Verhofste Bram P, Whitaker Amanda T, Glotzbecker Michael P, Miller Patricia E, Karlin Lawrence I, Hedequist Daniel J, Emans John B, Hresko Michael Timothy
Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA, 02115, USA.
Department of Orthopaedic Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
Spine Deform. 2020 Oct;8(5):911-920. doi: 10.1007/s43390-020-00131-3. Epub 2020 May 11.
Retrospective case-series.
To evaluate the outcomes of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis (IS) curves ≥ 40°.
In contrast to prior beliefs, the recent studies have reported successful outcomes with brace treatment may occur in some patients with moderate-severe scoliosis ≥ 40°. Despite other encouraging case-series, non-operative treatment is rarely attempted and the efficacy of bracing large curves remains uncertain.
100 skeletally immature children (mean 11.8 ± 2.36 years; range 6.1-16.5) with IS ≥ 40° were identified. 80 were adolescent IS (80%) and 20 juvenile IS (20%). The Risser plus score was used to evaluate skeletal maturity. 66 children were Risser 0 (66%). SRS-SOSORT outcome guidelines were used: > 5° progression, stabilization between - 5° and 5° and, > 5° improvement.
Mean initial Cobb was 45° ± 3.9° (range 40°-59°), with in-brace and % correction of 30° ± 8.7° (range 7°-48°) and 34 ± 17.5% (range 2-84%), respectively. 57 progressed (57%), 32 stabilized (32%), and 11 improved (11%) after a median of 1.8 years (IQR 1.2-2.9). Open triradiate cartilage at presentation (p = 0.005) and less in-brace correction (p = 0.009) were associated with progression. 58 children (58%) underwent surgery after a mean of 3.0 years (range 0.7-7.3). Surgical patients were younger (11.2 vs. 12.7 years; p = 0.003), more often Risser 0 (79% vs. 48%; p < 0.001); however, presented with similar curves (45° vs. 44°; p = 0.31). Open triradiate cartilage at presentation (OR 15.3; 95% CI 4.3-54.6; p < 0.001) and less in-brace correction (p = 0.03) increased the likelihood of surgery. All 20 JIS patients avoided temporary growth rods, with 18 (90%) eventually requiring surgery.
Non-operative treatment was successful in 42% of children. Risk factors for surgery were younger age, open triradiates, and less in-brace correction. Bracing can be effective in delaying surgery until skeletal maturity in patients with curves ≥ 40°. Patients should be counseled on the risks and benefits of bracing and surgery.
Level IV.
回顾性病例系列研究。
评估支具治疗对骨骼未成熟、中度至重度特发性脊柱侧凸（IS）曲线≥40°患者的疗效。
与先前的观点相反，最近的研究报告称，一些中度至重度脊柱侧凸≥40°的患者采用支具治疗可能会取得成功。尽管有其他令人鼓舞的病例系列研究，但非手术治疗很少尝试，且支具治疗大曲线的疗效仍不确定。
确定了100名骨骼未成熟儿童（平均11.8±2.36岁；范围6.1 - 16.5岁），其IS≥40°。其中80例为青少年特发性脊柱侧凸（80%），20例为幼年特发性脊柱侧凸（20%）。使用Risser加评分评估骨骼成熟度。66名儿童Risser评分为0（66%）。采用SRS - SOSORT结局指南：进展>5°、稳定在 - 5°至5°之间以及改善>5°。
初始Cobb角平均为45°±3.9°（范围40° - 59°），支具内及矫正百分比分别为30°±8.7°（范围7° - 48°）和34±17.5%（范围2 - 84%）。经过中位数1.8年（四分位间距1.2 - 2.9）后，57例进展（57%），32例稳定（32%），11例改善（11%）。就诊时开放的三辐射软骨（p = 0.005）和支具内矫正较少（p = 0.009）与进展相关。58名儿童（58%）在平均3.0年（范围0.7 - 7.3）后接受了手术。手术患者年龄更小（11.2岁对12.7岁；p = 0.003），Risser 0的比例更高（79%对48%；p < 0.001）；然而，曲线相似（45°对44°；p = 0.31）。就诊时开放的三辐射软骨（比值比15.3；95%置信区间4.3 - 54.6；p < 0.001）和支具内矫正较少（p = 0.03）增加了手术的可能性。所有20例幼年特发性脊柱侧凸患者均避免了临时生长棒，其中18例（90%）最终需要手术。
42%的儿童非手术治疗成功。手术的危险因素包括年龄较小、三辐射开放和支具内矫正较少。支具可有效延迟曲线≥40°患者的手术直至骨骼成熟。应向患者咨询支具和手术的风险与益处。
四级。
