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Computerized Medical Imaging and Graphics 31 (2007) 614–624

A 3D visualization tool for the design and customization of spinal braces

D. Fortin a,b , F. Cheriet a,b,∗ , M. Beauséjour a , P. Debanné b , J. Joncas a , H. Labelle a
a Research Center of Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine, Montréal,
Québec, Canada H3T 1C5
b École Polytechnique de Montréal, P.O. Box 6079, Succursale Centre-ville, Montréal, Québec, Canada H3C 3A7

Received 27 March 2006; received in revised form 19 June 2007; accepted 16 July 2007

Abstract
A new tool was developed and validated on an X-ray dummy to allow personalized design and adjustment of spinal braces. The 3D visualization
of the external trunk surface registered with the underlying 3D bone structures permits the clinicians to select pressure areas on the trunk surface for
proper positioning of correcting pads inside the brace according to the patient’s specific trunk deformities. After brace fabrication, the clinicians can
evaluate the actual 3D patient–brace interface pressure distribution visualized simultaneously with the 3D model of the trunk in order to customize
brace adjustment and validate brace design with respect to the treatment plan.
© 2007 Elsevier Ltd. All rights reserved.

Keywords: 3D reconstruction; X-ray images; Surface topography; Boston Brace System; Scoliosis

1. Introduction biomechanical action of the brace on the patient, using a three

Adolescent idiopathic scoliosis (AIS), the most common type
of scoliosis [1], is a musculo-skeletal disease that induces a three-
dimensional deformity of the trunk [2]. This disorder usually
appears during adolescent growth and progresses until skeletal
maturity [3,4]. Its etiology remains unknown and its prevalence
ranges from 2 to 3% [3–5]. According to Weinstein, 10% of
adolescents diagnosed with AIS require medical intervention
[6].
Bracing is the most common non-operative treatment to pre-
vent progression or even reduce spinal scoliosis curvatures [7].
Many bracing systems exist but the Boston Brace System is one
of the most widely used thoracolumbosacral orthosis (TLSO) in
North America [8,9]. Introduced in 1971 by Hall and Miller [8],
the basic design evolved into the actual Boston Brace System
[9] (Fig. 1). The rigid girdle is made from polystyrene and is
tightened around the trunk with two straps closing the poste-
rior opening. Foam pads, inserted inside the brace, enable the
∗ Corresponding author. Tel.: +1 514 340 4711/4277; fax: +1 514 340 4658.
E-mail addresses: impala07@hotmail.com (D. Fortin),
farida.cheriet@polymtl.ca (F. Cheriet), marie.beausejour@umontreal.ca
(M. Beauséjour), philippe.debanne@polymtl.ca (P. Debanné),
julie.joncas@recherche-ste-justine.qc.ca (J. Joncas), hubert.labelle@recherche-
ste-justine.qc.ca (H. Labelle).
or four pressure point principle.
The patient usually has to wear his brace 18–20 h a day until
skeletal maturity. Thus, bracing treatment is long, expensive
and may produce unwanted physical and psychological conse-
quences [10]. In order to prescribe an adequate brace for scoliotic
patients, many techniques have been suggested to personalize its
design and its adjustment. Fig. 2 summarizes the evolution of
the techniques developed for brace design.
According to the traditional method, the design process
begins with the acquisition of a postero-anterior radiograph
from which the orthotist makes a blueprint. The brace can be
built from prefabricated standardized symmetrical modules cho-
sen on the basis of the patient’s physical dimensions or using
a plaster cast of the patient’s trunk (Fig. 3). In the last case,
a sheet of polystyrene is heated and deformed on the plaster
trunk. In Sainte-Justine Hospital, the clinical team uses a bracing
approach very similar to the Boston Brace System and usually
relies on the use of a plaster cast for better customization of
the brace. The orthotist finalized the brace fabrication by adding
pads inside the brace according to the treatment plan taken from
the blueprint [8].
The main drawback of the standard procedure is that the
design process is based only on a 2D image of a complex 3D
deformity [11,12]. Therefore, this method is dependant on the
experience of the orthotist and on his ability to put into practice
the correction mechanisms in 3D.

0895-6111/$ – see front matter © 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.compmedimag.2007.07.006
 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624 615

Fig. 1. Photos of the Boston Brace System (front, back and top views).

Fig. 2. Classification tree for the design techniques of the Boston Brace System.

In the early 1980’s, Perdriolle, Graf and Dubousset empha-
sized the importance of a 3D evaluation of AIS [11,12] and
it was assumed that a 3D visualization of the trunk bone struc-
tures could improve the brace treatment. Several techniques have
been developed for the 3D reconstruction of the spine and rib
cage from biplanar radiographs [13–17]. A stereo-radiographic
method has been developed and used at Sainte-Justine Hospi-
tal over the past decade in order to reconstruct 3D spines, as
summarized in Section 2.1 [14,18].
At the beginning of the 1990’s, optical techniques were intro-
duced for acquiring the external geometry of the trunk, in order
to provide a non-invasive approach for the 3D evaluation of sco-
liotic deformities [19]. Optical techniques are generally based
on spatial triangulation combined with passive or active vision
systems. Passive vision systems allow the 3D reconstruction of
the scene from multiple images obtained from different points
of view. Belmajdoub used this methodology to design a bracing
system from the 3D reconstruction of the trunk surface [20].

Fig. 3. Major steps of the traditional brace design process. After X-ray acquisition (a, b), the orthotist creates a blueprint or a plan of the Boston Brace System (c).
The polystyrene module is deformed on the plaster cast of the scoliotic patient (d).
616 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624
Fig. 4. Classification tree for the adjustment techniques of the Boston Brace System.
On the other hand, active vision systems have the advantage
of avoiding the complex process of extraction and matching
of features on a pair of images. Several researchers have used
active vision systems to reconstruct the surface of the trunk ([21],
using laser light; [19,22], using visible light). These processes
have proven useful to bypass the unpleasant, long and expensive
plaster cast operation [23].
After its fabrication, the brace is generally adjusted on the
patient to verify the quality of the obtained correction. Clini-
cians are unable to visualize the biomechanical action of the
brace since the areas of pressure applied by the brace are not
visible when the patient is wearing it. Therefore, only the imme-
diate geometrical correction can be documented by radiographic
evaluation. Researchers [24–33] have suggested evaluating the
action of the brace by characterizing pressure distribution at the
trunk–brace interface using pressure sensors (Fig. 4).
However, clinicians have to mentally visualize the pressure
values on the 3D surface of the trunk since most of the developed
techniques display the values in 2D. Furthermore, the number
of sensors used in these systems is very limited and does not
allow coverage of the entire trunk of the patient. Moreover,
mechanical, pneumatic and electro hydraulic sensors are thick,
which may result in some modifications in the measured pressure
values.
Côté et al., and later Petit et al., have used a set of 192 thin
polymeric force sensing resistors mounted on a flexible mat
[31–33], which covers the entire trunk of the patient (Vistamedi-
cal Inc., Winnipeg, Canada). The pressure readings are dynamic
and a graphical interface was developed to display these val-
ues around the 3D reconstruction of the bone structures of the
patient. This is achieved by reconstructing the sensors’ connect-
ing wires as obtained from a radiographic acquisition of the
patient wearing the brace and the pressure mat. This procedure
is innovative but requires half a day of computer treatment and
manual processing by a technician and the radiopaque wires
inside the mat can decrease the quality of the X-ray images by
masking certain anatomical landmarks. In addition, the shape of
the mat does not replicate the exact shape of the patient’s trunk.
Despite all these research efforts, most brace designs for rou-
tine clinical use are still achieved using a single postero-anterior
radiograph, thus relying on a projection of the spine in a 2D
plane. Furthermore, the adjustment of the brace on the patient
requires the acquisition of another set of radiographs to eval-
uate the immediate correction. Therefore, the objective of this
study was to develop and validate a visualization software tool to
help clinicians improve the design, fabrication and adjustment
of spinal braces in 3D.
2. Materials and methods
The proposed study includes the description of an original
clinical protocol and the techniques used for the development of
the brace design and adjustment software tool. The protocol is
divided into three chronological steps: (a) an initial patient visit
to the scoliosis clinic for brace prescription, (b) the fabrication
of the brace and (c) a second patient visit for brace evaluation
and adjustment. The two visits are separated by a period of about
a month. For the feasibility study, the evaluation of the methods
was performed on an X-ray dummy and the protocol was eval-
uated in the clinical setting with two patients. Fig. 5 provides
an overall view of the clinical protocol, the outputs from the
successive processing steps and the validation steps undertaken.
2.1. Design of the brace
The first patient visit in the protocol occurs when a brace
is prescribed by a clinician at the scoliosis clinic and consists
in the acquisition of the external and internal geometries of the
patient’s trunk in order to build a complete 3D model. First, a
pressure mat (PM) is adjusted around the trunk. A new mat with
 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624 617

