The Current and Future State of Scoliosis Care and Research

In the United States alone, scoliosis affects an estimated 7 million people – just under twice the population of Los Angeles – according to the Scoliosis Research Society. Each year, an estimated 30,000 children begin wearing braces for treatment. 

Over time, the treatments available for different types of scoliosis have continued to advance, in large part due to the research being done by spine experts and the development of technologies that offer the best options for each patient. 

Clinicians in the Center for Comprehensive Spine Care at Nationwide Children’s Hospital are dedicated to supporting these efforts, driving the mission of providing the best care and advancing the field of pediatric medicine to improve outcomes for children everywhere.  

Allen Kadado, MD, pediatric orthopedic surgeon, is one of those clinicians. He serves as director of the Nationwide Children’s Hospital Center for Orthopedic Innovation, director of the Nationwide Children’s Pediatric Orthopedic Residency Program and adjunct assistant professor of orthopedic surgery at The Ohio State University.  

Scoliosis: Diagnosis and Treatment 

Scoliosis is a condition characterized by abnormal curvature and rotation of the spine. In the mild range of scoliosis, clinicians will typically observe with x-rays to monitor for worsening of the curve, at least while the child is still growing. Children with moderate range scoliosis often benefit from non-invasive management with bracing to prevent significant progression of the curve. In more severe cases, surgical management is pursued, and the specific treatment offered is individualized to the patient. Treatments for scoliosis have evolved rapidly over the past two decades, and surgeons continue to seek optimal modalities depending on the spinal deformity and needs specific to the child.  

Early-Onset Scoliosis

Early-onset scoliosis – scoliosis in anyone under age 10 – is seeing continued evolution in treatment. Dr. Kadado identifies this as one of the biggest areas for improvement in the field of scoliosis.  

Non-surgical offerings include bracing, casting, traction or different types of scoliosis-specific physical therapy options. 

Surgical management of early-onset scoliosis includes treatment such as growth-friendly spinal instrumentation, magnetically controlled growing rods, Halo-gravity traction, posterior spinal instrumented fusion, vertebral body tethering, bony resections and other non-fusion procedures.  

Regardless of which treatment is pursued, goals are similar – limit the progression of scoliosis while allowing the child to grow and develop. 

Surgical and Nonsurgical Advancements

Research in scoliosis diagnosis and treatment can be categorized into two groups: surgical and nonoperative.  

Surgical approaches aim to correct the scoliosis curvature using one of several main tactics – fusion surgery, motion preserving surgery, and/or growth friendly surgery. Fusion surgery, true to name, aims to achieve durable and lasting correction of scoliosis by fusing the involved segments of the spine. Alternatively, motion preservation procedures aim to maintain the natural flexibility of the spine as much as possible through the use of other techniques such vertebral body tethering and posterior dynamic distraction devices. Growth-friendly surgery is reserved for very young patients who require additional lung and spine development. 

Some of the most common nonoperative treatment options include: 

• Observation: Monitoring the curvature of the spine over the course of childhood development. 

• Bracing: Particularly effective in adolescents whose bones are still growing, this treatment aims to prevent the spinal curve from worsening with phases of rapid growth.  

• Casting: Similar to bracing but reserved for very young patients with worse curves.  

• Halo gravity traction: Used in severe stiff spinal curves to gradually stretch the spine and improve flexibility. This treatment is more common among patients with severe spinal deformities. Halo gravity traction features a halo device, which is attached to the patient’s skull using pins, connected to a novel dynamic spring system to stretch the spine.  

• Scoliosis-specific physical therapy: Nationwide Children’s offers the Schroth Method, a technique to manage scoliosis through scoliosis-specific exercises tailored to the patient’s curvature. Schroth is generally offered in conjunction with brace treatment for patients with moderate range scoliosis. 

Often, more than one treatment is implemented to maximize the potential for best outcomes. For younger patients with mild-to-moderate cases, most will be initially treated with bracing and physical therapy. 

“In our center, each patient benefits from an individualized and multidisciplinary approach. We continue to look and see how these different treatments work together and for which patients those might benefit most,” Dr. Kadado says. 

