slope downward from back tofront, the anterior thoracic derotation pad will beinferior to the posterior derotation pad on thethorax to give the appropriate force.Thoracic posterior derotational pads are notrecommended in patients who present with ahypo-kyphotic or lordoticthoracic spine.Anterior Thoracic Derotation Pad 39.