Fig. 5. Main steps of the proposed computerized design and adjustment process, as well as the validation steps undertaken. Items are grouped according to the time
steps.

more flexible, lighter, and robust sensors was designed (Vis-
tamedical Inc. and Verg Inc., Winnipeg, Canada). In addition,
the new shape of the mat better fits the trunk of young adoles-
cents. The PM is held by two shoulder straps marked at regular
intervals and is secured at the back with two Velcro fasten-
ers. Once fastened, the shoulder straps’ adjustment is recorded
using the markings (in order to reproduce the PM adjustment
at the second visit). Twelve markers (each consisting of a 2 cm
wide radiopaque metal cross-mounted on a flat round button) are
placed on the trunk surface in order to indicate the PM’s limits:
four markers are used in the front along the PM’s approximate
vertical midline and eight in the back (four on each side of the
two wrapping ends) (Fig. 9). The PM is then removed and the
trunk external geometry is acquired.
Surface acquisition of trunk geometry is achieved using four
3D optical digitizers (3D Capturor, InSpeck Inc., Montreal,
Canada; [34]). Each digitizer includes a structured light projector
and a CCD camera connected to a computer. For the acquisition,
618 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624
Fig. 6. Acquisition system for the external geometry of the trunk: configuration
of digitizers in examination room and fringe patterns projected on the X-ray
dummy.
the subject stands in erect position in the center of the set-up
(Fig. 6). The four projectors are turned on in succession and
project structured light, i.e. a pattern of black and white narrow
stripes which is deformed by the trunk’s external shape. The
fringe pattern is shifted three times, thus each CCD camera cap-
tures four fringe images. In addition, a fifth image without the
fringes, allowing texture mapping on the reconstructed geom-
etry, is also acquired by each camera. The complete process
requires around 4–6 s [35].
Afterwards, the patient is sent to the radiology department and
X-ray images are acquired for the purpose of 3D reconstruction
of the trunk bone structures along with the 12 markers [14,18].
The standard views used to reconstruct the internal 3D geometry
are one lateral (LAT) and two postero-anterior radiographs (PA
and PA-20◦ , the latter obtained with the X-ray tube raised and
angled downward 20◦ from the horizontal) of the spine, pelvis
and rib cage, taken with a digital Fuji FCR X-ray acquisition
system which has been used routinely at Sainte-Justine Hospital
over the past decade (Fig. 7a). The X-ray set-up is equipped with
a reference object composed of two acrylic sheets containing 55
embedded radiopaque beads. The calibration procedure for 3D
Fig. 7. Processing of the internal geometry data. (a) Radiographic set-up used in Sainte-Justine Hospital; (b) and (c) digital X-rays showing the identification of the
landmarks: lateral view in (b) and PA view in (c); (d) 3D reconstruction of the spine, rib cage and pelvis.
reconstruction of anatomical landmarks utilizes this reference
object.
During the month following the first visit, both the inter-
nal and the external data are processed. For the internal trunk
geometry, anatomical landmarks, as well as the 12 markers,
must be manually identified and matched on at least two X-
ray images by a trained technician (Fig. 7b). To reconstruct the
spine, six anatomical landmarks per vertebra (centers of supe-
rior and inferior vertebral endplates and the tips of both pedicles)
are identified on the PA and LAT views. The reconstruction of
the pelvis is obtained from 20 corresponding landmarks digi-
tized on the PA and LAT views as well. To reconstruct the rib
cage, the two PA views are considered and lines are drawn along
the centre of each rib image on both views. Eleven equidistant
points are marked on each of the lines in the first view and
the corresponding points in the second view are then inferred
from the epipolar constraint. The 3D reconstruction of the iden-
tified anatomical landmarks is achieved using an adaptation of a
standard close-range photogrammetry method called the Direct
Linear Transform (DLT) algorithm (Fig. 7c) [36]. This method
is well documented in the literature and has often been used for
the reconstruction of anatomical structures [18,37–39].
For the external trunk geometry, each digitizer acquires four
fringe images as well as a texture image using FAPS (Fringes
Acquisition and Processing Software, InSpeck Inc.). This device
uses Phase-Shifted Moiré projection, an interferometry mea-
surement method and an active optical triangulation technique
to reconstruct 3D textured surface models [34].
Spatial relations between the digitizers are established pre-
viously by a calibration procedure, in order to allow merging
of the 3D polygonal surfaces obtained from the four digitizers.
Thus, using this spatial information, EM (Editing and Merging,
InSpeck Inc.) software automatically merges the partial views
together to create a single 3D model. Textures from the various
images are also merged and mapped onto the surface model.
The 3D coordinates of the 12 markers placed on the trunk skin
to identify the pressure mat limits can then serve as the basis for
registering the internal and external geometries. The 3D radio-
graphic reconstruction file provides the set of 12 points in the
internal reference frame. Manual identification of the markers
on the textured surface model provides the set of 12 points in
 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624
the external reference frame. The two 3D point sets are then
brought into the same reference system using a point-to-point
least squares algorithm [40]. This algorithm searches for the
best rigid transformation in order to match the 12 corresponding
points from both geometries. This mathematical transformation
is then applied to the whole set of 3D points from the exter-
nal geometry to bring it into the same reference system as the
internal geometry.
The design and adjustment tool comprises a software inter-
face for visualizing the patient geometries. As a result of the
registration process, the 3D models of the trunk skeleton and
surface of the subject can be loaded and displayed in the soft-
ware interface in superposition by applying transparency to the
trunk surface. This allows the orthotist to easily determine where
pressure pads are needed on the 3D surface to correct the defor-
mity. A notepad incorporated in the software allows the user to
manipulate the 3D models in order to select clinically relevant
viewpoints and to draw contours for the desired pressure areas
inside the brace, as well as trim lines and areas of relief (void).
This treatment plan is then submitted to the prescribing clini-
cian and upon approval it is used by the orthotist to build the
brace.
The validation of this design process was performed using
32 markers placed on the external surface of an X-ray dummy.
The 12 markers identifying the PM limits were used for
internal–external geometries registration; the 20 remaining
markers were distributed over the whole trunk surface and used
as the test set for registration error computations. More specif-
ically, in the front, 8 markers were placed on the left and right
sides of the vertical midline; in the back, 12 markers were dis-
tributed over the left and right posterior aspects of the ribs and
along the back valley (Fig. 8). After the acquisition and 3D
reconstruction of both geometries, the point-to-point registration
algorithm was performed using the 3D positions of the mark-
ers provided by both acquisition systems and the overall fit was
assessed. The landmark identification and registration proce-
dures were repeated three times to assess stability of results. In
addition, a preliminary study was conducted using the above-
described approach with two scoliotic patients as a feasibility
evaluation of the protocol in the clinical environment and to
test the effect of patient movement between the two acquisition
modalities on registration precision.
Fig. 8. Results of registration of internal and external geometries for the X-ray dummy. (a) Internal geometry; (b) external geometry; (c) and (d) registered geometries
(back and lateral views).
619
2.2. Adjustment of the brace
The second goal of the software is to assist the orthotist and
clinician in properly adjusting the spinal brace on the patient at
their subsequent visit to the scoliosis clinic for brace delivery.
In this part of the protocol, the brace is adjusted by the orthotist
with the help of the PM. The PM is first wrapped around the
trunk, the shoulders straps being adjusted in the same way as
on the first visit by means of the markings. Then, the brace is
fitted on the patient over the PM and the brace straps are tight-
ened as prescribed. The hypothesis of treatment, or treatment
plan, which is based on strategic pressure points, can now be
tested. Pressure data recorded using the PM can be displayed
dynamically on the 3D geometrical model of the trunk using
color codes corresponding to pressure values ranging from 0
to 200 mmHg. For this purpose, a texture mapping procedure
has been developed [41]. First, a 2D texture image is obtained
by interpolating the pressure values of the 192 PM sensors (12
rows of 16 sensors each). Then, the mapping of the 2D texture
image, representing the pressure values, on the 3D surface of
the trunk is performed. This requires beforehand a parameter-
ization of the surface. Therefore, the polygonal surface of the
trunk produced by the InSpeck system is approximated by a
B-Spline surface that respects a tolerance specified by the user
[42,43]. The next step is to establish a mapping between the (u,
v) coordinate space of the B-Spline surface and the (s, t) coor-
dinate space of the texture image, for the region of the trunk
surface that is delimited by the 12 PM markers. A dense grid of
reference points is computed which covers that region in (u, v)
space: the border points are linearly interpolated between the PM
markers and an elliptical meshing algorithm spaces the interior
points equidistantly within the borders through an iterative pro-
cess [44]. Uniformly varying (s, t) coordinates are then assigned
to the reference points. Finally, texture coordinates are assigned
to the trunk surface points by bilinear interpolation within the
grid of reference points.
Hence, by visual inspection of the color distribution on the
reconstructed trunk surface, the orthotist and the clinician can
evaluate the biomechanical action of the brace on the patient’s
trunk shape without having to acquire another set of radiographs.
The clinicians can thus decide whether or not the brace design
is adequate for the patient’s specific scoliosis deformity.
620 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624

