Severe axial vertebral rotation: Boston Brace

Severe axial vertebral rotation treated with a modified Boston brace: a case report

Authors: Eustathios I Kenanidis, Michael E Potoupnis

Abstract
We report the case of a 13-year-old Caucasian girl suffering from severe axial rotation of the T5 to L4 vertebrae. The patient (initially examined during a school screening study) was at first considered to be suspicious of suffering from scoliosis due to a highly positive Adam's forward bending test. However, her radiographic evaluation revealed the existence of axial rotation in 12 of her vertebrae, without inclination in the sagittal and coronal planes. After an observation period of 12 months and due to the fact that both her physical appearance and the measured vertebral rotation deteriorated, the patient was given a modified thoracolumbar Boston brace that had an immediate positive derotational effect on all but two vertebrae. Twenty four months later, the progress of the vertebral rotation(s) seems to have been halted and most affected vertebrae appear to be stabilized in their new, 'post-brace', reduced position, with better results shown when the Boston brace is worn. The patient remains under constant medical observation. The application of a modified Boston brace seems to have served well (so far) a useful purpose for reducing and stabilizing this case of severe axial vertebral rotation, providing less deformity and (possibly) offering a better final cosmetic result.

Background
Adolescent Idiopathic Scoliosis (AIS) is a complex three-dimensional deformity of the spine [1]. The normal, non-scoliotic spine on the other hand demonstrates a pre-existent pattern of minimal axial vertebral rotation that somewhat corresponds to what is seen in the most prevalent types of thoracic idiopathic scoliosis [2]. It is rather uncommon [3] for a patient to be diagnosed with a condition (such as vertebral rotation in the horizontal plane without inclination in the sagittal and coronal planes) that seems to lie somewhere 'in the middle' between a normal and a scoliotic spine. This clinical entity is usually accompanied by minimal clinical deformity and (although rarely) it can interfere with the results of scoliosis screening studies, often leading to a false diagnosis of scoliosis and unnecessary radiographic examination [3]. Whether this deformity is an independent clinical entity or a precursor to structural scoliosis is currently not well understood [4].

Boston brace has been widely used for the treatment of children suffering from AIS [5-7]. This brace seems to beneficially affect the natural history of scoliotic children [5] with moderate influence on their quality of life [6,7]. However, no such treatment has ever been reported for patients suffering from axial vertebral rotation in the horizontal plane.

According to the best of our knowledge, this is the first report of a patient suffering from axial vertebral rotation in the horizontal plane, who was treated with the application of a modified Boston brace. Aim of this study is to remind the reader that, although it is not very frequent, axial vertebral rotation does occur, it is often misdiagnosed and/or may lead to a false diagnosis of scoliosis. Furthermore, it is not uncommon for this clinical entity to be accompanied by substantial physical deformity; hence a careful evaluation of all patients suffering from this deformity must always be performed.

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