Skip to main content

To tether or fuse? Significant equipoise remains in treatment recommendations for idiopathic scoliosis

Abstract

Purpose

Vertebral body tethering (VBT) continues to grow in interest from both a patient and surgeon perspective for the treatment of scoliosis. However, the data are limited when it comes to surgeon selection of both procedure type and instrumented levels. This study sought to assess surgeon variability in treatment recommendation and level selection for VBT versus posterior spinal fusion (PSF) for the management of scoliosis.

Methods

Surgeon members of the Pediatric Spine Study Group and Harms Study Group were queried for treatment recommendations and proposed upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) selection for PSF and VBT based on 17 detailed clinical vignettes. Responses were subdivided in each clinical vignette according to surgeon experience and treatment recommendations with assessment of intra-rater reliability. Binomial distribution tests were used to establish equipoise, selecting p < 0.10 to indicate the presence of a treatment choice with consensus set > 70% agreement. For treatment choice, responses were assessed first for consensus on the decision to proceed with PSF or VBT.

Results

Thirty-five surgeons with varied experience completed the survey with 26 surgeons (74%) completing the second follow-up survey. Overall, VBT was the recommended treatment by 47% of surgeons, ranging by clinical vignette. Consensus in treatment recommendation was present for 6 clinical vignettes including 3 for VBT and 3 for PSF, with equipoise present for the remaining 11. Of the 17 vignettes, 12 demonstrated moderate intra-observer reliability including the 3 consensus vignettes for VBT. Sanders stage ≤ 3 and smaller curve magnitude were related with VBT recommendation but neither age nor curve flexibility significantly influenced the decision to recommend VBT. Surgeons with high VBT volume, ≥ 11 VBT cases/year, were more likely to recommend VBT than those with low volumes (0–10 cases per year (p < 0.0001)). High VBT volume surgeons demonstrated consensus in VBT recommendation for Lenke 5/6 curves (75% mean recommendation). High VBT volume surgeons had a significantly higher VBT recommendation rate for Lenke 1A, 2A curves (71.8% vs 48.0%, p = 0.012), and Lenke 3 curves (62% vs 26.9%, p = 0.023). Equipoise was present for all vignettes in low volume surgeons. In addition, high VBT volume surgeons trended toward including more instrumented levels than low VBT volume surgeons (7.17 vs 6.69 levels).

Conclusion

Significant equipoise is present among pediatric spine surgeons for treatment recommendations regarding VBT and PSF. Surgeon-, patient-, and curve-specific variables were identified to influence treatment recommendations, including surgeon experience, curve subtype, deformity magnitude, and skeletal maturity. This study highlights the need for continued research in identifying the optimal indications for VBT and PSF in the treatment of pediatric spinal deformity.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

References

  1. Samdani AF, Pahys JM, Ames RJ et al (2021) Prospective follow-up report on anterior vertebral body tethering for idiopathic scoliosis: interim results from an FDA IDE Study. J Bone Jt Surg Am 103(17):1611–1619

    Article  Google Scholar 

  2. Newton PO, Bartley CE, Bastrom TP et al (2020) Anterior spinal growth modulation in skeletally immature patients with idiopathic scoliosis: a comparison with posterior spinal fusion at 2 to 5 years postoperatively. J Bone Jt Surg Am 102(9):769–777

    Article  Google Scholar 

  3. Wong HK, Ruiz JNM, Newton PO et al (2019) Non-fusion surgical correction of thoracic idiopathic scoliosis using a novel, braided vertebral body tethering device: minimum follow-up of 4 years. JB JS Open Access. 4(4):e0026

    Article  Google Scholar 

  4. Takahashi Y, Saito W, Yaszay B et al (2021) Rate of scoliosis correction after anterior spinal growth tethering for idiopathic scoliosis. J Bone Jt Surg Am 103(18):1718–1723

    Article  Google Scholar 

  5. Abdullah A, Parent S, Miyanji F et al (2021) Risk of early complication following anterior vertebral body tethering for idiopathic scoliosis. Spine Deform 9(5):1419–1431

    Article  Google Scholar 

  6. Hoernschemeyer DG, Boeyer ME, Robertson ME et al (2020) Anterior vertebral body tethering for adolescent scoliosis with growth remaining: a retrospective review of 2 to 5-year postoperative results. J Bone Jt Surg Am 102(13):1169–1176