For validation purposes, InSpeck acquisitions of the external
geometry of the two test patients, while wearing the PM, were
done to test the repeatability of PM positioning at the second
visit and its impact on pressure data localization.
3. Results and discussion
The registration of the internal and external 3D geometries
of an X-ray dummy is presented in Fig. 8. The accuracy of the
internal geometry is known to be of 2.1 ± 1.5 mm [14,18] as
previously assessed by comparing the 3D reconstructions of the
internal geometry with precise measurements made with a coor-
dinate measuring machine on 17 thoracic and lumbar vertebrae
extracted from a normal cadaveric spine specimen [45]. On the
other hand, the accuracy of the reconstructed external geome-
try is known from previous studies to be of 1.2 ± 1.0 mm [35],
as determined by the differences in coordinates of 30 markers
placed on a dummy and scanned with the InSpeck digitizers
compared to their 3D positions obtained from a coordinate mea-
suring machine.
Results of the present validation study show that the proce-
dure for point-to-point registration of both geometries provides
results of adequate accuracy. Indeed, in the case of the X-ray
dummy, a mean 3D registration error of 6.2 ± 4.4 mm was found
for the locations of the 20 test markers. These results were stable
across the three trials.
Results for the two test patients show that the pressure data are
displayed in the graphical interface with a mean positional error
of 10.0 ± 5.0 mm. This substantial error is however acceptable
since the clinicians are seeking to localize large pressure zones.
For example, standard thoracic and lumbar pads are of sizes
in the range of 90–100 mm by 100–120 mm [9]. In addition,
clinicians need to localize the pressure zones in relation to the
main trunk deformity characteristics and this is not significantly
affected by display errors on the order of 1 cm.
Fig. 9 presents an example, for a typical patient, of the pres-
sure values displayed on the external geometry and demonstrates
an anatomically coherent 3D representation of the trunk–brace
interface pressure distribution.
Registered geometries in the visualization software can be
used by the clinicians for the selection of pressure areas with
the notepad in accordance with the pressure points theory of the
Boston Brace System before brace fabrication. Fig. 10 presents
the software interface displaying an example of a thoracic pad
drawn on the patient’s geometry as part of the treatment plan
(left and top right panels) and the actual pressure data for the
patient (right panel) obtained at the second visit for brace deliv-
ery. Note that the displayed internal and external geometries

