RES E A R C H Open Access
Bracing in adult with scoliosis: experience
in diagnosis and classification from a
15 year prospective study of 739 patients
Jean Claude de Mauroy
1*
, Cyril Lecante
2
, Frédéric Barral
2
and Sophie Pourret
2
From 12th International Conference on Conservative Management of Spinal Deformities - SOSORT 2015 Annual Meeting
Katowice, Poland. 7-9 May 2015
Abstract
Background: Despite the frequency of adult scoliosis, very few publications concern the conservative orthopaedic
treatments. The indications have not been defined to date. The experience of a department specialized in rigid
bracingallowsustoconsolidateandclarifydiagnosisandindicationsaswell.
Methods: Individual observational prosp ective cohort study from a database started in 1998, with sele ction of
all 739 adult scoliosi s patients for which conservative orthopaedic treatmen t has been proposed to, even i n
case of drop-out. Scoliosis treated during ad olescenc e an d monito red in adulthood ar e i ncluded if a new
brace is prescribed.
A first descriptive study of the main parameters was performed: gender, age, Cobb angle.
A tentative classification accordin g to aetiology, age and angulation i s proposed.
Results:
1) Descrip tive Data:
The Ratio Female/Male is 88 %, the mean age: 56.97 ± 15.82, the mean Cobb angle: 35.58 ± 17.35.
The ra te of non-adherent patients no t wearing the brace is 17 % (but the plaster cast before
bracing was routine ly propo sed at the time).
2) All patients can be grouped into five d iagnoses, all statistically different, a ccording to the age and the
initial Cobb a ngle:
– Rotatory dislocation: 361 cases, age: 59.73 ± 13.52 (p = 0.05), (Cobb 39.08 ± 16.59 (p =0.02)*
– Instability and disc disease: 150 cases, age: 46.03 ± 15.49 (p = 0.00)*, Cobb: 25.29 ± 12.29 (p =0.00)*
– Camptocormia: 68 cases, age: 69.78 ± 12.19 (p = 0.00)*), Cobb: 38.09 ± 14.23 (p = 0.25)
– Kyphosis TL or T: 62 cases, age: 60.73 ± 15.51 ( p = 0.07), Cobb: 43.34 ± (21.48 (p =0.00)*
– Disabling pain: 33 cases, age: 48.3 6 ± 13.73 (p = 0.02)*, Cobb: 36.45 ± 25.21 (p =0.78)
(Continued on next page)
* Correspondence: demauroy@aol.com
1
Department of Orthopaedic Medecine, Clinique du Parc, 155 Boulevard
Stalingrad, Lyon 69006, France
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The Author(s) Scoliosis and Spinal Disorders 2016, 11(Suppl 2):29
DOI 10.1186/s13013-016-0090-y
(Continued from previous page)
Treatment after surgery and in the context of a lumbar stenosis and spondylolisth esis are independent
groups.
Despite the wide variety of etiol ogies, n early 2 /3 of patients have a discal pathology like rotatory dislocation
and disc instability. For these patients a short brace can be used. O ther patien ts usually have high kyphotic
pathology as Kyphosis or camptocormia. The y ne ed a long brace.
Conclusions: The wide variety of adult scoliosis makes any objective classification difficult. This first approach
is intended to specify the best indi cations of bracing in adulthood.
1. The female ratio is slightly hig her than that of the adolescent.
2. The dropout rate is high and j ustify improvements with adaptation of bracing to adults.
3. All proposed etiological groups are statistically significantly different.
Background
The evolution of scoliosis in adulthood is most often pe-
jorative [1]. Although scoliosis in adults is 10 % of the
population aged 65, conservative non-surgical ortho-
paedic treatment is the subject of few publications.
Many reasons may explain this lack of publications.
The progression at adulthood is less linear and much
more chaotic than during adolescence. As growth is the
main factor of progression for AIS; in adulthood, the
anatomical aetiologies are much more varied: disc, bone
with osteoporosis, muscle, and postural system for the
camptocormia which is characterized by forward flexion
of the spine when standing or walking and disappears
when lying down. It is related to atrophy of the deep
muscles of extra-pyramidal origin.
The aims of the treatment are more blurred: pa in,
cosmetics, postural imbalance, Radiological curve pro-
gression and orthotic solutions are more limited for
long braces.
Treatment time is much longer than during adolescence
and there is hope placed in surgical rapid solutions.
In all published series, the diagnosis is poorly specified
[2]. The most significant result seems to involve pain
[3]. In some cases, bracing allows to avoid or postpone
surgery [4].
It seemed interesting to publish a l ong-term pro-
spective study of the solutions used in Lyon for over
50 years and attempt a classification of the main
indications.
Methods
With approval of the French CNIL (n°1880517), we
retrospectively reviewed the prospective database that
started in 1998.
The only inclusion criteria was the indication of a rigid
brace, usually at the request of the General Practitioner.
