Vol.:(0123456789) 1 3 Spine Deformity https://doi.org/10.1007/s43390-020-00131-3 CASE SERIES Efcacy of bracing in skeletally immature patients with moderate–severe idiopathic scoliosis curves between 40° and 60° Bram P. Verhofste 1  · Amanda T. Whitaker 2  · Michael P. Glotzbecker 3  · Patricia E. Miller 1  · Lawrence I. Karlin 1  · Daniel J. Hedequist 1  · John B. Emans 1  · Michael Timothy Hresko 1 Received: 1 December 2019 / Accepted: 25 April 2020 © Scoliosis Research Society 2020 Abstract Study design Retrospective case-series. Objectives To evaluate the outcomes of bracing in skeletally immature patients with moderate–severe idiopathic scoliosis (IS) curves ≥ 40°. Background 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 efcacy of bracing large curves remains uncertain. Methods 100 skeletally immature children (mean 11.8 ± 2.36 years; range 6.1–16.5) with IS ≥ 40° were identifed. 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. Results 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. Conclusion 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 efective in delaying surgery until skeletal maturity in patients with curves ≥ 40°. Patients should be counseled on the risks and benefts of bracing and surgery. Level of evidence Level IV. Keywords Idiopathic scoliosis · Non-operative treatment · Bracing · Boston brace · Severe curves · Spinal fusion · Risk factors Introduction Surgical intervention is traditionally recommended in chil- dren with idiopathic scoliosis (IS) exceeding 45° due to curve progression, cosmetic deformity, pain, psychological distress, and respiratory compromise in severe cases [1–5]. Spinal fusion is major surgery with a signifcant burden on the health-care system, only second after appendectomies [6–8]. The young age at which the disease manifests along- side progressive spinal deformity, hardware failure, and * Michael Timothy Hresko Timothy.Hresko@Childrens.Harvard.Edu 1 Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA 02115, USA 2 Department of Orthopaedic Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA 3 Department of Orthopaedic Surgery, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA