How tight should a night time brace be?

[hdugger]

The over-treatment rate is a very small number in JIS cases. These points are nearly irrelevant to reality.

I'm not sure who you're directing your response to. Gayle talked about small (20 degree) curves being braced, and her specific experience with deciding not to run the risk of overtreating her son being validated when his curve spontaneously reduced.
No matter what the overall risk of overtreatment is in these cases, it would be a serious issue for her son, or for anyone's child, who would wear a brace for years in a curve which would have self-corrected on its own.

Likewise, because the long-term risks of VBS are unknown, it appears that the surgeons are being very careful not to overtreat (by making the curve range very narrow). Again, it may not be a huge number of cases that they'd needlessly operate on if they loosened their protocol, but it appears to be something they're keeping in mind.

So, while the numbers are statistically small, they matter very much to the individuals being treated.

[Pooka1]

It didn't occur to me I have to continually state it's over-treatment "IN THE TREATMENT WINDOW."

Comments about curves OUTSIDE the treatment window are irrelevant to this discussion. EVERYTHING outside the treatment window is "over-treatment."

[hdugger]

BTW, the reason I'm (trying) to stick to JIS cases in this thread is because I believe FAHSAI's daughter may fall into this group. At least, my reading of the first post is that she was diagnosed (with, I assume, a smaller curve then she currently has) at age 10 although she is now 11.

So, while I'm (certainly) talking about different treatments here, I'm trying to at least keep it (somewhat) relevant to the case at hand.

[Pooka1]

She fits well within the criteria for AIS. Bringing in JIS issues is not helpful for this girl. It is irrelevant and potentially confusing.

[hdugger]

She fits well within the criteria for AIS. Bringing in JIS issues is not helpful for this girl. It is irrelevant and potentially confusing.

Every guideline I see says it goes up to age 10. Can you show me where you're getting your guidelines from?

[mariaf]

You and your partners in the VBS site have really made a difference for a lot of kids. It's something to be very proud of!



As we have seen, there is no escaping conspiracy theorists.

Thanks, Sharon. There are so many people trying to get the word out so that parents are aware of all the options available to them (parents, medical professionals who gladly answer our many questions, etc.) - I may just be the most visible :-)

And, yes, my daughter went through a phase where you could not bring up anything without her connecting it to some conspiracy theory - thankfully, that phase has passed for the most part - LOL!

[mariaf]

Likewise, because the long-term risks of VBS are unknown, it appears that the surgeons are being very careful not to overtreat (by making the curve range very narrow). Again, it may not be a huge number of cases that they'd needlessly operate on if they loosened their protocol, but it appears to be something they're keeping in mind.

I just don't think the two are related (any potential long-term risks and the surgeons' care not to overtreat with VBS).

The latter is simply because (as has been stated above) no surgeon should perform unnecessary (or in this case, unsuccessful) surgery. There's nothing more to it than that.

[hdugger]

I just don't think the two are related (any potential long-term risks and the surgeons' care not to overtreat with VBS).

The latter is simply because (as has been stated above) no surgeon should perform unnecessary (or in this case, unsuccessful) surgery. There's nothing more to it than that.

Thanks Maria. I wanted to clear up one thing in my earlier posts about bracing and JIS. I'm much more familiar with the AIS literature on this topic. So, when the research article I found reported similar success rates in JIS kids (assuming you controlled for compliance), it jibed with what I knew. But Gayle's comment about most kids in braces still needing surgery makes it sound as if bracing works very differently in this population. Is the general thinking that JIS kids over a certain degree (30 or 35) just are going to progress to surgery in braces and all you're trying to do is slow them down? that is, is bracing considered ineffective in halting progression in this population (although it might slow it somewhat)? I feel as if I'm hearing both things (that it holds curves and that it doesn't) and I'm trying to figure out what the general understanding is.

[mariaf]

But Gayle's comment about most kids in braces still needing surgery makes it sound as if bracing works very differently in this population. Is the general thinking that JIS kids over a certain degree (30 or 35) just are going to progress to surgery in braces and all you're trying to do is slow them down? that is, is bracing considered ineffective in halting progression in this population (although it might slow it somewhat)?