The study parameters were: age after Risse r 5, Cobb
angle and diagnosis. All patients are consecutive. The
initial diagnosis included 18 categories that were second-
arily regrouped into 8 categories (Table 1).
Some diagnostics were grouped a s the mean age and
average Cobb angle showed no significant difference.
For instance, discopathy, lumbar instability, dysfunc-
tion and herniated disc. Disabling pain includes : sciat-
ica, neuropathic pain, rheumatic rigidity and disability
(Additional file 1).
This is an exhaustive presentation. For example, some
young patients have severe pain after Risser 5 or with
Cobb angles between 10° and 30°. In fact, we don’t treat
scoliosis but discal pain.
Statistics were made using the SPSS 20 pack with a
Confidence interval of 95 %.
Description of the brace system and treatment protocol
The Lyon Conservative treatment requires: 1. A plaster
cast made in a specific standing frame for 3 week s. 2. A
rigid polyethylene bivalve overlapped brace worn for at
least 4 h per day. 3. A specific physiotherapy to prevent
muscle atrophy [5]. The plaster cast is an indispensable
prerequisite for this treatment. Besides the therapeutic
Table 1 Distribution of diagnostics. The 8 most frequent
diagnoses with their percentage
1 After surgery (n = 86) = 11 %
2 Rotatory Dislocation (n = 361) = 48 %
3 Lumbar instability (n = 150) = 19 %
4 Disabling pain (n = 33) = 5 %
5 Spinal Stenosis (n =5)
6 Camptocormia (n = 68) = 9 %
7 Thoraco-lumbar kyphosis (n = 62) = 8 %
8 Spondylolisthesis (n = 14)
The Author(s) Scoliosis and Spinal Disorders 2016, 11(Suppl 2):29 Page 26 of 91
role of muscular-ligamentous adjustment of paraverteb-
ral tension, it can also be used as a test. The patient
must be pain-free while pursuing normal activities. The
rigid brace is usually short, the upper limit being at the
thoracic base under the breast. (Figs. 1 and 2) When
there is a high thoracic kyphosis, the anterior limit is
high at the sternoclavicular level.
Results
Descriptive parameters are grouped in ( Table 2).
In 14 cases, information on age or Cobb angle was
incomplete.
The number of non-adherent patients, ie patients who
do not respond to treatment indicated, is 183/739 = 17 %
(Table 3).
There is no statistically significant difference between
the 2 groups of patients.
In adulthood, it is difficult to talk about non-
compliance because the wear time of the brace is 4 h a
day for six months and then the brace is worn to the pa-
tient’s request.
Regroupings according to the aetiology when n > 20
are compared with the group of patients constituting the
whole of Statistics and summarized in (Table 4).
The results of patients who completed the treatment
will be presented in another publication.
Discussion
The group after surgery is different from the overall
average. Patients are younger and the angle is more
Fig. 1 Patient with 70° scoliosis. Thoraco-lumbar scoliosis T10-L3 70°, with rotatory dislocation L3-L4. Treatment was s tarted 12 ye ars ago, th e
angulation remains stable, the brace is worn in case of pain and after sport acti vities
Fig. 2 Same patient with brace. The brace is a classical polyethylene bivalve overlapping brace of 3 mm
The Author(s) Scoliosis and Spinal Disorders 2016, 11(Suppl 2):29 Page 27 of 91
important. These results confirm that the decompensa-
tion under arthrodesis is fa ster. The most significant an-
gulation may also explain the quickest decompensation.
The brace is not always an alternative to surgery, it can
complement and in some cases avoid multiple re-
interventions.
The group with rotatory dislocation is the largest and
constitutes almost half of the patients. The average age
is borderline with statistical significance, the average an-
gulation is signi ficantly higher. The diagnosis is per-
formed on the X-ray with displacement of the spinous
processes. Rotatory dislocation is a specific complication
of lumbar scoliosis and difficulty of treatment in adult-
hood justify a conservative treatment during adolescence
with short braces.
The group with lumbar instability is the youngest
group and the angulation is the lowest which does not
justify surgery. The diagnosis is made clinically with pain
and mostly a dysfunctional anterior lateral inflexion of
the trunk. This instability can be discal or ligamentous
in origin. There is no radiological dislocation. Treatment
is important because low back pain is the leading cause
of disability before age 45.
The group with disabling pain is also younger, but the
angulation is not statistically different from the overall
average. The diagnosis is difficult without clin ical dys-
function and no particular radiological abnormalities. It
is the failure of conventional treatments that can justify
bracing.
The camptocormia group is the oldest, but the angle
was not statistically different. The difficulty in this
group, besides age is that camptocor mia is most often
accompanied by extrapyramidal depression, with less
bracing motivation.
For the group with thoracolumbar kyphosis, age is
close to the overall average, but angulation significantly
greater. The difficulty is the poor tolerance of the ster-
noclavicular thrust.
The small number of patients with spondylolisthesis
confirms the positive evolution of this disease in adult-
hood. The spinal stenosis often evolves quickly and then
the indication is surgical.
