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Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: Quality of Evidence and Recommendations From a Systematic Overview of Systematic Reviews in Literature

  • International Journal of Spine Surgery
  • November 2025,
  • 8822;
  • DOI: https://doi.org/10.14444/8822

Abstract

Background This systematic overview investigates prior systematic reviews exploring vertebral body tethering (VBT) in managing adolescent idiopathic scoliosis (AIS). The aim is to assess the quality of literature, present the current best evidence, and formulate recommendations.

Methods We independently conducted duplicate electronic searches in Embase, Medline, Scopus, and Web of Science until 19 August 2023, for systematic reviews on VBT for AIS. Methodological quality was assessed using Oxford Levels of Evidence, Assessment of Multiple Systematic Reviews (AMSTAR) scoring, and AMSTAR 2 grading. The Jadad decision algorithm was utilized to identify the study with the highest quality, representing the current best evidence for recommendations.

Results Ten systematic reviews meeting eligibility criteria were included. AMSTAR scores ranged from 4 to 10 (mean: 6.8), indicating varied methodological quality. Most studies had critically low reliability in result summaries per AMSTAR 2 grades. The current best evidence (level IV) suggests VBT as an effective surgical approach for scoliosis, with 73.9% achieving clinical success. However, 15.8% required unplanned reoperations, and 52.2% experienced complications, with a 22% tether failure rate. Thus, patient discussions should address the high reoperation and complication rates associated with this procedure.

Conclusion The quality of evidence on VBT for AIS is critically low. Despite the systematic overview and identifying the best evidence in the literature, high-quality recommendations for practice could not be generated. Future studies with extended follow-up periods are imperative to comprehend VBT’s utility in AIS management.

Clinical Relevance Evidence around the use of VBT for AIS is critically low, hence usage of VBT must be considered with caution in AIS.

Level of Evidence 4.

Introduction

Vertebral body tethering (VBT) is a fusion-sparing alternative for surgically managing idiopathic scoliosis in pediatric patients who have not yet reached skeletal maturity. This technique, which maintains spinal flexibility, was approved by the US Food and Drug Administration in 2019, supported by 6 years of follow-up data.1,2 A key advantage of VBT is that it provides an alternative to the traditionally accepted use of rigid spinal columns for correcting spinal curvature and alignment.

Traditional spinal fusion offers a definitive correction of spinal curvature by permanently fusing vertebrae using bone grafts and metal rods. This technique significantly restricts spinal mobility, an important consideration for patients and families receiving treatment for scoliosis.2 The VBT technique uses a less invasive approach with lower blood loss, length of stay, and opioid use, using flexible cords attached to vertebrae that permit spinal growth, allowing for more natural spinal function and quicker postoperative recovery.3,4

Despite these advantages, VBT is not without challenges. Postoperative reoperation rates are notably higher in VBT patients, with some being converted to fusion procedures. Additionally, being a relatively recent development in scoliotic treatment, the long-term outcomes and broader applicability of VBT remain under continuous evaluation.5 As such, the comparative analysis of spinal fusion and VBT is critical to understanding their respective impacts on patient outcomes.

This umbrella review aims to systematically consolidate and evaluate the highest level of evidence in the published research surrounding VBT, encompassing meta-analyses. By integrating outcomes related to curve correction, rates of complications, and postoperative recovery, this review seeks to provide a robust foundation for clinical decision-making. Furthermore, it endeavors to identify gaps in the current literature, thus guiding future research directions in the treatment of scoliosis and application of VBT.

Methods

This systematic review and meta-analysis was performed in accordance with the guidelines of the Back Review Group of Cochrane Collaboration6 and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).7

Search Strategy

Two reviewers independently conducted a literature search for systematic reviews assessing VBT in adolescent idiopathic scoliosis (AIS) management. Electronic searches covered Embase, Medline, Scopus, and Web of Science until 19 August 2023. The search was not restricted by language or time frame. Key search terms “Vertebral body tethering” OR “VBT” OR “Growth modulation spine” OR “restrained differential growth” AND “Scoliosis” were combined with Boolean operators. Manual searches of reference lists were conducted to identify additional studies. All studies meeting the inclusion criteria were included and analyzed. Any discrepancies between reviewers were resolved through discussion to achieve consensus. A PRISMA flow diagram depicting study selection is provided in Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the included studies.
Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the included studies.

Eligibility and Exclusion Criteria

We included reviews that met the following criteria:

  1. Systematic reviews analyzing VBT in AIS management.

  2. Analysis of at least 1 outcome such as radiological improvement, clinical improvement, quality of life measures, complications, or reoperations.

