Bracing for Early Onset Scoliosis
By Grant Wood, MSc, CO
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Introduction
Early onset scoliosis (EOS) brace treatment protocols, types, and quality vary depending on where and who is providing the treatment. Treatment must be individualized for each patient using the highest level of care, skill, quality, technique, and follow-up. Incorrect design can have a long-lasting negative impact on the patient’s disability and quality of life. The prognosis for patients with EOS depends on the severity of the scoliosis and the underlying conditions associated with the case. This article discusses scoliosis brace characteristics for patients diagnosed with idiopathic EOS. The type of the scoliosis is determined by the patient’s age at the time of diagnosis.- Infantile idiopathic scoliosis (IIS): Diagnosed between birth and age three years (before four years).
- Juvenile idiopathic scoliosis (JIS): Diagnosed between age four and ten years.
- Adolescent idiopathic scoliosis (AIS): Diagnosed between age ten and 18 years.
- Early onset scoliosis (EOS): Diagnosed between birth and age ten years. Patients with IIS and JIS are grouped under the EOS umbrella.
- Idiopathic EOS: No apparent cause or cause unknown.
- Congenital EOS: Vertebrae develop incorrectly in útero. Sometimes associated with cardiac and renal abnormalities.
- Neuromuscular EOS: In children with neuromuscular disorders including spinal muscular atrophy, cerebral palsy, spina bifida, and brain or spinal cord injury.
- Syndromic: Certain syndromes, such as Marfan, Ehlers-Danlos, and other connective tissue disorders, as well as neurofibromatosis, Prader-Willi, and many bone dysplasias, may be associated with EOS.(1)
Early Onset Scoliosis Bracing
EOS brace design must be customized according to each patient’s particular morphology and needs. The medical team should have realistic expectations for the in-brace percentage of Cobb angle correction, which varies for each individual presentation.
Brace modification for EOS patients must be approached differently than brace modification for AIS patients. Specifically, IIS patients and early JIS patients must be evaluated and treated by a high-quality, professional scoliosis team that includes an orthotist with significant knowledge and skill in modifying and fitting of EOS braces. Success should not be determined solely by Cobb angle measurement but rather on many factors, including the type of EOS, structural changes to the spine, amount of spinal rotation, clinical/postural deformity, flexibility or rigidity of the curves, curve type/pattern, skeletal age, and patient weight.
Brace quality can be assessed by in-brace clinical presentation and in-brace radiological correction. Reviewing the in-brace x-ray allows the practitioner to determine the Cobb angle and evaluate the effect of the brace on the proximal thoracic curve, pelvis, rib position, chest/rib compression, and derotation of the spine. Verticalization of the ribs is caused primarily by too much lateral pressure. In a left single thoracic curve pattern, excessive lateral translation of the trunk to the right, over the pelvis, causes more frontal plane imbalance.
Figure 1: This X-ray demonstrates how not to modify and fit a brace to a patient. Note the lateral compression from the brace to the ribs, causing vertical-Izatlon of the ribs, as well as the incorrect location of the pressures.
Figure 2: A patient with IIS was treated with a Wood-Cheneau-Rigo (WCR) brace, Rigo-Cheneau type, starting at age four years. The brace was carefully hand modified and designed to provide good 3-D correction with consideration given to clinical presentation (aesthetics) and radiological improvement.
Less Cobb angle correction early on might be better for an EOS patient in the later stages of child growth and puberty. Maximizing Cobb angle correction must be carefully balanced with the exigencies of other considerations, such as body shape, curve characteristics, and condition.
Nonexistent or insufficient expansion room for the concavity of the curve can lead to compression of the ribs, reduced Cobb angle correction, absent or insufficient rotational correction, and poor breathomechanics of the brace. With a good brace design and fabrication, the patient should have improved respiration and trunk expansion.
The ribs on the convex thoracic side should not have too much expansion room on the concave side of the curve, since this could lead to too much postural overcorrection. A window completely cut out from an area of contact should be limited or nonexistent. Otherwise, soft tissue and/or chest protrusion could occur, causing a poor clinical presentation.
Every pressure and expansion area must be designed correctly (correct amount of pressure at the correct level and orientation) for each patient’s particular curve type, shape, clinical presentation, rotation, and scoliosis flexibility or rigidity.