Data-Driven, Personalized Care for Better Outcomes

The Center for Comprehensive Spine Care is gathering information from patients and families with patient-reported outcomes. With this, the surgeons are continually reflecting on the work they are doing for families and how things can be improved. On Dr. Kadado’s team, members contribute and support patients from every angle to help with treatment adherence, program support, and outcomes. These team members encompass the following roles: 

• Surgeon 

• Nurse practitioner 

• Registered nurse 

• Athletic trainer 

• Social worker  

• Orthopedic psychologist 

• Administrative assistant 

And for some patients, and some treatments, the latest treatment option might not be the best one.  

“While a patient may be a candidate for appealing newer procedures, we find it very important to involve families so that we all understand the specific risks and outcomes related to these procedures,” he says. “We make every effort to offer what we think is right for each patient.” 

Enabling Technology

In addition to personalized care, integrating advanced technologies supports Dr. Kadado and team in their mission to improve options and outcomes. New and developing technologies offer potential to make treatment outcomes even better. Innovations using artificial intelligence, machine learning and machine vision are all becoming stronger players in the diagnosis and treatment practices. 

Some such enabling technologies include pre-operative planning, intraoperative navigation and scoliosis correction techniques.  

The team at Nationwide Children’s is currently developing a novel biomechanical 3D scoliosis model for scoliosis simulation and training. This approach aims to better simulate scoliosis correction surgery, train future surgeons and allow for better research on the biomechanical properties of scoliosis correction using virtual and physical models. The team is also utilizing a new imaging system called EOSedge, which features much lower doses of radiation as compared to traditional X-ray machines. This is particularly important in children who are receiving many radiographs over the course of their childhood. Using the system, they’re able to develop 3D modeling and flexibility assessments from those images. Additionally, the team is now using novel techniques for preoperative planning software and translating them for intraoperative execution. 

“Before surgery, we use all the information available to plan the surgery in a multidisciplinary conference and then take that to the operating room and execute the procedure exactly as planned,” Dr. Kadado says. “It’s remarkable how far this technology has come.”  

Nationwide Children’s is also one of the only centers in the country to offer long-term Halo-gravity traction program as a treatment option for young children with severe and stiff spinal deformities, bringing new hope for patients who otherwise aren’t good candidates for traditional spinal surgery.  

Bracing, which has long been used for patients with scoliosis, has evolved to include different types of braces and strategies, and that area is still evolving. One area the team is focusing on with bracing is the development of a novel brace compliance system set to help improve patient and provider engagement and optimize outcomes.   

“We aim to leverage the philosophy and interactive nature of modern wearable technologies and translate these to the sensors contained within the brace,” Dr. Kadado says. “The brace sensor wirelessly links to your phone to help log how many hours of the day the brace is being worn. The goal is to provide live feedback to the patient and clinicians and identify when to offer praises and/or encouragement when needed.” 

Feedback from technology such as this would benefit the child and parent, providing a notification loop and engaging the clinical team when necessary.   

Another area where Dr. Kadado and team are pushing the status quo is spinal motion analysis.  

“We’re fortunate to be one the first pediatric centers to have a specific lab dedicated to the analysis of spinal motion. At Nationwide Children’s, we’re lucky to have industry experts in spinal motion analysis like Kirsten Tulchin-Francis, PhD, and Reid Chambers, DO,” Dr. Kadado says.  

This is a newer, lesser studied area in scoliosis research. Dr. Kadado says spinal motion analysis is becoming a larger focus in scoliosis research due to its implications on treatment decision making and assessing outcomes of surgical treatments. Both the Gait Lab and the Spine Motion Lab at Nationwide Children’s are working to develop protocols and standard practice on how to assess spinal motion in all patients. 

“There’s so much exciting surgical innovation happening in the space of pediatric spinal deformity. Participating in this innovation from a clinical and academic lens for the benefit of our patients is one of my favorite aspects of this job,” he says. 

As time passes, research and technology will continue to develop and grow.  

“We have so many new surgical correction techniques that we’re achieving very powerful correction with,” Dr. Kadado says. “I’m very proud to say that our scoliosis treatments are continuing to improve, and I’m excited for the future of this field.”