Fig. 9. Results of the 3D visualization of the pressure values on the external surface of the patient’s trunk. (a) 2D texture image of the pressure values; (b) grid of
surface reference points obtained from the elliptical mesh generation; (c) pressure values texture-mapped onto trunk surface. Trunk geometry is measured at patient’s
first visit (out of brace).
 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624
Fig. 10. Design and adjustment graphical interface. Example of a pressure area (pad) drawn on the trunk surface (left and top right panels) and display of the pressure
measurements on the patient’s geometry (bottom right panel). Trunk geometry is measured at patient’s first visit (out of brace).
(Figs. 9 and 10) correspond to the patient’s first visit, i.e. not
wearing the brace.
When compared to the standard TLSO brace making method,
the proposed tool is innovative in many aspects and has the
potential to help clinicians improve the design and adjustment
of all types of spinal braces.
The first set of functionalities provided in the graphical inter-
face aims at personalizing the spinal brace design. These features
are of fundamental importance because the brace is fabricated
from the blueprint for the specific needs of a given patient. When
compared to the traditional method of brace design, the proposed
method has the following advantages. Firstly, the 3D reconstruc-
tion of the bone structures facilitates visualization of the 3D
spine deformity [38,39]. This is of primary importance consid-
ering the complex 3D deformation involving lateral deviation of
the spine, vertebral rotation, modification of the sagittal profile
and global geometrical torsion.
Secondly, the 3D reconstruction of the trunk surface, acquired
with 3D optical digitizers, allows the treatment strategy to
take detailed patient morphology into account (decompensation,
shoulders’ inequality, waistline and pelvis asymmetry, etc.) and
moreover to avoid the long, messy and expensive method of
plaster impression. The optical devices used, as compared to
a laser technique, are faster, which can reduce artifacts from
the patient’s movement, and provide color data, which allows
texture matching for easier merging of partial trunk views.
Thirdly, the ability to display both geometries in superposi-
tion in the graphical interface allows improved evaluation of the
whole 3D trunk deformity of the patient. In fact, this enables
for the first time a 3D simultaneous and synchronized visual-
621
ization of both internal (spine, pelvis and rib cage) and external
(entire trunk) geometries of the patient, as compared to the tradi-
tional method where only the (2D) postero-anterior radiographic
image of the bone structures is available as a blueprint to design
the brace. This is crucial, since it has been well demonstrated
that the Boston Brace System does not adequately correct the
3D scoliosis deformity with the traditional method [10] and that
3D spinal curve correction can be achieved in biomechanical
modeling by a more proper localization of pressure areas over
the trunk structures [46].
Fourthly, the proposed graphical tool enables the orthotist
and the clinician to easily discuss and achieve consensus on the
treatment plan following iterative changes (size, shape and local-
ization of prescribed pressure areas) made on the “3D blueprint”
according to the specific 3D model of a patient. Therefore, better
interaction and discussion between the orthotist and the treating
clinician should reduce the rate of inadequately located pressure
areas as well as ill-fitted pads.
Finally, once the method is implemented routinely, a CAD-
CAM step (Computer Aided Design and Manufacturing) can
be considered to take advantage of the complete information
contained in the 3D blueprint.
The second set of functionalities provided in the graph-
ical interface was developed to facilitate the spinal brace
adjustment. This is justified by the important consequences of
improper pressure distribution that can cause negative bracing
effects, especially in relation to the involvement of the cou-
pling mechanisms between the scoliotic spine and rib cage in the
transmission of corrective movements at the patient–brace inter-
face [37,46]. When compared to the traditional method of brace
622 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624
adjustment, the proposed method has the following advantages.
Firstly, a PM containing 192 fine piezoelectric sensors and cov-
ering the entire patient trunk is used to evaluate where pressure
is generated at the trunk–brace interface. Pressure values given
by the PM are displayed in 3D around the external geometry
of the patient in the visualization interface, providing valuable
feedback which was previously unavailable to the orthotist. This
approach is well adapted to clinical practice because the concept
of correcting pressures is similar to the Boston Brace System
theory of three or four pressure points and is coherent with the
manual correction approach used by the clinician during patient
evaluation and by the orthotist during molding of the plaster
cast. However, since braces do not actively apply forces on the
patient’s trunk but rather constrain the trunk into a corrected