Figure 3: A patient with neuromuscular EOS has improved posture and a more upright stance in a neuromuscular WCR brace. The brace allows for improved breathing by reducing the collapse of the trunk to the right into the concavity of the left thoracic curve.
Idiopathic Early Onset Scoliosis Brace Goals
The goals for EOS bracing are to hold or correct the scoliosis out-of-brace; improve the patient’s clinical presentation; allow for improved lung function and chest and spine movement; reduce the number of hospital visits and procedures under anesthesia; and, in some cases, slow down the progression of the scoliosis and reduce and/or delay surgical intervention for as long as possible to allow the patient to grow.
The in-brace clinical presentation can be assessed by viewing the alignment of the head and trunk over the pelvis. In most EOS-patient curve patterns, a balanced clinical presentation (improved aesthetics) is optimal. This is unlike the goals for AIS patients and some older JIS patients, in which postural overcorrection is often preferred.
Figure 4: This 2-year-old boy initially had an elongation-derotation-flexion (EDF) cast, or Mehta cast, which reduced the main thoracic curve from 29 degrees to 15 degrees in-cast. After the first two rounds of casts, an infantile/EOS WCR scoliosis brace was handmade to allow good space on the concavities of the scoliosis and provide comfortable breathing and good 3-D correction of the spine.
The in-brace clinical presentation of the shoulders can be assessed by reviewing the curve type followed by the vertebral end plates to determine the correct height of the axilla extension. This results in leaving sufficient brace
length to accommodate patient growth and a sufficient lever arm to apply correctional forces at the correct curve levels. The objective is to avoid leaving the brace so long that it causes progression of a proximal thoracic curve or so low that the brace pushes into the concavity of the thoracic curve. Close follow-up of brace fit is required. When a physical visit is not possible, the clinician can ask the parents to take in-brace photos of the patient, record the patient’s height, and send the measurements and pictures to the orthotist.(3) In-brace radiological and clinical presentation of the patient in the sagittal plane should provide an optimal physiological profile.(4)
The EOS brace wear schedule is determined by the risk of progression, not by the type or name of the brace.(5) For example, a patient who requires a full-time scoliosis brace due to the high risk of progression should wear the brace for 18-23 hours per day.
Casting or Scanning of the Patient
The patient image can be captured by a hand cast or scan. IIS and early JIS patients often need to have their casts taken in an upright position, standing if possible, to capture their individual body shape and optimal trunk and pelvis alignment. Casting is best done with the assistance of two people to allow for better patient alignment and positioning. A scan could be considered if the patient is able to stand still in the optimal alignment and position required to modify the brace.
Figure 5:
A. Seven-year-old girl with EOS associated to Chiari I + C5-T11 syrinx, who showed
progression from 44 degrees to 55 degrees Cobb angle after neurosurgical decompression.
B. The girl In her first Rlgo-Cheneau brace showing good In-brace correction.
C. The girl at age 12 years In her fourth brace, with a gradual In-brace correction.
D. The girl at age 13 years, just post-menarche, still Rlsser 0, showing a residual right thoracic
curve under 15 degrees Cobb angle. Back asymmetry Is well corrected. The mild over-
correction of the left shoulder was postural, while not associated with a structural left proximal thoracic curve.
References:
1. Early Onset Scoliosis. SRS: Scoliosis Research Society, https://www.srs.org/patients-and-families/ conditions-and-treatments/parents/scoliosis/early-onset-scoliosis. Updated date unavailable. Accessed July 2018.
2. Wood G. Five-year case study of an infant with scoliosis using Schroth therapy and Chéneau-type bracing. The O&P EDGE. 2015;14(8):56-66.
3. Rigo M, Janssen B, Campo R, Tremonti L. Conservative treatment of juvenile with Chiari I malformation, syringomyelia and scoliosis. Two case reports. Scoliosis. 2013;8(l):O52.
4. Wood G. Sagittal plane normalization using CAD/CAM for patients with idiopathic scoliosis. The Academy Today. 2016; 12(2)11-13.
5. Wood G. To brace or not to brace: the three-dimensional nature and growth considerations for adolescent idiopathic scoliosis. The Academy Today.20139(3):5-8.
Cite this article as: Wood G. 2019. The Academy Today Winter 2019: Bracing for Early Onset Scoliosis. The Academy Today Winter 2019; 15 (1): 9-11