It can be bloodless or surgical.
The surgical therapy must be proposed for serious curves considerably greater than 40 degrees, in which – according to the clinical seriousness – respiratory insufficiency, an inacceptable aesthetic look, the failure of a corset and the progress of the curves in adults’ age constitute the most suitable indication.
The bloodless therapy is still essentially based on the orthopaedic corset as the only effective means against progressive idiopathic scoliosis; some other rules too are of primary significance, namely:

• Avoiding hypertreatment, i.e. the prescription of a corset for a non-developing deformity (further on we will see why it is more important to base ourselves on the extent of and increase in the hump rather than on the angular values of repeated X-rays)
  

• Avoiding corsets with wide stiff surfaces in contact with the ribcage, which can cause further deformities such as verticalizations for the ribs, reduced development of the ribcage with a limited pulmonary respiratory capacity (the Lyonnese, Cheneau, Boston corsets and some others have detrimental effects).

• Evaluating the deformity in a thee-dimensional sense: in case of an associated worsening of sagittal curves – such as hyperkyphosis or hypokyphosis – considering precocious surgery instead of the corset.

• Favouring the patient’s collaboration and “compliance”: this depends mainly on the comfort of the corset and on the aesthetic damage this can involve (leather on the pelvic girdle rather than plastic, for example – which is hardly born in the summer months).
  
  
• Following the application times of the corset (full time or defined time).

As we will see further on (in the biomechanics of the MW corset), the treatment of idiopathic scoliosis must be directed towards the curves which do not exceed
40 / 45 degrees in radiographic terms, beyond which surgery is recommended.
The corsets used in our treatment are the following:
A) MILWAUKEE CORSET
B) LOW MILWAUKEE CORSET (without the cervical ring)
C) RIVIERA CORSET

A ) MILWAUKEE CORSET (MW) (fig. 16)
Used in all the curves of idiopathic scoliosis.
At first it was proposed in 1946 by Blaunt and Schmidt and consists of a well-moulded pelvic section (pelvic grip) and two rear rod with a single front rod which connect the pelvic section to the cervical ring: this latter has a grip moulded on the throat and two occipital supports; suitable posterolateral thrusts (pressure pads) are mounted onto the rods so as to correct the specific deformity or deformities (fig. 17). The first phase in the manufacturing of the corset is the pelvic section: this is adapted individually to each patient and made using a plaster cast – at first negative – from which the positive model is obtained (fig. 18); this model is then further modified flattening the abdominal area and kyphotizing the lumbar lordosis. The model of the pelvic grip is covered using leather (preferably with plastic material); this leather pelvic grip is properly finished (on the back side, on the buttocks, and at the front just above the pubes) in order to allow a 100° flexion of the hips; the rods are connected to the cervical ring and finally joined by established pressure pads.

Biomechanics
The MW corset acts according to the principle of the three points:
1st point: corrective thrust above the convexity of the curve on the top of the hump.
2nd and 3rd points: another two thrusts, the one on the side of the pelvic grip and the other one on the same side as the cervical ring, both situated on the side opposite the 1st point (fig. 19).
At first, another corrective principle – called traction or elongation principle – was associated to the MW corset through the cervical ring: the uselessness of this principle can be shown through this simple experiment (fig. 20): if we pull the edges of a metal bar bent by 90°, we can straighten it from 90° to no more than 40°; going on pulling, the residual curve is not eliminated, while it can be more easily straightened with the simple lateral pressure. This is the reason why the bloodless treatment is performed with the corset for the correction of curves reaching at most 40°: for curves exceeding 40°, the surgical correction is the most indicated one.
In the MW, the cervical ring is spaced out from the chin and from the occiput so as to avoid causing – as it used to occur in the past – mandibular deformities; it only has a function of connecting the dorsal and frontal rods.

