Adolescent Idiopathic Scoliosis Bracing Failure Risk Factors

Peer Reviewed

New findings show 3 key risk factors for brace treatment failure and curve progression in adolescents with idiopathic scoliosis: poor brace compliance, low level of skeletal maturity, and initial Cobb angle >30°. “The results allow us to better educate patients and families and to help them make an informed decision regarding bracing,” lead author Ron El-Hawary, MD, MSc, FRCS(C) told SpineUniverse.
thoracic scoliosis, x-ray imageStudy findings determined risk factors for approximately 25% of patients with AIS who were not successful with spinal bracing. Photo Credit: eyenigelen. Photo Source:

Study Methods

The findings build on the prospective BrAIST trial (Bracing in Adolescent Idiopathic Scoliosis Trial) from 2013, which found bracing success in 72% of patients randomized to this treatment for at least 18 hours per day.1

“We sought to determine the risk factors for the approximately 25% of patients with scoliosis who were unsuccessful with bracing,” said Dr. El-Hawary, who is Professor of Surgery (Orthopaedics and Neurosurgery) at Dalhousie University, and Chief of Paediatric Orthopaedics at IWK Health Centre in Halifax, Nova Scotia, Canada.

To accomplish this, Dr. El-Hawary and colleagues reviewed the literature and identified 25 articles on bracing for adolescent idiopathic scoliosis (AIS) that met inclusion criteria, such as identified specific risk factor(s) for AIS curve progression and sample size ≥15 patients. Studies that examined night-time bracing or compared one brace to another were excluded.

Common Causes of Bracing Failure in Scoliosis

Seven risk factors for curve progression during bracing were identified: Poor brace compliance, lack of skeletal maturity, Cobb angle >30°, vertebral rotation, poor in-brace correction, thoracic curve type, and osteopenia.

“Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion,” Dr. El-Hawary explained. “In general, skeletally immature patients with relatively large magnitude scoliosis [>30°] who are noncompliant are at a higher risk of failing brace treatment.”

“We are keen advocates for bracing; however, if skeletally immature patients with relatively large curves become non-compliant, we now have a lower threshold to discuss fusionless surgical techniques in an effort to avoid spinal fusion surgery,” Dr. El-Hawary said.

Poor Brace Compliance Is Common in Adolescents With Scoliosis

A high rate of poor brace compliance (27%-69%) was found in this review, which Dr. El-Hawary said he was not surprised by. The impact of this poor brace compliance is shown in the BrAIST study, which found that patients who wore a brace for an average of 12.9 hour per day had a success rate of 90% to 93%, while those who wore the brace for <6 hours per day had success rates that were comparable to an observation control group (41% and 48%, respectively).

Overcoming Compliance Barriers to Bracing in Teens

“Anecdotally, challenges for children treated with bracing include the social stigma and embarrassment of wearing a brace,” Dr. El-Hawary said. “In addition, lack of comfort in the brace can affect compliance.”

“Multidisciplinary bracing clinics, including nursing and orthotist support are key to helping patients overcome these barriers,” Dr. El-Hawary continued. “At our institution, the scoliosis bracing clinic is run independently with a nurse practitioner and an orthotist. Our nurse practitioner has the skill set to help the patients overcome the potential psychosocial ramifications of bracing.”

Dr. El-Hawary is a Consultant with Medtronic, WishBone Medical, ApiFix, and Globus developing fusionless technology.

Hawary RE, Zaaroor-Regev D, Floman Y, Lonner BS, Alkhalife YI, Betz RR. Brace treatment in adolescent idiopathic scoliosis: risk factors for failure—a literature review. Spine J. 2019;19(12):1917-1925.

1. Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013;369(16):1512-1521.


Baron S. Lonner, MD
Professor of Orthopaedic Surgery
Icahn School of Medicine at Mount Sinai
Chief of Minimally Invasive Scoliosis Surgery
Mount Sinai Hospital
New York, NY

The recently published article, “Brace treatment in adolescent idiopathic scoliosis: risk factors for failure—a literature review,” by El-Hawary, et al provides information that may prove to be useful for the specialist in the care of the patient with adolescent idiopathic scoliosis (AIS). Bracing is an important tool in the treatment of moderate severity AIS in the skeletally immature child with curvature between 25° to 45°. An understanding of the risk factors for curve progression despite bracing is important for specialists in order to provide the family of the adolescent with realistic expectations about the likelihood of success or failure and the potential need for surgical correction despite bracing. In the event of a poor prognosis for brace success, the family and patient may opt to pursue an alternative path including new surgical alternatives such as posterior dynamic distraction1 or anterior vertebral body tethering,2 both recently approved by the FDA for the treatment of AIS.

The authors, myself included, performed a structured literature review for published articles on the subject of bracing in AIS, excluding nighttime bracing or studies comparing different bracing types, or bracing in combination with physical therapy. Studies had to include a minimum of 15 patients. Studies that included juvenile idiopathic scoliosis were evaluated as long as there were also AIS patients included. A total of 1022 English language papers were found in the search, of which the full text of 193 articles were read after further exclusion and resulted in 25 articles meeting the inclusion criteria. The level of evidence associated with each publication varied with only one level I paper, a report on the BrAIST prospective randomized multicenter study, available and several level II studies being included in addition to level III and IV reports in the literature.

Brace failure was defined as progression to a surgical recommendation, to surgery, curvature of 50° or curve progression of 6° or more depending on the study. A total of seven risk factors were reported. These included poor brace compliance (8 studies), skeletal immaturity (6 studies), large curve magnitude (6 studies), poor in-brace correction (3 studies), vertebral rotation (4 studies), osteopenia (2 studies), and thoracic curve type (2 studies). There were three risk factors that were highly repeated in the literature, identifying patients who are at a much higher risk of curve progression and brace failure. Patients with larger curves, who are less skeletally mature, and who are non-compliant with prescribed duration of brace wear have the highest rates of failure. Patients who are Risser 0 (or Sanders 3 or less) with a curve greater than or equal to 40° are at a 70% to 100% risk of progression to the surgical threshold with patients who have open triradiate cartilage carrying the highest risk. The literature showed that 60% to 70% of patients referred for bracing are Risser 0 and 30% to 70% do not wear the brace for enough hours per day to avoid curve progression. Compliance with bracing consisting of wearing a brace for 13 or more hours per day was associated with brace success in 90% in the level I study and less than 6 hours of brace wear per day had an outcome that was no better than observation alone.

These data should assist scoliosis specialists in counseling their patients, and in a shared decision-making interaction that includes a discussion of alternative approaches.

Dr. Lonner is a Consultant with DePuy Synthes, Unyq Align, ApiFix, and Zimmer Biomet.

1. U.S. Food and Drug Administration. Minimally Invasive Deformity Correction (MID-C) System - H170001. August 23, 2019. Accessed January 27, 2020.

2. U.S. Food and Drug Administration. The Tether™ - Vertebral Body Tethering System - H190005. August 16, 2010. Accessed January 27, 2020.

Updated on: 01/29/20
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Modified SHILLA Technique for Scoliosis Remodulates the Apex Vertebra
Ron El-Hawary, MD, MSc, FRCS(C)
Chief of Paediatric Orthopaedics
IWK Health Centre
Baron S. Lonner, MD
Professor of Orthopaedic Surgery
Icahn School of Medicine at Mount Sinai

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