    Article  Google Scholar 

  7. Newton PO, Kluck DG, Saito W et al (2018) Anterior spinal growth tethering for skeletally immature patients with scoliosis: a retrospective look two to four years postoperatively. J Bone Jnt Surg Am 100(19):1691–1697

    Article  Google Scholar 

  8. Shin M, Arguelles GR, Cahill PJ et al (2021) Complications, reoperations, and mid-term outcomes following anterior vertebral body tethering versus posterior spinal fusion: a meta-analysis. JBJS Open Access 6(2):e21.00002

  9. Qiu C, Talwar D, Gordon J, Capraro A, Lott C, Cahill PJ et al (2021) Patient-reported outcomes are equivalent in patients who receive vertebral body tethering versus posterior spinal fusion in adolescent idiopathic scoliosis. Orthopedics 44(1):24–28

    Article  Google Scholar 

  10. Newton PO (2020) Spinal growth tethering: indications and limits. Ann Transl Med 8(2):27

    Article  Google Scholar 

  11. Corona J, Miller DJ, Downs J et al (2013) Evaluating the extent of clinical uncertainty among treatment options for patients with early-onset scoliosis. J Bone Jt Surg Am. 95(10):e67

    Article  Google Scholar 

  12. Betz RR, Kim J, D’Andrea LP et al (2003) An innovative technique of vertebral body stapling for the treatment of patients with adolescent idiopathic scoliosis: a feasibility, safety, and utility study. Spine (Phila Pa 1976) 28(20):S255–S265

    Article  Google Scholar 

  13. Jain V, Lykissas M, Trobisch P et al (2014) Surgical aspects of spinal growth modulation in scoliosis correction. Instr Course Lect 63:335–344

    PubMed  Google Scholar 

  14. Lavelle WF, Samdani AF, Cahill PJ et al (2011) Clinical outcomes of nitinol staples for preventing curve progression in idiopathic scoliosis. J Pediatr Orthop 31(1 Suppl):S107–S113

    Article  Google Scholar 

  15. Minkara A, Bainton N, Tanaka M et al (2020) High risk of mismatch between sanders and risser staging in adolescent idiopathic scoliosis: are we guiding treatment using the wrong classification? J Pediatr Orthop 40(2):60–64

    Article  Google Scholar 

  16. Sanders JO, Khoury JG, Kishan S et al (2008) Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Jt Surg Am 90(3):540–553

    Article  Google Scholar 

  17. Krakow AR, Magee LC, Cahill PJ et al (2021) Could have tethered: predicting the proportion of scoliosis patients most appropriate for thoracic anterior spinal tethering. Spine Deform 9(4):1005–1012

    Article  Google Scholar 

  18. Alanay A, Yucekul A, Abul K et al (2020) Thoracoscopic vertebral body tethering for adolescent idiopathic scoliosis: follow-up curve behavior according to sanders skeletal maturity staging. Spine (Phila Pa 1976) 45(22):E1483–E1492

    Article  Google Scholar 

  19. Cahill PJ, Auriemma M, Dakwar E et al (2018) Factors predictive of outcomes in vertebral body stapling for idiopathic scoliosis. Spine Deform 6(1):28–37

    Article  Google Scholar 

  20. Lenke LG, Betz RR, Harms J et al (2001) Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Jt Surg Am 83(8):1169–1181

    CAS  Article  Google Scholar 

  21. Slattery C, Verma K (2018) Classification in brief: SRS-Schwab classification of adult spinal deformity. Clin Orthop Relat Res 476(9):1890–1894

    Article  Google Scholar 

  22. Lonstein JE (2018) Selective thoracic fusion for adolescent idiopathic scoliosis: long-term radiographic and functional outcomes. Spine Deform 6(6):669–675

    Article  Google Scholar 

  23. Larson AN, Fletcher ND, Daniel C et al (2012) Lumbar curve is stable after selective thoracic fusion for adolescent idiopathic scoliosis: a 20-year follow-up. Spine (Phila Pa 1976) 37(10):833–839

    Article  Google Scholar 

  24. Lenke LG, Edwards CC 2nd, Bridwell KH (2003) The Lenke classification of adolescent idiopathic scoliosis: how it organizes curve patterns as a template to perform selective fusions of the spine. Spine (Phila Pa 1976) 28(20):S199-207