All groups are statistically different in terms of age
and Cobb angle. The Conservative orthopaedic treat-
ment should be adapted according to these two criteria.
The results of treatment are not the subject of this
study.
Conclusions
The descriptive parameters are used to specify the usual
indications of bracing 739 scoliosis. The ratio of women
(88 %) is higher than during adolescence. The average
age is 57 years and the angulation of 35.5°. The rate of
non-adherent patients is 17 %.
The statistical study based on the aetiology enable d to
individualize 6 characteristic groups depending on the
age and Cobb angle: after surgery, rotatory dislocation,
lumbar instability, disabling pain, camptocormia and
thoraco-lumbar kyphosis. The differences in age and ini-
tial angle are significant. The number of Spinal stenosis
and spondylolisthesis is very low in this study.
Additional file
Additional file 1: Excel spreadsheet: Spreadsheet used for the diagnostic
comparison of average according to the age and angulation. (XLSX 80 kb)
Acknowledgements
Thanks to Agnès de M auroy and Alexander Thornton, who corrected the
English of this article.
Table 2 Descriptive parameters. Frequency, mean and standard
deviation by gender, age and sex of adult scoliosis
Gender Female 644
Male 81
Age 56.80 ± 15.83 (Min 16–Max 91) 725
Cobb angle 35.51 ± 17.18 (Min 10–Max 143) 725
Table 3 Descriptive parameters of drop out group. There is no
significant difference regarding age and sex between the 2
groups of drop outs and patients who have completed the
proposed treatment
Non-adherent Age = 58.49 ±
14.74 ns (p = 0.201)
Cobb = 36.49 ±
18.20 ns (p = 0.637)
138
Non DO Age = 56.58 ±
16.05 ns (p = 0.178)
Cobb = 35.38 ±
17.36 ns (p = 0.647)
661
Table 4 Diagnostic regrouping. The 6 main diagnoses were
studied according to the mean and standard deviation of age
and Cobb angulation. Each diagnosis is compared with the
general statistics which is the control group (t test)
All patients Age 56.97 ± 15.82 Cobb 35.58 ± 17.35
1 - After surgery 53.09 ± 12.91
(p = 0.01)*
40.49 ± 15.38
(p = 0.01)*
2 - Rotatory Dislocation 59.73 ± 13.52
(p = 0.05)
39.08 ± 16.59
(p = 0.02)*
3 - Lumbar Instability 46.03 ± 15.49
(p = 0.00)*
25.29 ± 12.29
(p = 0.00)*
4 - Disabling Pain 48.36 ± 13.73
(p = 0.02)*
36.45 ± 25.21
(p = 0.78)
6 - Campto-cormia 69.78 ± 12.19
(p = 0.00)*
38.09 ± 14.23
(p = 0.25)
7 - Thoraco-lumbar kyphosis 60.73 ± 15.51
(p = 0.07)
43.34 ± (21.48
(p = 0.00)*
*Significant P value
The Author(s) Scoliosis and Spinal Disorders 2016, 11(Suppl 2):29 Page 28 of 91
Declarations
This article has been published as part of Scoliosis and Spinal Disorders Volume
11 Supplement 2, 2016. Research into Conservative Management of Spinal
Deformities: Short Articles from the SOSORT 2015 Meeting. The full contents of
the supplement are available online http://scoliosisjournal.biomedcentral.com/
articles/supplements/volume-11-supplement-2.
Availability of data and materials
All statistical data can be obtained from the first author.
Authors’ contributions
JCdM draft the work. All authors give substantial contribution to analysis and
interpretation of data. CL, FB & SP revise it critically and give the final approval.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Informed consent was obtained from all patients.
Ethics approval and consent to participate
This observational study was approved by the Committee of Bientraitance of
the Clinique du Parc - Lyon (201406).
Author details
1
Department of Orthopaedic Medecine, Clinique du Parc, 155 Boulevard
Stalingrad, Lyon 69006, France.
2
Orten, 125 Rue Bataille, Lyon 69008, France.
Published: 14 October 2016
References
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2. Papadopoulos D. Adult scoliosis treatment combining brace and exercises.
Scoliosis. 2013;8 Suppl 2:O8. doi:10.1186/1748-7161-8-S2-O8.
3. Weiss HR, Dallmayer R, Stephan C. First results of pain treatment in scoliosis
patients using a sagittal realignment brace. Stud Health Technol Inform.
2006;123:582–5.
4. Gallo D. Case reports: orthotic treatment of adult scoliosis patients with
chronic back pain. Scoliosis. 2014;9:18. doi:10.1186/1748-7161-9-18.
5. De Mauroy JC, Vallèse P, Lalain JJ. Lyon conservative treatment of adult
scoliosis. Minerva Ortopedica e Traumatologica. 2011;62(5):385–96.
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The Author(s) Scoliosis and Spinal Disorders 2016, 11(Suppl 2):29 Page 29 of 91