posture, it is important that the patient stay in a relaxed pos-
ture during brace evaluation and not voluntarily avoid pressure
points.
Secondly, there is currently no clinical method to assess how
a brace interacts with the underlying bone structures. One advan-
tage of this new method comes from the fact that the pressure
zones are visible in 3D. These pressure areas can then be used to
verify the loading pattern obtained from the actual brace config-
uration and, if necessary, to modify the size, shape or location
of the pressure pads. Furthermore, this information reveals the
treatment efficiency, i.e. the degree to which the brace’s actual
design fits the treatment plan, without the need for additional
radiographs.
The main focus of this paper was to provide a technical
description of a software tool and clinical protocol for spinal
brace design and adjustment. Since the validation procedure has
confirmed the compatibility of the software with the clinical set-
ting, a prospective and randomized study in patients with AIS is
currently in progress to compare the correction obtained with the
spinal brace designed and adjusted with the help of this graphical
interface versus the traditional method. A set of standard use-
ful clinical indices [10] such as Cobb angles, axial rotation and
orientation of the plane of maximum deformity was compared
in the two groups to assess the software’s clinical validity. Pub-
lished results for 48 patients show a statistically and clinically
significant improvement in correction of coronal curves and of
curves in the plane of maximal deformity, for thoracic and lum-
bar curves, in the group using the design and adjustment tool
[47]. In addition, a significant improvement in the orientation
of the plane of maximum deformity in the lumbar region was
noted in this group. As a complement to the present study, these
results greatly support the usefulness and relevance of the design
and adjustment tool for brace treatment improvement in young
scoliosis patients.
4. Summary
The traditional method for spinal brace design uses only the
postero-anterior (2D) radiographic image of the spine, rib cage
and pelvis as a blueprint. However, a spinal brace is intended
to reduce a complex 3D deformity involving lateral deviation of
the spine, vertebral rotation, modification of sagittal profile and
global geometrical torsion. In this paper, a new tool is proposed
to help clinicians improve the 3D design and adjustment of spinal
braces.
In an attempt to improve design and fabrication of spinal
braces, a computer tool providing the 3D visualization of
the bone structures and the surface topography of a scoliotic
trunk has been tested and validated. The internal geometry is
3D-reconstructed from three X-rays images and the external
geometry is obtained by the use of 3D optical digitizers. Both
geometries are then registered in a common reference frame.
The complete trunk model is then displayed in a graphical inter-
face in which the orthotist can interactively draw the contours
of the desired pressure areas corresponding to the pressure pads
to be added inside the spinal brace. Hence, before brace fab-
rication, the orthotist can validate the treatment plan with the
orthopaedist.
As far as the brace adjustment manoeuvres are concerned, the
software enables the orthotist to dynamically adjust the spinal
brace on a patient using a thin mat of pressure sensors inserted
between the patient’s trunk and the brace. The measured pressure
values can be displayed in 3D and in real time in the graphical
interface over the external geometry of the patient. This enables
the orthotist to easily evaluate where pressure is being generated
on the trunk surface, thus allowing immediate modification of
the brace design, including the position of the pressure pads,
if the actual pressure areas do not correspond to the treatment
plan. This interactive tool is currently being tested in a clini-
cal randomized trial to evaluate its effectiveness compared to
the traditional method of brace fabrication in terms of clinical
outcome improvement.
Acknowledgments
This work was supported by the Canadian Institutes of
Health Research (CIHR, Canada, Grant MOP-38033), the Fonds
québécois de la recherche sur la nature et les technologies
(FQRNT, Québec) and the Canadian Foundation for Innova-
tion (CFI). Special thanks to Valérie Pazos for her help with the
InSpeck system, Christian Bellefleur, Nathalie Bourassa and Luc
Duong for the programming of the software, Philippe Labelle for
the graphic design work and Benoit Bissonnette from Orthèses-
Prothèses Rive-Sud (Québec, Canada) for his kind collaboration.
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Dave Fortin was born in Normandin, Canada, in 1977. He received a bachelor
degree in biophysics in 1999 from the University of Quebec in Trois-Rivières and
a master’s degree in biomedical engineering in 2002 from École Polytechnique
de Montreal. His master’s research project focussed on developing a software
tool to design and adjust orthopaedic braces in scoliosis treatment. This project
served as the basis (including the clinical protocol, 3D modeling, software pro-
totyping and validation steps) for the spinal brace design and customization
