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Observation with a 100% chance of progression to >50° deformity
2%
63/2606
Rigid TLSO for 2 hours/day with a 75% decrease in the need for surgery
1%
24/2606
Rigid TLSO for 13 hours/day with a 50% decrease in the need for surgery
86%
2244/2606
Rigid TLSO for 24 hours/day with a 100% decrease in the need for surgery
7%
194/2606
Posterior spinal fusion
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In a skeletally immature patient with a curve between 25-45°, rigid bracing of at least 12.9 hours/day decreases the need for surgery by 50%. Adolescent idiopathic scoliosis (AIS) can be effectively treated with bracing. Indications for bracing include skeletally immature patients with flexible curves measuring >25° and <45°. Various brace designs exist but there is no substantial evidence that one type of brace is more effective than another. However, compliant brace wear of at least 12.9 hours in these patients has been shown to decrease the risk of progression and allow patients to reach skeletal maturity with a curve <50°. Compliance can be improved with frequent office visits and patient/family education. Weinstein et al. conducted a multi-center trial studying both a randomized arm and a reference arm in regards to bracing versus observation. They found that 72% of curves treated with bracing were kept from progressing compared to 48% of curves treated with observation alone. The trial was stopped early due to the efficacy of bracing. They concluded that bracing is an effective treatment for AIS in skeletally immature patients if compliance of at least 12.9 hours of daily brace wear is achieved. Gomez et al. reviewed the nonsurgical management of AIS including the various bracing options and the Schroth method of daily exercise and postural control to limit curve progression. They state that effective nonoperative treatment of AIS relies on a working relationship between all team members and the family, a knowledge of the biomechanics of the curve, and compliance with treatment principles. Figure A shows a 32° curve in a skeletally immature (Risser 2) patient. Incorrect Answers: Answer 1: Observation would not be indicated due to a higher likelihood of curve progression and the need for surgical stabilization. Answer 2: Compliance of at least 12.9 hours/day is needed to achieve the maximal benefit of bracing and to decrease the need for surgery. Answer 4: Even with 24-hour bracing, this curve could progress to >50° and require a posterior spinal fusion. Answer 5: Posterior spinal fusion would be too aggressive in this patient, given that she may never reach a 50° curve with appropriate bracing.
3.4
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