Socioeconomic and Racial Disparities in Surgical Management of Adolescent Idiopathic Scoliosis: Vertebral Body Tethering Versus Posterior Spinal Fusion.

Abstract

Background: Adolescent idiopathic scoliosis (AIS) affects 2% to 3% of children aged 10 to 18, and progressive cases often require surgery. Posterior spinal fusion (PSF) remains the standard treatment but restricts mobility, while vertebral body tethering (VBT) offers a motion-preserving alternative. However, VBT is costly, concentrated in specialized centers, and inconsistently reimbursed, raising concerns that access is limited to higher socioeconomic status (SES) populations. This study examined patterns of VBT utilization compared with PSF across SES and hospital characteristics.

Methods: A retrospective analysis of the 2022 Healthcare Cost and Utilization Project Kids' Inpatient Database identified patients aged ≤18 years diagnosed with AIS undergoing elective PSF or VBT. Race, insurance, and ZIP code income quartile served as SES proxies, while hospital characteristics represented institutional access. Weighted χ2 and t tests compared covariates. Multivariable logistic regression identified predictors of VBT utilization, reporting adjusted odds ratios (OR) and 95% confidence intervals (CI), with P<0.05 considered significant.

Results: Among 6507 AIS patients, 259 (4.0%) underwent VBT and 6248 (96.0%) PSF. VBT patients were younger (13.2 vs. 14.3 y, P<0.001) and incurred higher hospital charges ($301,050 vs. 226,124, P<0.001). VBT utilization was higher among White (83.8% vs. 60.8%, P<0.001), privately insured patients (77.5% vs. 58.2%, P<0.001) residing in higher-income neighborhoods (42.1% vs. 27.1%, P<0.001), and at private (55.8% vs. 38.6%, P<0.001), urban hospitals (69.9% vs. 50.1%, P<0.001) in the Northeast (38.2% vs. 17.9%, P<0.001). Adjusted multivariable analysis showed significantly reduced odds of VBT among Black (OR 0.39, 95% CI 0.22-0.67) and Hispanic (OR 0.32, 95% CI 0.17-0.61) patients, those with Medicaid (OR 0.50, 95% CI 0.33-0.74), and those residing in the lowest-income neighborhoods (OR 0.51, 95% CI 0.31-0.87). Hospitals in the South (OR 0.16, 95% CI 0.10-0.24) and Midwest (OR 0.65, 95% CI 0.44-0.95) performed fewer VBTs.

Conclusions: VBT was predominantly performed in White, privately insured, higher-income patients at metropolitan hospitals, while minority and lower-SES groups had significantly lower utilization. These findings reveal persistent inequities in access to advanced surgical options for AIS.

Level of evidence: Level III.