Flexibility radiographs in pediatric spine surgery are often used but lack consistency.

Purpose: Despite agreement on the importance of spinal curvature flexibility in surgical decision making, there is no consensus regarding optimal radiographic assessment and how this impacts care. We sought to further understand traction film indications and techniques.

Methods: A nine-question survey was administered to 194 members of the Pediatric Spine Study Group (PSSG). The survey aimed to elucidate flexibility radiograph practices of pediatric spine surgeons and how these results inform operative plans and timing.

Results: Ninety-six of 194 (49.5%) respondents were included in the analysis. 96.9% (93/96) performed radiographic assessment of curve flexibility. Amongst these surgeons, roughly half (52.7%, 49/93) do so for surgical planning only (level selection, osteotomies, construct type, etc.), while 45.2% use them for both surgical planning and surgical timing. Radiographs performed included: supine traction (68.8%, 64/93), supine bending (61.3%, 57/93), standing bending (39.8%, 37/93), supine without traction (20.4%, 19/93), and other (21.5%, 20/93). Supine traction films were typically performed by one person holding the legs and one pulling the arms (62.5%, 40/64) or pulling the chin or head (23.4%, 15/64). Traction is routinely applied by physicians (48.4%, 45/93), radiology technicians (39.8%, 37/93), and physician assistants (20.4%, 19/93). Nearly half (45.2%, 45/93) of surgeons feel that traction films are not a consistent or reproducible measure within their department, and 68.8% (64/93) feel that these films are not reproducible across institutions.

Conclusion: The marked variability observed amongst institutional practices and concerns about reproducibility within and across departments warrant the development of a more standardized method to assess curve flexibility.