This 2008 Lancet seminar by Weinstein et al. reviews the epidemiology, genetics, natural history, and management of AIS. It asks what we actually know — and do not know — about why curves progress, whether bracing works, and what surgery achieves long-term. The paper is as notable for the evidence gaps it names as for the data it summarizes.
40° at age 16 → 70% risk
40° at age 10–12 → 100% risk
The surgical threshold of Cobb >45° and the bracing indication of 25–40° in a skeletally immature patient were both standard of care long before this paper — but Weinstein explicitly showed that bracing's efficacy rested on a single non-randomised study that had never been replicated.
When a family asks whether the brace will prevent surgery, the honest answer in 2008 was: we do not know for certain. This paper named that gap, which directly catalyzed the BrAIST trial (Weinstein et al., NEJM 2013). The RCT that finally provided Level I evidence that bracing reduces progression to surgical threshold.
In clinic, use Table 1 to frame shared decision-making: a 12-year-old with a 35° curve has a 90% progression risk. That is a very different conversation than a 15-year-old with the same curve (70% risk) or a 16-year-old with a 20° curve (10% risk).
Radiographic correction does not equal a better life. Long-term data consistently show QOL is similar across treated and untreated groups. Which means patient-reported outcomes and cosmetic concerns should drive the decision to treat, not Cobb angle alone.
This 2008 Lancet seminar by Weinstein et al. reviews the epidemiology, genetics, natural history, and management of AIS. It asks what we actually know — and do not know — about why curves progress, whether bracing works, and what surgery achieves long-term. The paper is as notable for the evidence gaps it names as for the data it summarizes.
40° at age 16 → 70% risk
40° at age 10–12 → 100% risk
The surgical threshold of Cobb >45° and the bracing indication of 25–40° in a skeletally immature patient were both standard of care long before this paper — but Weinstein explicitly showed that bracing's efficacy rested on a single non-randomised study that had never been replicated.
When a family asks whether the brace will prevent surgery, the honest answer in 2008 was: we do not know for certain. This paper named that gap, which directly catalyzed the BrAIST trial (Weinstein et al., NEJM 2013). The RCT that finally provided Level I evidence that bracing reduces progression to surgical threshold.
In clinic, use Table 1 to frame shared decision-making: a 12-year-old with a 35° curve has a 90% progression risk. That is a very different conversation than a 15-year-old with the same curve (70% risk) or a 16-year-old with a 20° curve (10% risk).
Radiographic correction does not equal a better life. Long-term data consistently show QOL is similar across treated and untreated groups. Which means patient-reported outcomes and cosmetic concerns should drive the decision to treat, not Cobb angle alone.