    Article  Google Scholar 

Download references

Acknowledgements

The Pediatric Spine Study Group (PSSG) consists of the following: Noriaki Kawakami, MD, Kenneth Cheung, MD, Kenny Kwan, MD, Jason Cheung, MD, The University of Hong Kong, Hong Kong; John Emans, MD, Lawrence Karlin, MD, Brian Snyder, MD, Boston Children’s Hospital, Boston, Massachusetts; Firoz Miyanji, MD, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada; Jaime Gomez, MD, Children’s Hospital at Montefiore, New York, NY; Lindsay Andras, MD, Children’s Hospital Los Angeles, Los Angeles, California; David Skaggs, MD, Cedars-Sinai Hospital, Los Angeles, California; Sumeet Garg, MD, Children’s Hospital of Colorado, Aurora, Colorado; Benjamin Roye, MD, Michael Vitale, MD, Lisa Saiman, MD, New York-Presbyterian Morgan Stanley Children’s Hospital of New York, New York, NY; Patrick Cahill, MD, Jack Flynn, MD, Oscar Mayer, MD, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Matthew Oetgen, MD, Children’s National Hospital, Washington, DC; Josh Murphy, MD, Children’s Healthcare of Atlanta, Atlanta, Georgia; Peter Sturm, MD, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Stefan Parent, MD, Hospital Ste-Justine (HSJ), Montreal, Quebec, Canada; Ron El-Hawary, MD, IWK Health Centre, Halifax, Nova Scotia, Canada; Paul Sponseller, MD, Johns Hopkins University, Baltimore, Maryland; Jeffrey Sawyer, MD, Le Bonheur Children’s Hospital, Memphis, Tennessee; A. Noelle Larson, MD, Mayo Clinic, Rochester, Minnesota; Robert Murphy, MD, Medical University of South Carolina (MUSC), Charleston, South Carolina; G. Ying Li, MD, Mott Children’s Hospital, Ann Arbor, Michigan; Suken Shah, MD, Nemours Alfred I DuPont Hospital for Children, Wilmington, Delaware; Richard Anderson, MD, Neurosurgery, New York, NY; Laurel Blakemore, MD, Pediatric Specialists of Virginia, Merrifield, Virginia; Douglas Brockmeyer, MD, John Smith, MD, Primary Children’s Hospital, Salt Lake City, Utah; Behrooz Akbarnia, MD, Burt Yaszay, MD, Rady Children’s Hospital-San Diego, San Diego, California; Michael Glotzbecker, MD, Christina Hardesty, MD, George Thompson, MD, Rainbow Babies & Children’s Hospital, Cleveland, Ohio; Gregory Redding, MD, Klane White, MD, Seattle Children’s Hospital, Seattle, Washington; Purnendu Gupta, MD, Shriners Hospital-Chicago, Chicago, Illinois; Steven Hwang, MD, Josh Pahys, MD, Amer Samdani, MD, Shriners Hospital- Philadelphia, Philadelphia, Pennsylvania; Charles Johnston, MD, Amy McIntosh, MD, Texas Scottish Rite Hospital, Dallas, Texas; James Sanders, MD, University of North Carolina, Chapel Hill, North Carolina; Scott Luhmann, MD, Washington University-St. Louis and Shriner’s Hospital-St. Louis, St. Louis, Missouri; Gokhan Demirkiran, MD, Hacettepe University, Ankara, Turkey; Kenny Kwan, MD, Grant Hogue, MD, Boston Children’s Hospital, Boston, Massachusetts; Kevin Smit, MD, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Jason Anari, MD, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Michael Heffernan, MD, LSU, New Orleans, Louisiana; Jason Howard, MD, Nemours Alfred I DuPont Hospital for Children, Wilmington, Delaware; Timothy Oswald, MD, Pediatric