Determining the Best Indications for Initiating Brace Treatment for Adolescent Idiopathic Scoliosis

Bracing is the mainstay treatment for preventing adolescent idiopathic scoliosis (AIS) progression and the main purpose for treatment is to prevent deformities from reaching the surgical threshold. It has been shown to be effective at reducing curve progression especially in patients with good compliance to treatment. However, bracing should not be used indiscriminately as certain complications have been reported. Bracing too early is safe for curve control but may subject children to prolonged discomfort with the bracing and increased consumption of resources for periodic brace fabrication. Prolonged bracing also reduces spinal mobility, lead to poor body image and self-esteem, and worsen quality of life. Additional risks of osteoporosis and muscular atrophy may also occur. Hence, being able to initiate prompt and appropriate bracing is crucial for achieving optimal curve control and avoiding complications.

Yet, there are still have difficulties identifying patients who may deteriorate. Generally speaking, skeletally immature AIS patients with curves of 20-40 degrees should consider bracing. However, not all of these patients require bracing and some may not need any treatment. More importantly, the resulting curve magnitude on radiographs may not correlate directly with health-related quality of life (HRQOL) measures. As such, the relationship of the Cobb angle prior to initiating brace treatment with long-term HRQOL measures is unknown. The above suggest that there is a significant gap in our knowledge of the optimal timing of brace initiation for managing AIS patients.

In the current setting of rising health-care expenditures, it is also important to assess the "value" of management options and provide the best and cost-effective care for our AIS patients without compromising outcomes or safety. Some clinicians may be more aggressive by bracing children with minor curves while some are content with prescribing braces only when deterioration occurs in moderate curves. In this modern era of healthcare, there is increasing emphasis placed on monitoring and controlling health-care costs to the patient, hospital and insurance companies. Hence, it is an appropriate time to consider the relationship of cost-effectiveness factors and HRQOL measures in designing bracing protocols for AIS patients. With increasing health-care costs, consumption of resources, and the imperative to provide the best healthcare to these children, and focus on a cost-effective delivery of care.

It is thus timely for us to perform this prospective cost-effectiveness comparative study to identify the best indications for initiating brace treatment for AIS patients. Evidence for the best HRQOL outcomes at the lowest cost from both the patient and health-care perspective is necessary to further improve the care for AIS patients. There is potential for the derived model to be applied in other healthcare systems by using a more personalized approach.

For this study, the investigators will utilize mathematical modeling based on factors including initial Cobb angle, maturity status, brace duration, and HRQOL measures to determine the best cost-effective indications for brace treatment. Outcomes will be dependent on the Cobb angle at the end of bracing, HRQOL measures and the overall costs incurred to patients and infrastructure. Our hypothesis is given an AIS patient with significant growth potential, a Cobb angle of 25 degrees is most cost-effective for initiating bracing. On the contrary, bracing for subjects with Cobb angles of 40 degrees or more is not cost-effective regardless of remaining growth.