A recent study published in The New England Journal of Medicine has yielded convincing results in support of back bracing as the first line of treatment for scoliosis patients. Bracing is not a new concept. Spine surgeons and physicians have been using this treatment for decades, but bracing has not always been universally lauded or above question in the medical community. The magnitude and level of evidence of this study lends strong support to the treatment and goes a long way to dispel the notion that bracing is an ineffectual or undesirable scoliosis treatment, according to Neel Anand, MD, a clinical professor of surgery and director of spine trauma at Cedars-Sinai Spine Center in Los Angeles.
Here Dr. Anand comments on this study and what it means for the future of scoliosis care.
Q: Why is this particular study important to the field of spine surgery?
Dr. Neel Anand: This study gives credence to the concept of back bracing for scoliosis treatment and it is a very well done study. It was randomized, which is very difficult to do. The study monitored how long patients wore the braces. Compliance has always been a big issue. Bracing does work, but it depends on how long the patient wears the brace, the trend being the longer a brace is worn the better it works.
Q: Why do you think it has taken this long for a study to produce conclusive results?
NA: Nothing is ever completely conclusive. The study shows that 72 percent of patients with bracing will improve and likely not require surgery. But, we never know when you see patients whether they are part of the 72 percent or the 28 percent. This study did show everyone should try a brace, but it also showed that braces will fail in certain patients.
When you randomize a study like this, one group of patients receives a brace and one does not. This becomes an ethical issue. It is difficult to see a patient without a brace and knowing that bracing could be doing something, do we just continue treating without a brace? That is why this study has always been difficult to conduct.
Q: What does this study mean for the future of scoliosis treatment?
NA: This study has added a lot of value to the field. Bracing is at present and going forward will be the first line of treatment. Before, some people thought bracing wasn't worth it at all. Now, it is difficult to say that bracing has no role. Patients of 10 or 11 years old are still very skeletally immature. Bracing should certainly be used in these cases, for a minimum of 13 to 14 hours. As spine surgeons, this study really reinforces our beliefs. Surgeons need to emphatically tell patients that we have the evidence to support back brace use. There is a 28 percent chance that it won't work, but a 72 percent chance that it will.
The biggest issue is the curve progression of the spine even in the brace. If the progress is greater than 10 degrees between visits with the patients, the brace has failed. On the flip side of this study, we have to realize this doesn't mean everyone will avoid surgery.
Surgical techniques for scoliosis surgery have changed immensely. Spine surgeons have better materials for fusion and correction. Minimally invasive surgical techniques are gaining popularity. Technology is making surgery safer, better and helping us achieve better correction. This study reinforces that bracing should be done, but reminds spine surgeons to always remember the 28 percent.
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