Orthopaedic Associates, Atlanta, Georgia; Judson Karlen MD, Phoenix Children’s Hospital, Phoenix, Arizona; Ryan Fitzgerald, MD, Riley Hospital for Children at IU Health, Indianapolis, Indiana; Selina Poon, MD, Shriners Hospital-Pasadena, Pasadena, California; Michelle Welborn, MD, Shriners Hospital-Portland, Portland, Oregon; Jaysson Brooks, MD, Texas Scottish Rite Hospital, Dallas, Texas; Stephanie Ihnow, MD, University of Florida, Gainesville, Florida; Susan Nelson, MD, University of Rochester, Rochester, New York; Laura Bellaire, MD, University of Wisconsin, Madison, Madison, Wisconsin; Chris Bonfield, MD, Vanderbilt University, Nashville, Tennessee; Hazem El Sebaie, MD, Cairo University Hospital, Cairo, Egypt; Oheneba Boachie-Adjei, MD, Focos Orthopaedic Hospital, Accra, Ghana; Raphael Vialle, MD, Hopital d’Enfants Armand Trousseau, Paris, France; Sanchez Marquez, MD, Javier Pizones, MD, Hospital Universitario la Paz, Madrid, Spain; Adrian Gardner, MD, Jwalant Mehta, MD, Royal Orthopaedic Hospital, Birmingham, United Kingdom; Ilkka Helenius, MD, Turku Children’s Hospital, Turku, Finland; Craig Birch, MD, Daniel Hedequist, MD, Timothy Hresko, MD, Boston Children’s, Boston, Massachusetts; Jacob Schulz, MD, Children’s Hospital at Montefiore, New York, NY; Kenneth Illingworth, MD, Children’s Hospital Los Angeles, Los Angeles, California; Mark Erickson, MD, Children’s Hospital of Colorado, Aurora, Colorado; John Thometz, MD, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; John Anderson, MD, Nigel Price, MD, Richard Schwend, MD, Children’s Mercy Hospital, Kansas City, Missouri; Nicholas Fletcher, MD, Children’s Healthcare of Atlanta, Atlanta, Georgia; Jonathan Martin, MD, Connecticut Children’s Medical Center, Hartford, Connecticut; Robert Lark, MD, Duke Orthopaedic Surgery, Durham, North Carolina; Tenner Guillaume, MD, Daniel Miller, MD, Walter Truong, MD, Gillette Children’s Specialty Care, St. Paul, Minnesota; Norman Ramirez-Lluch, MD, Hospital De La Concepcion, San German, Puerto Rico; Abdullah Saad Abdulfattah Abdullah, MD, IWK Health Centre, Halifax, Nova Scotia, Canada; Luis Rodriguez, MD, Johns Hopkins All Children’s Hospital-Florida, St. Petersburg, Florida; Frances Farley, MD, Mott Children’s Hospital, Ann Arbor, Michigan; Peter Gabos, MD, Stuart Mackenzie, MD, Nemours Alfred I DuPont Hospital for Children, Wilmington, Delaware; John Heflin, MD, Primary Children’s Hospital and Shriners Hospital-Salt Lake City, Salt Lake City, Utah; Greg Mundis, MD, Peter Newton, MD, Rady Children’s Hospital-San Diego, San Diego, California; Erin MacKintosh, MD, Seattle Children’s Hospital, Seattle, Washington; Kim Hammerberg, MD, Michal Szczodry, MD, Shriners-Chicago, Chicago, Illinois; John Vorhies, MD, Stanford University, Stanford, California, Haemish Crawford, MD, Starship Children’s Hospital, Auckland, New Zealand; Josh Holt, MD, Stuart Weinstein, MD, University of Iowa, Iowa City, Iowa; William Lavelle, MD, Upstate Medical University, Syracuse, New York; Jeffrey Martus, MD, Vanderbilt University, Nashville, Tennessee; and Brian Kelly, MD, Washington University-St. Louis, St. Louis, Missouri.