624 D. Fortin et al. / Computerized Medical Imaging and Graphics 31 (2007) 614–624
system described in this paper. He currently works as a production manager in
the food industry.
Farida Cheriet was born in Algiers, Algeria, in 1961. She received her B.Sc.
degree in computer science from the University USTHB, Algiers, Algeria in
1984 and her D.E.A. degree in the field of Languages, Algorithms and Pro-
gramming from the University of Paris VI, France in 1986. She received the
Ph.D. degree in computer science from the University of Montreal, Canada in
1996. She held a postdoctoral position at the Biomedical Engineering Institute
of the École Polytechnique de Montréal, Canada, from 1997 to 1999. Since
1999, she has been appointed in the department of Computer Engineering at
École Polytechnique de Montréal where she is currently a full professor. Prof.
Cheriet’s research interests include, 3D reconstruction of bone structures from
X-rays, calibration of X-ray imaging systems, non-invasive 3D modeling of
scoliosis deformities, 3D navigation systems for minimally invasive surgery, 3D
reconstruction of vascular structures from angiographic images and 3D motion
estimation from spatio-temporal sequences.
Marie Beauséjour was born in Trois-Rivieres, Canada, in 1974. She received
a bachelor degree in physics in 1996 and a master’s degree in biomedical engi-
neering in 1999 from the University of Montreal. Her master’s research project
focussed on the biomechanical modeling of the trunk muscles and the study
of motor control. She has held the position of research associate and director
of operations with the musculoskeletal research group at Sainte-Justine Hospi-
tal Research Center. She has also coordinated the Quebec Scoliosis Network,
a multi-center and multi-disciplinary group of researchers and clinicians pro-
moting concerted research in scoliosis. She is now a Ph.D. candidate in Public
Health and Epidemiology at the University of Montreal. Her research interests
concern the appropriateness of care, the study of medical practice and health
care utilization patterns as well as the evaluation of treatments in adolescent
patients with scoliosis.
Philippe Debanné was born in Ottawa, Canada in 1969. He received his B.E.
degree in electrical engineering from the University of Ottawa in 1991 and his
M.A.Sc. degree in electrical and computer engineering from École Polytech-
nique de Montréal in 2000. Since 2001 he has worked as a research associate
at École Polytechnique de Montréal, both for the Mechanical Engineering and
Computer Engineering departments. He has been involved in several software
development projects aiming at developing medical tools (simulation, computer-
aided design) for use in scoliosis treatments. He is currently principal research
associate at the Laboratoire d’Imagerie et de Vision 4D (LIV4D) under the direc-
tion of prof. Farida Cheriet. His research interests include 3D visualization in
the medical field and graphical user interface design.
Julie Joncas was born in Montreal, Canada, in 1963. She received the R.N.
degree in 1983, a business degree from the University of Quebec in Montreal
in 1988, a minor in management of health services in 1990 and a minor in
public health in 1991. Since 2004, she has held the position of research nurse,
management associate and agent for research projects in the musculoskeletal
research group at Sainte-Justine Hospital Research Center. She has worked as
an orthopaedic nurse for over 15 years and has been with the musculoskeletal
research group since its inception. She is actively involved in several aspects
of the clinical studies carried out by the group, including establishing clinical
protocols, recruiting patients, measurement acquisitions and patient follow-up.
The mental and physical health of pediatric patients is one of her priorities. She
is principal author of the book “La Scoliose”, intended for teenagers who will
undergo surgery for a scoliosis, and has published several medical articles on
scoliosis.
Hubert Labelle was born in Montreal, Canada, in 1952. He received the M.D.
degree and completed his residency in orthopaedics at University of Montreal,
Montreal, Canada, followed by a two-year fellowship in pediatric orthopaedics
at Sainte-Justine Hospital, Montreal, Rancho Los Amigos Hospital, CA, and the
A.I. Du Pont Institute, DE. Since 1982, he has been appointed in the Department
of Surgery at University of Montreal and at Sainte-Justine Hospital where he
is currently full professor of surgery and holds the Motion Sciences Research
Chair of Sainte-Justine Hospital and the University of Montreal. His clinical
work is focused on the evaluation and treatment of scoliotic deformities in
children and adolescents. He is head of the musculoskeletal research group at
Sainte-Justine Hospital Research Center and Director of the Three-Dimensional
Scoliosis Laboratory. His research interests include the three-dimensional (3-D)
evaluation and treatment of scoliotic deformities, with a particular emphasis on
computer assisted surgery, 3-D design and evaluation of braces for the treatment
of idiopathic scoliosis, and 3-D evaluation and simulation of surgery for scoliotic
deformities.