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EDITORIAL PERSPECTIVE
The reviewers found the article interesting and relevant but noted that there had been previous attempts at meta-analysis, most recently in Lancet 2008 by S Weinstein et al [1] using the Cochrane review and Medline from 1996 – 2006 and by Sponseller in 2011 [2]. It should, however, be noted that the Weinstein systematic review is primarily a summary of case series from both treatment arms that reduces the level of evidence of their findings substantially.
Only one of the studies (Fernandez-Feliberti, 1995) used in the systematic review by Weinstein [1] was also used in the published EBSJ systematic review, which includes 8 articles: Mannherz (1988); Nachemson (1995); Fernandez-Feliberti (1995); Ugwonali (2004); Cheung (2006); Pham (2008); Danielsson (2007); Parent (2009).
In addition, the Weinstein article [2] consisted of a review of surgical techniques versus bracing without mention of observation only. As to the Sponseller article [2], its creation coincided with the writing of the present EBSJ article. Its main focus was aimed at identifying consensus for indications for bracing.
The reviewers concur with the EBSJ authors' conclusion that the evidence for bracing in the treatment of adolescent idiopathic scoliosis (AIS) is—at best—marginal. Despite a literal explosion of publications on the subject of AIS in the general literature and a steadily growing body of studies in the orthopaedic literature there remains a paucity of clarity. There are two current well-funded and well-controlled prospective trials under way in North America, but it will likely be many years before any conclusions can be reached.
Are there then patients well suited for bracing using a best practices standard? The present EBSJ systematic review was not designed to provide any directed help in this regard.
Sponseller in his recent review suggests that patients with AIS curves between 25 to 45 degrees during their Risser 0 to 1 status should be considered for initial bracing [2]. He goes on to suggest that patients of Risser scores 2 or 3 and curves of 30 – 45 degrees may be offered bracing on their initial visits.
This recommendation, however, is again tempered by questions surrounding the reliability of the Risser sign, thus limiting the validity of these recommendations. Patient compliance with brace wear and brace acceptance remains another important variable, which cannot be fully accounted for despite technological advances, such as thermal scanners and electrical impedance measuring devices.
Finally, the reviewers noted that the authors of the EBSJ systematic review touched upon, but did not elaborate on the importance of cultural expectations, family dynamics, and physician-interactions in the determination for or against bracing. Both, the Sponseller review [2] and the Weinstein review [1] recommended a shared decision-making model to be used. The effects of a shared decision-making model in regards to patient outcomes and conversion rates to surgery of patients presenting with adolescent idiopathic scoliosis remain unknown. In terms of study size and long-term dimensions the reviewers recommend reading the Nachemson study from 1995, which was part of the systematic review performed here [3].
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Weinstein SL, Dolan LA, Cheng JC, et al (2008) Adolescent idiopathic scoliosis. Seminar. Lancet; 371 (9623): 1527 – 1537.
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Sponseller PD (2011) Bracing for adolescent idiopathic scoliosis in practice today. J Pediatr Orthop; 31 (1Suppl): S53 – S60.
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Nachemson A, Peterson LE (1995) Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis: a prospective, controlled study based on data from the brace study of the Scoliosis Research Society. J Bone Joint Surg Am; 77: 815 – 822.