Funding

None.

Author information

Authors and Affiliations

Authors

Consortia

Contributions

KAS: study design, data analysis, data interpretation, manuscript drafting, manuscript approval, and accountable. MCW: study design, data analysis, data interpretation, manuscript editing, manuscript approval, and accountable. HM: study design, data analysis, manuscript editing, manuscript approval, and accountable. SP: study design, data interpretation, manuscript editing, manuscript approval, and accountable. NS: study design, data analysis, manuscript editing, manuscript approval, and accountable. RE-H: study design, data interpretation, manuscript editing, manuscript approval, and accountable. DS: study design, data interpretation, manuscript editing, manuscript approval, and accountable. PON: study design, data interpretation, manuscript editing, manuscript approval, and accountable. LB: study design, data interpretation, manuscript editing, manuscript approval, and accountable. MV: study design, data interpretation, manuscript editing, manuscript approval, and accountable. AS: study design, data interpretation, manuscript editing, manuscript approval, and accountable. JSM: Study design, data analysis, data interpretation, manuscript editing, manuscript approval, and accountable.

Corresponding author

Correspondence to Joshua S. Murphy.

Ethics declarations

Conflict of interest

Dr. Shaw is a committee member for NASS and AAOS; Dr. Welborn is a consultant for Nuvasive, Depuy, and Stryker, speaker for Nivasive, Stryker, and Synthes, receives research support from POSNA and Shriners Hospital for Children, is a committee member for POSNA, and an editorial member for Journal of Spine Deformity, Journal of Pediatric Orthopaedics; Dr. Matsuomoto is a committee member for the American Academy of Cerebral Palsy and Developmental Medicine; Dr. Parent is a consultant for Depuy, EOS Imaging, an employee with stock options of Spinologics, receives IP royalties from Rodin 4D and EOS Imaging, is a paid speaker for Depuy, receives research support from Depuy, EOS Imaging, and Setting Scoliosis Straight Foundation, is a committee member for Canadian Spine Society, POSNA and Scoliosis Research Society; Ms. Sachwani has nothing to disclose; Dr. El-Hawary is a consultant for Apifix, Depuy, Globus Medical, Medtronic, and Wishbone Medical, receives stock options from Orthopediatrics, and Apifix, receives IP royalties from Wishbone Medical, receives research support from Depuy, Joint Solutions, and Medtronics, receives publishing royalties from Springer, is a committee member for Children’s Spine Foundation, PSSG, and SRS; Dr. Skaggs is a consultant for Grand Rounds, Orthobullets, and Zimmer Biomet, receives stock options from Zipline Medical, Green Sun Medical, Orthobullets, received IP royalties from Zimmer Biomet, receives publishing royalties from Wolters Kluwer Health, is a paid speaker for Zimmer Biomet, receives research support from Nuvasive, is a committee member for CHLA Foundation, Growing Spine Foundation, GSSG, and an editorial board member for Journal of Children’s Orthopaedics, Orthobullets, Orthopedics Today, Spine Deformity; Dr. Newton is a consultant for Depuy, Globus Medical, Mirus, Pacira, Stryker, receives IP royalties from Depuy and Stryker, is a paid speaker for Medtronic, receives publishing royalties from Thieme, receives research support from Depuy, EOS Imaging, Medtronic, Nuvasive, Stryker, and Zimmer Biomet, is a committee member for Harms Study Group, International Pediatric Orthopedic Think Tank, Setting Scoliosis Straight Foundation; Dr. Blakemore is a consultant, receives IP royalties and is a paid speaker for Stryker, and is a board member for Spine Deformity, POSNA, PSSG, and SRS; Dr. Vitale is a consultant for Biomet, Stryker, receives IP royalties from Biomet, receives research support from Children’s Spine Foundation, OREF, SRS, POSNA, and OSRF, received financial support from FOX and Children’s Spine Foundation, is a committee member for Children’s Spine Foundation, IPOS, POSNA, Project for Safety in Spine Surgery; Dr. Samdani is a consultant for Depuy, Ethicon, Globus Medical, Medical Device Business Services, Mirus, Nuvasive, Orthofix, Stryker, and Zimmer Biomet, receives IP royalties from Nuvasive and Zimmer Biomet, is a committee member for Setting Scoliosis Straight Foundation PSSG; Dr. Murphy is a consultant for Depuy and OrthoPediatrics, receives research support from OrthoPediatrics, and board member for Journal of Pediatric Orthopedics, POSNA, Spine Journal, Journal of Spine Deformity, and Scoliosis Research Society

Ethical approval

Not applicable.

Informed consent

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The members of the Pediatric Spine Study Group are mentioned in Acknowledgements section.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 1535 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Shaw, K.A., Welborn, M.C., Matsumoto, H. et al. To tether or fuse? Significant equipoise remains in treatment recommendations for idiopathic scoliosis. Spine Deform 10, 763–773 (2022). https://doi.org/10.1007/s43390-022-00497-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s43390-022-00497-6

Keywords

  • Scoliosis
  • Vertebral body tethering
  • Posterior spinal fusion
  • Juvenile idiopathic scoliosis
  • Adolescent idiopathic scoliosis
  • Survey