Outcomes of high-compliance bracing in patients with severe adolescent idiopathic scoliosis declining operative intervention.

BACKGROUND: Surgery is typically recommended for patients with severe adolescent idiopathic scoliosis (AIS); however, some patients explicitly refuse due to concerns about surgical risks and other factors. Conventional wisdom suggests that bracing has limited effectiveness for severe cases, yet evidence for this specific population remains insufficient. METHODS: This single-center retrospective cohort study included patients with severe AIS (Cobb angle >40°) who met surgical indications but refused surgery during the study period (January 2021 to April 2025). All patients received custom-fitted Chêneau braces; a dual-verification compliance was monitored using a dual-verification approach (structured daily diaries cross-checked against physician-assessed skin indentation grading). Multivariate linear regression was used to analyze predictors of treatment outcomes. RESULTS: A total of 82 patients were enrolled, with a mean follow-up of 14.4 ± 2.1 months. The overall correction rate was 18.0% ± 14.0%, with 56.1% of patients achieving a Cobb angle below 40°, and 39.0% showing improvement greater than 10°. Multivariate analysis revealed that daily brace-wearing time was an independent predictor of correction rate (each additional hour increased the correction rate by 1.88%, P = 0.003). In the high-compliance group (>16 h/day), 71.7% of patients achieved a final Cobb angle below 40°. The four core domains of the SRS-22r quality-of-life questionnaire (function/activity, pain, self-image, and mental health) demonstrated significant improvement, and treatment satisfaction was high at final follow-up. Patient motivation showed a strong positive correlation with wearing time (r = 0.654). Complications were infrequent. CONCLUSIONS: For patients with severe AIS who refused surgery, conservative bracing achieved satisfactory short-to-mid-term outcomes with a favorable safety profile within a shared decision-making framework. Actual daily wearing time demonstrated the strongest independent association with radiographic outcomes among measured variables, while patients' intrinsic motivation showed a strong correlation with compliance, suggesting a potential indirect pathway to improved outcomes. It should be emphasized that this study did not establish bracing as equivalent or superior to surgical correction in severe AIS.