Narrative reviews, correspondence articles, conference abstracts, case reports, animal model studies, and cadaveric studies were excluded.

Data Extraction

Two reviewers independently extracted data from the systematic reviews with or without meta-analysis. Extracted data included first author, date of last literature search, publication year and journal, number and nature of included studies, language restrictions, inclusion/exclusion criteria, databases searched, software used for analysis, subgroup or sensitivity analysis, Grading of Recommendations Assessment, Development, and Evaluation (GRADE) summary, publication bias analysis, conflict of interest, and I 2 statistic values for each meta-analysis variable. Disagreements were resolved through consensus.

Quality Assessment

The methodological quality was evaluated using the Oxford Levels of Evidence.8 Additionally, the Assessment of Multiple Systematic Reviews (AMSTAR)9 and its updated grading tool AMSTAR-210 were employed to assess methodological robustness.11 Two reviewers independently assessed methodological quality and resolved discrepancies through consensus.

Heterogeneity Assessment

The I 2 test was used for heterogeneity assessment.12 Significant heterogeneity (I 2 > 50%, P < 0.1) was noted in all outcomes due to the retrospective nature of included studies. Sensitivity or subgroup analyses were conducted in some studies to explore heterogeneity sources.

Application of the Jadad Decision Algorithm

Variability among included meta-analyses was interpreted using the Jadad decision algorithm. As per Jadad et al, the differences in study question, inclusion/exclusion criteria, quality assessment, data pooling, and statistical analysis were considered as the possible reasons for discordance in the results among the included studies.13 It is commonly used for generating recommendations among systematic reviews with conclusions that are discordant.14–17 Two reviewers independently used this algorithm to arrive at a study with the highest methodological quality, restrictions in study selection, and data analysis protocols to represent the current best evidence.

Results

Search Results

Initial electronic database search yielded 1115 articles, reduced to 799 after removing duplicates. Upon title and abstract screening, 779 articles were excluded, leaving 20 for full-text review. Of the 20 full-text reviews assessed for eligibility, 10 were excluded due to 1 or more of the following reasons: (1) overlapping data synthesis without added methodological insight, (2) the absence of predefined outcomes relevant to our study (e.g., Cobb angle correction and complication/reoperation rates), and (3) narrative review format without systematic methodology. Finally, after full-text review, 10 systematic reviews were included. The included reviews were published between 2021 and 2023, as shown in Table 1, which demonstrates the characteristics of the included studies. The number of studies analyzed in the included reviews ranged from 7 to 33, with only 4 reviews performing meta-analyses. Publication years of included studies ranged from 2014 to 2022, as shown in Table 2, which lists the primary studies included in each systematic review.

View this table:
Table 1

Characteristics of the included studies.

View this table:
Table 2

Primary studies included in each systematic review.

Search Methodology

Although the included systematic reviews conducted comprehensive searches, the databases searched varied among the studies. All reviews included PubMed and Embase; 4 also searched Medline and the Cochrane Library. Additionally, 3 reviews searched Web of Science, Scopus, and Google Scholar. Six of the studies included only English-language publications, while the others did not specify any language restrictions. Further details on the search methodology employed by the included studies were presented in Table 3.

View this table:
Table 3

Search methodology used by each study.

Methodological Quality

Using Oxford Levels of Evidence, all included studies were classified as level IV evidence due to the retrospective nature of primary studies, as shown in Table 4. Only 1 study used GRADE, while 2 conducted sensitivity analysis, and 1 performed subgroup analysis. Five studies assessed for publication bias in their analysis. AMSTAR scores ranged from 4 to 10 (mean 6.8). According to AMSTAR 2 grading, none of the studies were without critical methodological flaws as shown in Table 5. The meta-analysis by Feng Zhu et al was identified as the highest quality study with an AMSTAR score of 10/11, despite lacking the list of excluded studies along with their reasons for exclusion.

View this table:
Table 4

Methodological information of each study.

View this table:
Table 5

AMSTAR scores and AMSTAR 2 grading for included studies.

Heterogeneity Assessment

All studies conducting meta-analysis used I 2 statistic for heterogeneity assessment. Significant heterogeneity was observed in all outcomes during meta-analysis due to the retrospective nature of the included primary studies, as shown in Table 6. While 2 studies conducted sensitivity analysis, only 1 conducted subgroup analysis to explore heterogeneity sources, as shown in Table 4.

View this table:
Table 6

I 2 statistic values of variables analyzed in each meta-analysis.