The adaptation to the MW corset (and the other corsets) occurs gradually in approximately 15 days, wearing it progressively – in this period – until reaching the prescribed time (be it partial or full).
The corset is always worn on a shirt, bodysuit or seamless tubular vest: the vest cannot have any creases while being worn.
With the corset all sports and physical activities can be performed except from those involving contact (soccer, hockey, etc.), gymnastics (trampolining, acrobatics, etc.), water-skiing and swimming; swimming can be allowed for 1-2 hours without corset.
The weaning from the corset occurs – once the osseous maturity has been reached – (Risser 5) progressively, gradually increasing then removal time until succeeding in wearing it only at night for 6 months-1 year.

B) LOWERED MILWAUKEE CORSET (without cervical ring) (fig. 21)
It is used in case of a low simple thoracic scoliosis – apex T9 – as well as of a thoracolumbar scoliosis. It is identical to the previous corset; for the elimination of the cervical ring it proves to be better accepted by the patient because it is easier to hide.

C) RIVIERA CORSET (fig. 22)
It is used for the bloodless treatment of lumbar scoliosis and thoracolumbar scoliosis with apical vertebra on T12.
The corrective forces of this simple tutor act in the three following points:
1st point = the thrust pad on the top of the hump
2nd point = the pelvic grip
3rd point = the subaxillary support on the opposite side

The mechanical principles are inspired by those of the MW corset, providing both a passive and active corrective action. The particularly important detail is the moulding of the side upright on the side opposite the side thrust pad so as to allow the translation of the trunk induced by the pad itself with its pressure. A possible thoracic thrust pad prevents a possible worsening of the thoracic compensation curve, which is sometimes favoured by the forces acting upon the main curve.
Since there are no wide zones of rigid contact with the thorax, the corset cannot cause –thoracic deformities – rib verticalization – drop in the respiratory capacity.
Easy to hide, it does not cause any aesthetic damage, and is therefore easily accepted by patients and parents.

Methodology of the treatment
As for the diagnosis and prognosis, for the therapy too it is the hump itself to guide us in facing the cure of idiopathic scoliosis, from the very first observation up to the osseous maturity; the hump is not only the most evident aspect but also the most important one: the treatment based on the use of corsets through the measurement of the hump will lead us to limit the angular evaluation of the curves on the X-rays, reducing the radiological exposures during the long curse of the disease.
Once the corset has been worn, in the periodical visits every 3-4 months it will be the hump – remaining unchanged or, vice versa, improving by decreasing – to stress the basic concept of the bloodless treatment: the corset stops the evolutionary potential improving the patient’s aesthetic aspect and this means that a corset made according to the state of at, well-worn and controlled in the prescription will avoid a worsening over time.
According to the chronological age and to the seat of the curve(s), we act as follows:

TREATMENT OF INFANTILE IDIOPATHIC SCOLIOSIS (0-3 years)
In most cases, the hump stable or decreasing during the clinical tests does not require any corset treatment, but just observation (scoliosis often disappears spontaneously). In cases characterized by an increase in the hump and curve in the X-rays, the bloodless therapy with a MW corset (well tolerated by the child) or plastered corset will become necessary.
In extremely rare serious cases and highly susceptible of developing, we have recourse to a surgical treatment.

TREATMENT OF JUVENILE IDIOPATHIC SCOLIOSIS (from 4 years-to the beginning of puberty)
It is always the hump(s) to guide us – through their increase – in choosing the corset therapy. The evolution in youth years is variable: the serious curves of this period can be residuals of the infantile evolutionary variety, but most of these children can start the disease around the age of 6 and then develop and stop at the age of 8; then it will begin to increase again with the nearing of puberty. In these years of pre-adolescence the school screening programmes are particularly useful.

TREATMENT OF TEENAGE IDIOPATHIC SCOLIOSIS (beginning of puberty –vertebral osseous maturity)
It is above all during childhood when some subjects suffering from idiopathic scoliosis show small non-evolutionary curves, while other, on the contrary, show considerably serious curves.
At the beginning of adolescence, all the ossification centres become unusually active ad bring about a quick increase in height, so that curves moderately structured in the juvenile period, or new curves, can rapidly increase.
As regards the type of corset used according to the seat, see
Tables 2 – 3 – 4 - 5.