What Are the Pros and Cons of Invasive and Noninvasive Scoliosis Treatments

Those among us of a certain age remember traditional scoliosis testing at school: bending over in front of the school nurse to check the straightness of our spines as we wondered what in the world this all was for - and, more importantly for a school kid, what's for lunch?

Since then, there's been a sea change in the screening and treatment of idiopathic scoliosis. That progress is in no small part due to the contributions of Amer F. Samdani, M.D., and his orthopedic team at Shriners Children's Philadelphia, who have helped pioneer vertebral body tethering (VBT), an alternative to traditional fusion surgery and growing rods (more on that in a minute).

In short, today's patients and their parents have more options than ever before for treating scoliosis in all its forms and phases. But with these choices come questions. Which treatment is most effective? What's the quickest approach? Which is least painful? What if my kid is extremely active?

For June, Scoliosis Awareness Month, we decided to explore the positives and negatives of six common invasive and noninvasive scoliosis treatments offered today. We turned to three members of the Shriners Children's team proficient in scoliosis treatment for their professional insights.

Invasive

Spinal Fusion

The most common surgery for severe scoliosis, spinal fusion involves the insertion of screws into select vertebrae of the spine to bind them together and maintain a straighter position long-term. Although it's a big operation, it's very reliable, with about a 90% to 95% success rate, said Joshua M. Pahys, M.D., an orthopedic surgeon at Shriners Children's Philadelphia, who has worked side-by-side with Dr. Samdani. Fusion carries very few risks and has a quick recovery time, he noted.

However, undergoing any type of surgery can be daunting for children and their families, and, depending on how much of the spine is fused, the procedure can limit motion in the back. Rebecca L. Rouse, PT, DPT, at Shriners Children's Twin Cities, said that some children cannot return to their chosen activities due to this.

Growing Rods

Meant for younger children who have a lot of growth ahead of them, metal growing rods are attached at the top and bottom of the spine and adjusted over time to correct the curve. The first scoliosis procedure created for young children, rods don't impede development like spinal fusion, which essentially halts the growth of the spine (impacting a child's height, thoracic cavity and lungs), said Dr. Pahys. After the initial surgery, the rods are adjusted in less invasive ways, depending on the rod type, lessening inpatient time and overall trauma on the child.

But growing rods tend to have higher complication rates than spinal fusion, said William A. Phillips, M.D., an orthopedic surgeon at Shriners Children's Texas, and children are discouraged from rigorous activity. "I would tell families, 'You're going to have at least one unplanned trip to the operating room.' But rods can still be very valuable in managing a very, very challenging clinical problem."

Vertebral Body Tethering

"Tethering is a relatively newer option for patients who are skeletally immature, meaning they have some growth left," said Dr. Pahys. For VBT, screws are inserted in the vertebrae, but, unlike rigid metal growth rods, a flexible cord is used to connect the screws together. It allows for the spine to continue growing while its development and direction are more precisely controlled.

Although it is an invasive surgery, it's less invasive than fusion because, instead of a large incision down the back, VBT is performed thoracoscopically through small incisions, Dr. Pahys said. Rouse added: "These patients also retain more spinal mobility post-operatively when compared to patients who have undergone a fusion and tend to do very well when returning to their normal activities and sports."

All three of our sources agree that the biggest downside of VBT is its newness, having only been FDA-approved in 2019. "The long-term studies aren't there yet," said Dr. Phillips. He added that there is also a higher reoperation rate for VBT than traditional fusion surgery, and that VBT can only be effectively performed during a narrow window in the patient's growth.

Noninvasive

Physical Therapy

Physical therapists today use scoliosis-specific exercises to help patients improve posture, flexibility and core strength - all of which can potentially slow curve progression and reduce pain. In particular, the Schroth Method is a go-to because it aims to stabilize, elongate and de-rotate the spine. "Physical therapy allows patients a way to address their scoliosis [in a way] that bracing or just watching and waiting does not allow for," Rouse said. "I think it can be really empowering for patients when they have a diagnosis that they have no other control over."

However, physical therapy (PT) alone hasn't proven effective in treating scoliosis, and Dr. Pahys said it's best paired with bracing for optimum results. Rouse noted that the PT process is time-intensive (when done correctly) and requires a big commitment from the patient and their family. "I always tell my patients that the worst-case scenario in doing PT is that you will come out of it stronger and more well-equipped to face recovery after surgery if that is the ultimate outcome," she said. "Best-case scenario: If you stay consistent and wear your brace, we will hopefully see no further progression of your scoliosis."

Bracing

Bracing involves the patient wearing an orthotic device - typically a custom-fit jacket made of rigid plastic with straps to keep it in place - for 16 to 23 hours a day. While bracing won't correct a curve, research has shown that it's highly effective in slowing the progression of a mild curve. Many patients who brace will never need surgery, said Dr. Pahys, who wore a brace himself as a middle school student and never needed surgery. Plus, new designs like dynamic, nighttime and ScoliBrace (made using 3D scanning) braces can help further tailor the orthotic to the patient and their lifestyle.

Unfortunately, patient compliance is a common issue with bracing. "Many patients do not like to wear their braces because they are not the most comfortable, and many patients don't like to have them on in public because they are embarrassed," Rouse said. In addition, some children who brace correctly and consistently still see curve progression and wind up needing surgery, said Dr. Phillips.

Halo Traction

Halo traction involves placing a ring (or "halo") around a child's head and affixing it with small pins during a procedure done under anesthesia. A sort of pulley system with weights or springs is then attached to the halo, which slowly puts tension, or traction, on the spine and stretches out the curve. "Halo traction is a very old school - but very powerful - tool for safely and slowly correcting a child's spine curvature," said Dr. Phillips. "We reserve it for really, really severe curves." The slow pace of traction is a safe but effective correction method, sometimes followed by surgery once the degree of the curve has decreased enough.

Of course, wearing such a device can be difficult for a child to manage, and most halo traction patients remain in the hospital for the duration of the process, often six to eight weeks, per Dr. Phillips. This can put a strain on the family and child. And, while the operations to install and remove the halo are minimally invasive, they're still operations - and come with all the attendant anxieties and fears.