When does scoliosis in children need a brace?

What is adolescent idiopathic scoliosis?

Adolescent idiopathic scoliosis is a sideways curve of the spine with rotation that develops in children and adolescents without a known cause, usually around the growth spurt. It is more likely to progress in girls. Signs include uneven shoulders, a prominent shoulder blade, an uneven waist or a rib hump when bending forwards.

The curve is measured on X-ray as the Cobb angle. Most curves are small and do not need treatment beyond monitoring.

Which curves are at risk of progressing?

The risk of progression depends mainly on how much growth remains and the size of the curve. Curves in younger children who have not yet had their growth spurt or started menstruation, and larger curves, are more likely to progress.

Skeletal maturity is assessed using X-rays of the pelvis or hand and signs of puberty. Once growth is complete, smaller curves usually stop progressing.

Does bracing work?

A multicentre trial (BrAIST) included 242 adolescents who were at risk of curve progression 1. Treatment success, defined as reaching skeletal maturity without the curve progressing to 50 degrees or more, occurred in 72 per cent after bracing compared with 48 per cent after observation 1. In the randomised group, success was 75 per cent with bracing and 42 per cent with observation 1.

The trial was stopped early because of the benefit of bracing, and there was a significant positive association between hours of brace wear and treatment success 1. Participants were instructed to wear the brace for at least 18 hours a day 1.

What do guidelines recommend?

International guidelines from the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) include 68 recommendations on assessment, bracing, physiotherapeutic scoliosis-specific exercises and other conservative treatments during growth 2.

Brace treatment is usually considered for growing children with moderate curves, depending on remaining growth and the risk of progression. Specific exercises may be used to reduce progression in smaller curves or alongside bracing 2.

What is it like to wear a brace?

Most braces are custom-made rigid plastic devices worn under clothing. They work by applying corrective pressure to the spine while the child grows. Wearing time is prescribed by the specialist and is often many hours a day, including at night.

Adjusting to a brace can be challenging physically and emotionally. Support from family, clinicians and peers, and continuing sport and physical activity, help adolescents cope.

When is surgery considered?

Surgery, usually spinal fusion, is considered for large curves, such as those reaching about 50 degrees, the threshold for surgery used in the bracing trial 1, or curves that continue to progress despite bracing, because very large curves may keep progressing in adulthood.

The decision takes into account curve size, flexibility, remaining growth, symptoms and the young person's preferences.

How can young people cope with wearing a brace?

Wearing a brace during adolescence can affect body image, comfort, sleep and social life. Choosing clothing that fits over the brace, planning when it is removed for sport or showering, and building wear time gradually at the start help young people adapt.

Talking to other young people who wear braces, involving the school when needed and having regular check-ins with the clinical team can improve confidence and adherence. Families should raise concerns about skin problems, pain or distress, as adjustments are often possible.

When should back symptoms be assessed promptly?

Scoliosis in adolescents is usually painless. Seek prompt assessment for significant back pain, night pain, a rapidly progressive curve, weakness, numbness, changes in walking, or bladder or bowel problems.

These features may suggest a different cause of scoliosis, such as a problem in the spinal cord, and may require an MRI.

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