TLSO for Kyphosis

A brace for kyphosis is an anti-flexion orthosis: rather than pushing a sideways curve as a scoliosis brace does, it works against the forward rounding of the upper back, encouraging the spine to extend and straighten. In a growing child this can be an underarm thoracolumbosacral orthosis (TLSO) designed to correct the thoracic curve, or, for higher or larger curves, a full-length brace such as the Milwaukee brace with its extension up to the neck. The aim is to hold the spine in a more extended posture during the years of growth.

The brace applies corrective forces that oppose the kyphosis and encourage extension of the thoracic spine. In a flexible, still-growing spine, sustained bracing can reduce the kyphosis angle and, importantly, encourage the wedge-shaped growing vertebrae to remodel into a more normal shape. Bracing is generally combined with physiotherapy and postural exercises delivered by specialist physiotherapists. As with scoliosis bracing, results depend on the curve being flexible, the child still growing, and the brace being worn consistently.

Kyphosis bracing is generally considered for a skeletally immature adolescent with Scheuermann's kyphosis where the curve is above the normal range, still flexible, and either progressing or large enough to warrant treatment. It is less effective once growth is nearly complete or when the curve is very large and rigid, situations in which a surgical opinion becomes more relevant. Whether bracing is appropriate is a specialist judgement based on the size and flexibility of the curve and the growth remaining.

The evidence supports bracing for Scheuermann's kyphosis in the growing, flexible spine. Classic and more recent series report meaningful reductions in the kyphosis angle during treatment — for example from around 60 degrees down towards 40 — and controlled cohort studies show bracing can halt progression in the great majority of cases. There are two honest caveats. First, some of the in-brace correction is typically lost after the brace is stopped, more so for larger curves, so the realistic goal is to control the curve and improve it modestly rather than to fully normalise it permanently. Second, predictors of a good outcome are well recognised: a flexible curve, an earlier start, a curve that is not too large (broadly under about 65 degrees), a good initial in-brace correction and remaining skeletal growth all favour success, while rigid, very large curves in a nearly mature spine respond poorly. Within its indications, bracing is an effective alternative to surgery for adolescent Scheuermann's kyphosis.

The brace is designed and fitted by a specialist orthotist, worn during the growing years and often combined with physiotherapy. Treatment is monitored in clinic with periodic X-rays to track the kyphosis angle, and the brace is gradually withdrawn as the spine matures, with the curve monitored afterwards.

• —Long-term outcome after brace treatment of Scheuermann's kyphosis: an observational controlled cohort study. (PMC10548888)
• —Scheuermann's kyphosis — long-term results of Milwaukee brace treatment. (PMID 6782681)
• —Successful brace treatment of Scheuermann's kyphosis with different angles. (PMID 28694598 / PMC5490348)
• —The duPont kyphosis brace for the treatment of adolescent Scheuermann kyphosis. (PMID 14577720)
• —Maria Adelaide brace in the management of Scheuermann's kyphosis. (PMC7921048)
• —Treatment stability of Milwaukee brace in idiopathic hyperkyphosis. (PMID 23950552)