Results of Jadad Decision Algorithm

The conclusions from each of the included systematic reviews, along with their limitations and practice implications, are given in Table 1. Based on the Jadad decision algorithm, the meta-analysis by Zhu et al was identified as the highest quality study, representing the current best evidence, as shown in Figure 2. This study reported VBT as an effective surgical approach for scoliosis treatment, with 73.9% clinical success. However, 15.8% required unplanned reoperations, and 52.2% experienced complications. The study acknowledged limited high-quality evidence on the topic and recommended discussing high reoperation and complication rates with patients considering this technique for AIS management.

The flowchart of the Jadad decision algorithm.
Figure 2

The flowchart of the Jadad decision algorithm.

Discussion

AIS being a 3-dimensional deformity of spine with a lateral curve of >10° Cobb angle without any underlying etiology necessitates appropriate attention in its management.69,70 Despite being a painless condition to begin with, the progressive nature of the condition may result in pain at a later date along with cardiopulmonary deterioration and mortality.71,72 Furthermore, the condition progresses with growth spurts, which mandate early identification and appropriate management.73 The current management is based on the Cobb angle of the major curve and skeletal maturity. The primary management of patients with major curve Cobb angle ≥45° remains surgical correction since they are likely to progress to cause disability and deterioration if managed by conservative means.74,75 Posterior spinal fusion remains the surgical method of choice that prevents the curve progression by achieving fusion after deformity correction.76 Potential limitations of spinal fusion include reduced spinal mobility and risk of disc degeneration at adjacent, unfused segments—particularly when fusion involves the lumbar spine. These concerns are relatively minimized when instrumentation is restricted to the thoracic region. However, the limitation of residual spinal growth, thoracic expansion, and limited pulmonary function becomes a concern in thoracic fusions.77

In order to address the limitation of fusion surgery in skeletally immature patients with severe curves, growing rod stabilization was contemplated.78 However, it is reserved for early onset scoliosis and requires surgical lengthening every 4 to 6 months as the spine grows in length, which heightens the risk of wound infections, multiple anesthetic exposure, spontaneous fusion, and eventual fusion procedure after skeletal maturity.79–81 Hence, the management of AIS in these young individuals remains a challenge that is balanced between the risk of curve progression with the thoracospinal residual growth. Unlike early-onset scoliosis, which is often managed using growth-friendly constructs such as traditional or magnetically controlled growing rods, VBT is typically reserved for skeletally immature adolescents with idiopathic scoliosis who exhibit moderate curves (approximately 40°–65°), sufficient flexibility on bending radiographs, and growth potential (eg, Sanders score ≤ 4) to enable effective modulation. VBT has been developed as a procedure to tackle this scenario without compromising on either of them. VBT involves using a tether to the convex surface of the major curve that works based on the Hueter-Volkman law to induce asymmetric growth that results in correction of the residual deformity, thereby allowing further spinal growth.82,83 The procedure was developed off-label in 2010 and later approved for the indication in 2019.84

Since its approved usage, various studies have outlined their clinical experience with the procedure. However, most of them are retrospective in nature with limited quality of evidence to effectively evaluate the VBT procedure for AIS. Since 2021, various systematic reviews have been published with this limited quality of primary evidence, thereby limiting the generalization of their results. This systematic overview of available systematic reviews on VBT is to analyze the quality of the systematic reviews on VBT in the literature and identify the best quality of evidence to generate practice recommendations. The key findings of our review are as follows:

  1. The mean AMSTAR scores ranged from 4 to 10 (mean: 6.8), indicating varied methodological quality of the systematic reviews.

  2. Most studies had critically low reliability in result summaries per AMSTAR-2 grades.

  3. The current best evidence on the subject as per Jadad algorithm is from Zhu et al (level IV).24

  4. The best evidence suggests VBT as an effective surgical approach for scoliosis, with 73.9% achieving clinical success. However, 15.8% required unplanned reoperations, and 52.2% experienced complications with 22% tether failure rate. Thus, patient discussions should address the high reoperation and complication rates associated with this procedure.

Deformity Reduction

Although the included systematic reviews and the primary studies they included demonstrated reduction of the major deformity curves at minimum 2 year follow-up, no long-term follow-up data is available from the existing literature. Since AIS is a progressive condition, the procedure has not only reduced the presurgical deformity but also prevented further progression in deformity with skeletal growth.85 Most of the included studies considered a final major curve Cobb's angle less than 35° without an indication for fusion as the success of the procedure. Although the current evidence shows the final angle of the major curves to be under 35° the need for fusion could not be clearly made out with the limited follow-up period in the included studies. However, the correction rate in the immediate postsurgery period of 46.6% improved to 53.2% by 2 years.24 While VBT preserves motion segments and offers growth modulation, the average curve correction achieved (~47%) is notably lower than that of posterior spinal fusion, which typically results in correction rates approaching 70%. This underscores a key trade-off between maintaining spinal flexibility and achieving a greater magnitude of deformity correction.

