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

  • Consensus Study
  • Published:
Spine Deformity Aims and scope Submit manuscript

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.

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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

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA

    K. Aaron Shaw

  2. Department of Spine Surgery, Shriners Hospital for Children Portland, Portland, OR, USA

    Michelle C. Welborn

  3. Department of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children’s Hospital of New York, New York, NY, USA

    Hiroko Matsumoto & Michael Vitale

  4. Department of Orthopaedic Surgery, Hospital Ste-Justine (HSJ), Montreal, QC, Canada

    Stefan Parent

  5. Department of Pediatric Orthopaedic Surgery, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Numera Sachwani & Joshua S. Murphy

  6. Department of Orthopaedic Surgery, IWK Health Centre, Halifax, NS, Canada

    Ron El-Hawary

  7. Department of Orthopaedics, Cedars-Sinai, Los Angeles, CA, USA

    David Skaggs

  8. Department of Pediatric Orthopaedic Surgery, Rady Children’s Hospital, San Diego, CA, USA

    Peter O. Newton

  9. Department of Pediatric Orthopaedic Surgery, Pediatric Specialists of Virginia, Merrifield, VA, USA

    Laurel Blakemore

  10. Department of Neurosurgery, Shriners Hospital-Philadelphia, Philadelphia, PA, USA

    Amer Samdani

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  1. K. Aaron Shaw
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  2. Michelle C. Welborn
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  3. Hiroko Matsumoto
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  4. Stefan Parent
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  5. Numera Sachwani
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  6. Ron El-Hawary
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  7. David Skaggs
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  8. Peter O. Newton
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  9. Laurel Blakemore
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  10. Michael Vitale
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  11. Amer Samdani
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  12. Joshua S. Murphy
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Consortia

Pediatric Spine Study Group

  • Noriaki Kawakami
  • , Kenneth Cheung
  • , Kenny Kwan
  • , Jason Cheung
  • , John Emans
  • , Lawrence Karlin
  • , Brian Snyder
  • , Firoz Miyanji
  • , Jaime Gomez
  • , Lindsay Andras
  • , David Skaggs
  • , Sumeet Garg
  • , Benjamin Roye
  • , Michael Vitale
  • , Lisa Saiman
  • , Patrick Cahill
  • , Jack Flynn
  • , Oscar Mayer
  • , Matthew Oetgen
  • , Josh Murphy
  • , Peter Sturm
  • , Stefan Parent
  • , Ron El-Hawary
  • , Paul Sponseller
  • , Jeffrey Sawyer
  • , A Noelle Larson
  • , Robert Murphy
  • , G Ying Li
  • , Suken Shah
  • , Richard Anderson
  • , Laurel Blakemore
  • , Douglas Brockmeyer
  • , John Smith
  • , Behrooz Akbarnia
  • , Burt Yaszay
  • , Michael Glotzbecker
  • , Christina Hardesty
  • , George Thompson
  • , Gregory Redding
  • , Klane White
  • , Purnendu Gupta
  • , Steven Hwang
  • , Josh Pahys
  • , Amer Samdani
  • , Charles Johnston
  • , Amy McIntosh
  • , James Sanders
  • , Scott Luhmann
  • , Gokhan Demirkiran
  • , Kenny Kwan
  • , Grant Hogue
  • , Kevin Smit
  • , Jason Anari
  • , Jason Howard
  • , Timothy Oswald
  • , Judson Karlen
  • , Ryan Fitzgerald
  • , Selina Poon
  • , Michelle Welborn
  • , Jaysson Brooks
  • , Stephanie Ihnow
  • , Susan Nelson
  • , Laura Bellaire
  • , Chris Bonfield
  • , Hazem Sebaie
  • , Oheneba Boachie-Adjei
  • , Raphael Vialle
  • , Sanchez Marquez
  • , Javier Pizones
  • , Adrian Gardner
  • , Ilkka Helenius
  • , Craig Birch
  • , Daniel Hedequist
  • , Timothy Hresko
  • , Jacob Schulz
  • , Kenneth Illingworth
  • , Mark Erickson
  • , John Thometz
  • , John Anderson
  • , Nigel Price
  • , Richard Schwend
  • , Nicholas Fletcher
  • , Jonathan Martin
  • , Robert Lark
  • , Tenner Guillaume
  • , Daniel Miller
  • , Walter Truong
  • , Norman Ramirez-Lluch
  • , Abdullah Saad Abdulfattah Abdullah
  • , Luis Rodriguez
  • , Frances Farley
  • , Peter Gabos
  • , Stuart Mackenzie
  • , John Heflin
  • , Greg Mundis
  • , Peter Newton
  • , Erin MacKintosh
  • , Kim Hammerberg
  • , Michal Szczodry
  • , John Vorhies
  • , Haemish Crawford
  • , Josh Holt
  • , Stuart Weinstein
  • , William Lavelle
  • , Jeffrey Martus
  •  & Brian Kelly

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.

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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

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

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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

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