Adolescent and Adult Spinal Deformity: Nonoperative Management

116 Adolescent and Adult Spinal Deformity: Nonoperative Management

Patrick Thornley MD1 and Colby Oitment MD FRCSC2

1 Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada

2 Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada

Clinical scenario

  • You see an asymptomatic 13‐year‐old Risser 0 female patient in your orthopedic clinic with a first‐time presentation of a right thoracic curve with associated 30° Cobb angle from T7 to L1. She presents with a normal examination and an unremarkable past medical and developmental history.
  • The patient, along with her mother and father, wishes to avoid surgical intervention but worries about the effectiveness of bracing therapy and has read about the negative psychosocial effects of bracing.
  • The patient’s mother is concerned about her daughter becoming short of breath with any type of exertional activity, like her aunt who had untreated scoliosis.
  • The patient’s father asks how you can be certain her current curve will not progress when she is done growing and cause her “problems” as an adult.

Top three questions

  1. In patients with adolescent idiopathic scoliosis (AIS), how does bracing influence health‐related quality of life (HRQoL)?
  2. In patients with AIS, does nonoperative management result in pulmonary compromise in adulthood?
  3. Which risk factors predict patients with adult scoliosis curves will progress and cause low back pain (LBP)?

Question 1: In patients with adolescent idiopathic scoliosis (AIS), how does bracing influence health‐related quality of life (HRQoL)?


Older reports suggest a negative impact of bracing on psychosocial development and HRQoL. It is important to understand whether bracing therapy for AIS continues to cause negative HRQoL.

Clinical comment

The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) is a landmark multicenter randomized cohort trial demonstrating efficacy of brace treatment in preventing curve progression to surgical thresholds among adolescents with remaining growth and curve magnitudes under 40°.1 Importantly, brace treatment has traditionally been associated with poor body image, decreased psychosocial wellbeing, and self‐esteem when compared to healthy peers.2 Brace treatment has also been associated with poor psychosocial health due to body image disturbance.3 Furthermore, Danielsson et al. showed that after brace treatment patients report greater subjective body distortion than nonbranched peers with similar truncal rotation and curve magnitude.4

Available literature and quality of the evidence

BrAIST provides level II evidence on HRQoL among those patients undergoing bracing treatment compared to nonbraced controls.1 Further available evidence to inform HRQoL predictors related to bracing therapy for AIS comes from level II studies spun off of the BrAIST trial. Schwieger et al. provided two level II prospective cohort studies based on BrAIST analyzing the HRQoL of braced patients at baseline and up to two‐year follow‐up post initiation of bracing therapy.5,6 Importantly, Schwieger et al. examined whether HRQoL and body image affected compliance to brace therapy.6 The largest cohort of braced AIS patients comes from Cheung et al. (level III).7 Cheung et al. analyzed 652 patients with scoliosis using the refined Scoliosis Research Society 22‐item (SRS‐22r) and 5‐level EQ‐5D (EQ‐5D‐5L) questionnaires. They compared patients undergoing clinical observation to a group of patients in thoracolumbar orthosis and patients who were previously braced.


In Cheung et al. HRQoL scores were initially higher when bracing was initiated; however, there was a time‐dependent deterioration associated with duration of brace treatment.7 The respective SRS‐22r scores were higher for the observation than bracing and previously braced groups (p <0.001). Curves greater than 40° had worse HRQoL (p <0.001). Additionally, previously braced patients had better HRQoL than currently braced patients, with 0.23 higher SRS‐22r scores (p <0.001), thus supporting a transient effect to bracing therapy in AIS.

Interestingly, the BrAIST trial found no differences in pediatric quality of life scores between the bracing control group at baseline or follow‐up (mean scores in primary analysis 82.9 and 81.9, respectively p = 0.97).1 Schwieger et al. found no significant differences within or between study arms of observation or braced AIS patients; however, patients with Cobb angles >40° had significantly poorer body self‐image.5 In Schwieger et al., 167 patients undergoing brace treatment were found to have no statistically significant correlation to compliance with brace wear; however, there was a trend toward improved satisfaction with treatment when these patients were involved in their treatment decisions.6 Therefore, while initial reports suggested that bracing may be associated with poorer psychosocial development, poor body‐image, and reduced HRQoL, newer evidence suggested this to not be the case.

Resolution of clinical scenario

  • Level II evidence supports that bracing is a safe and effective method of treating scoliosis in patients with growth remaining and curves ranging from 20 to 40° in their coronal cobb angle.
  • While initial reports suggested that bracing in scoliosis was associated with a negative effect on self‐image and psychosocial health, newer level II reports suggest that HRQoL may not be significantly different between patients receiving brace treatment and those not receiving brace treatment.
  • Level II evidence supports improved treatment satisfaction in patients taking on an active role in making decisions regarding their own bracing treatment.

Question 2: In patients with AIS, does nonoperative management result in pulmonary compromise in adulthood?


Thoracic curves in AIS can affect respiratory function, leading to restrictive respiratory abnormalities based on alterations to the anatomy of the thorax. It is important to identify nonoperatively treated AIS patients at an early age to best understand who is at greatest risk in adulthood of pulmonary compromise.

Clinical comment

While the causal relationship between spinal deformity and pulmonary function has yet to be fully elicited, there is a known negative correlation between curve magnitude and pulmonary function.8 Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1), both measures of pulmonary function, are most significantly reduced with greater thoracic curves and higher apical vertebral levels.9 Long‐term follow‐up of patients with AIS has demonstrated clinically relevant pulmonary compromise affecting mortality only in thoracic curves which progress over 100°.8

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Adolescent and Adult Spinal Deformity: Nonoperative Management
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