The current best evidence in the literature documented the success of the procedure only in 73.88%, thereby necessitating further improvisations with the procedure to enhance the favorable procedure outcomes.24 Furthermore, the indication of the procedure expanded from main thoracic and main lumbar curves to double major curves, idiopathic scoliosis in skeletally mature individuals, and also in scoliosis of syndromic origin. However, careful patient selection is needed to avoid unnecessary complications due to the primary disease.40 For example, patients of Sanders type II reported overcorrection, while Sanders type III to V reported reduced mechanical complications like tether breakage.38

Complications

The best evidence by Zhu et al noted 15.8% of patients undergoing anterior VBT (AVBT) to experience unplanned reoperations and every other patient (52.2%) to experience complications. The unplanned reoperations were made for conversion to posterior fusion, tether removal, and tether replacement.24 The commonly reported complications include breakage of the tether, overcorrection, spontaneous fusion, and pulmonary complications.24 The most common of the above is breakage of the radiolucent tether, which is identified when the angle between 2 adjacent screws is more than 5° between 2 follow-up time points, which has been noted to result in the progression of the curve severity in some of the studies.33,41,44 The clinical implications of the breakage need further investigation in the future. Despite the tether being broken in 21.9% of the patients, 11.4% managed to experience overcorrection, which needs further exploration to understand the patient characteristics that contributed to this contrary outcome.5

The patient population that underwent VBT had major curves preoperatively and was destined for a fusion procedure as their only surgical option. Notably, spontaneous fusion at tethered levels—an unintended outcome that compromises the motion-preserving intent of AVBT—was reported in approximately 7% of cases.5,24 However, longer follow-up is necessary to ascertain the actual fusion rates in those undergoing VBT procedures. Furthermore, in patients presenting with different primary pathologies, with different grades of scoliosis, the rate of complications and reoperations depends on their growth potential, which warrants further investigation to aid in making effective management decisions.

Directions for Future

AVBT acts by limiting the growth of the spinal column in the convex side through application of mechanical compression through tether, resulting in unrestricted growth of the concave side, thereby reversing the deformity.40 The chondral growth of the vertebral body in these immature spines has a threshold, as illustrated through chondral growth force response curves, beyond which the uninterrupted growth fails to occur, thereby resulting in under-correction of the primary curves.86 To make an effective growth-modulated deformity correction, an in-depth understanding of the growth behavior of the immature spine to these mechanical forces is vital. Biomechanical studies on this aspect may throw some light to optimize the treatment strategies using VBT.

Although VBT has demonstrated to be an effective fusion alternative in the management of AIS, the procedure has been in practice only since 2010; hence, continued follow-up is necessary given the growing adolescent population that undergoes this procedure. The implications of broken tethers need to be investigated to further the knowledge on its biomechanical implications on the curve progression. Further exploration into the timing at which this surgery could be introduced into the timeline of curve progression to achieve optimal reduction without over/under correction to make an effective growth modulation to make an effective growth moduo make an effective growth modu.

Limitations

This study is not without limitations. Systematic reviews with and without meta-analyses were identified to be of level IV evidence. Hence, a high-level recommendation with the current literature cannot be concluded.11 This systematic overview may be influenced by the limitations and biases involved in the meta-analysis of the systematic reviews and their primary studies. Additionally, there was an inconsistency in the databases searched among the included systematic reviews and heterogeneity in the reported outcomes, which complicates the interpretation of the results.

Conclusion

The quality of evidence on VBT for AIS is critically low. Despite the systematic overview, high-quality recommendations for practice could not be generated. VBT appears to be a promising management strategy in the management of AIS; however, a higher rate of complications limits their usage. Therefore, future studies should focus on consistent outcome reporting and extended follow-up periods to comprehend VBT’s utility and long-term outcomes in AIS management.

Footnotes

  • Funding The authors received no financial support for the research, authorship, and/or publication of this article.

  • Declaration of Conflicting Interests The authors report no conflicts of interest in this work.

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In this Issue

International Journal of Spine Surgery

Vol. 19, Issue 6

1 Dec 2025

Table of Contents Index by author

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Keywords

vertebral body tethering, adolescent idiopathic scoliosis, systematic overview, systematic reviews, AMSTAR scoring, jadad decision algorithm