Comments on: Efficacy of Bracing versus Observation in the Treatment of Idiopathic Scoliosis (Evid Based Spine Care J 2011;2(2):25-34).

As enthusiastic readers of EBSJ, we thank the authors for the immense work they have done in tackling a difficult and important topic.1 In general, we agree with their conclusions. We also support their call for more reliable evidence. And we share the hope of the editors that large studies currently on the way in North America will provide it. There are, however, two points in their article we are wondering about. The first one is the inclusion of the work by Mannherz et al. According to the inclusion criteria, only publications dealing with adolescent idiopathic scoliosis should be considered. The article by Mannherz et al, however, is reporting on patients with juvenile idiopathic scoliosis. This is declared in the title of the article with the patients' mean age being 7 years. The second point is related to the “Illustrative Case.” This leaves several questions. What is the purpose of the authors having selected this case? Fig. 3 shows a lumbar curve of approximately 44 degrees with marked apical rotation and a thoracic curve of approximately 43 degrees with minimal rotation. No further data are provided (Skeletal age? Menarchal status? Risser grade?). In our opinion, the majority of surgeons using braces would have said at this point that a successful outcome of bracing is very unlikely because the curve magnitude is beyond the generally accepted indication criteria. Provided that the patient would have a significant amount of growth left, some would possibly have started bracing immediately. To wait for further progression and to start bracing 6 months later (lumbar curve 48 degrees, apical rotation increased, Fig. 4) seems very strange. Continuation of bracing at the age of 15 years (lumbar curve 64 degrees, Fig. 7) is also difficult to understand. Necessary core conditions for successful brace treatment are satisfactory in-brace correction and patient compliance. No reliable data are given on that. In the text, it is said that the patient was “extremely compliant.” How was this measured? Unfortunately, both points raised by us skew the picture into the direction of a more nihilistic attitude toward bracing. This could give the reader the wrong impression of possible bias. For the sake of the reputation of the journal, this should be avoided by all means.