If you asked me my personal opinion of what I believe after a decade of being around JIS, I would say that all you are trying to do is slow them down.

I know a lot of parents who were told by various, well-respected orthos that their child (who presented with, say, a 35 or 40 degree curve) was going to almost certainly need fusion at some point. I would agree with this. Again, just my personal view - but I find it hard to picture it turning out differently. Assuming that the brace can at best maintain the curve (and I have seen no proof to the contrary with regard to curves of this magnitude), where does that leave the patient? Also, this is assuming LONG-TERM, FULL COMPLIANCE with wearing the brace. Having raised 3 kids who are now 25, 22 and 15, I can tell you that is an assumption of enormous proportion.

[hdugger]

If you asked me my personal opinion of what I believe after a decade of being around JIS, I would say that all you are trying to do is slow them down. .

Thanks, Maria. As always, your experience in this area is invaluable.

[Pooka1]

If you asked me my personal opinion of what I believe after a decade of being around JIS, I would say that all you are trying to do is slow them down.

I know a lot of parents who were told by various, well-respected orthos that their child (who presented with, say, a 35 or 40 degree curve) was going to almost certainly need fusion at some point. I would agree with this. Again, just my personal view - but I find it hard to picture it turning out differently. Assuming that the brace can at best maintain the curve (and I have seen no proof to the contrary with regard to curves of this magnitude), where does that leave the patient? Also, this is assuming LONG-TERM, FULL COMPLIANCE with wearing the brace. Having raised 3 kids who are now 25, 22 and 15, I can tell you that is an assumption of enormous proportion.

That's my sense, also.

Over-treatment, while a HUGE problem in AIS, never really seems to be an issue in JIS either because you simply have to try to slow the bigger curves ahead of a definitive fusion or because VBS and bracing can decrease smaller JIS curves and avoid definitive fusion. I seriously doubt anyone thinks in terms of "over-treatment" with JIS. It's a game of finding the least burdensome treatment for the best outcome.

VBS and tethering are the best hopes for these kids in my own opinion.

[hdugger]

VBS and tethering are the best hopes for these kids in my own opinion.

I don't know that VBS is available for the kids Maria is talking about - those JIS patients presenting with 35 to 40 degree curves. Betz (at least) is not offering VBS above 35 degrees. Perhaps other centers are.

[hdugger]

I don't know that VBS is available for the kids Maria is talking about - those JIS patients presenting with 35 to 40 degree curves. Betz (at least) is not offering VBS above 35 degrees. Perhaps other centers are.

And tethering, at least according to this - http://www.vertebralstapling.com/upl...NG_May2012.pdf - is targeted at 10 and over (to avoid the risk of over-correction).

I'm not sure what the JIS kids with curves over 35 degrees are doing.

[Pooka1]

I don't know that VBS is available for the kids Maria is talking about - those JIS patients presenting with 35 to 40 degree curves. Betz (at least) is not offering VBS above 35 degrees. Perhaps other centers are.

I wasn't addressing that.

[mariaf]

I don't know that VBS is available for the kids Maria is talking about - those JIS patients presenting with 35 to 40 degree curves. Betz (at least) is not offering VBS above 35 degrees. Perhaps other centers are.

Virtually every child with a curve under, say, 50 degrees or so falls into either the VBS or VBT (tethering) category AS LONG AS they have enough growth remaining.

It's not completely cut and dry. You mentioned that tethering is aimed mainly at kids 10 and up. Yes and no. The majority of tethering patients are 10 or older. However, let's say that a 9 year-old child presented with a 38 degree curve and was not overly flexible upon bending x-ray, they might very well be accepted as a tethering patient. If they were extremely flexible, then perhaps they'd be considered for VBS.

I've really never heard of anyone being told that they were not a candidate for either procedure unless they were either too skeletally mature OR they had a very large curve. But absent those factors, the doctors take everything into consideration and decide which procedure is best.

Hope this is helpful.