Individuals with scoliosis were recruited to the NSC through multiple mechanisms, including social media and the NSC website. NSC members were enrolled nationwide in the SRT study between October 1, 2023 and September 1, 2024. All NSC members using SRT during the aforementioned time period were invited by email to participate in the closed, web-based, cross-sectional survey about surgical intention. A formal sample size calculation was not performed, given that this was an exploratory study. In addition to demographics and clinical characteristics, the survey asked, “Has a surgeon ever told you you need scoliosis surgery, or offered you surgery?”, “Have you ever intended to have scoliosis surgery?” and “Since you have started working with the NSC SRT, what is your current intention to have scoliosis surgery?” Responses to the questions about surgical intent were graded on a 4-point Likert scale, where 1=No Intent for Surgery, 2=Low Intent, 3=Moderate Intent, and 4=High Intent for Surgery. Given that this was an exploratory web-based survey, radiographic parameters were not collected.

The primary outcome measure was the intent to pursue surgical correction of scoliosis pain. A nonparametric Wilcoxon signed-rank test for paired data was conducted to evaluate the difference in intention scores before and after SRT. The Wilcoxon test is appropriate for small samples that are not normally distributed. All analyses were performed using R software (version 4.4.1; R Foundation for Statistical Computing).

For potentially averted spinal surgeries, annual cost savings per 100,000 beneficiaries were estimated separately for US commercial payers and Medicare using published literature and multiple public data sources (Table 1). Payer expenditures were inflation-adjusted to US dollars in 2024 by using the Hospital Services component of the Consumer Price Index.

Users with prior spinal fusion surgery were excluded from the surgical intent analysis. Participants were given 2 weeks to respond to the survey, with subsequent reminders. Users who failed to respond to the surgical intent questions were excluded.

This web-based survey evaluated a wellness program, not a medical treatment, and study data were deidentified for privacy and confidentiality protection. The datasets generated and analyzed during this study were restricted to the researchers conducting the analysis. NSC members who participated in the web-based survey study were provided US $50 gift cards for the completion of the survey.

Per the Office of Human Research Protections, under the US Department of Health and Human Services, research that (1) involves only survey procedures of adults and (2) is collected in a deidentified fashion is exempt from institutional review board (IRB) review and informed consent can be waived [26]. A retrospective IRB exemption was obtained for this study, confirming that both conditions are met, and therefore, this study was IRB exempt, and informed consent was not indicated.

In total, 160 NSC members were invited to participate in the survey; 62 (38.8%) individuals nationwide voluntarily completed the survey. Six participants were excluded from the intention to pursue surgery analysis: 5 who had prior fusion surgery and 1 who did not respond. Among survey respondents who reported age (N=47), the mean (SD) age was 65.3 (13.5) years (age <65 years, 40%; age ≥65 years, 60%). The mean (SD) SRT duration of use was 118 (86.6 days); the majority were female (47/48, 98%) and White (45/46, 98%; Table 2).

This web-based, cross-sectional survey study explored whether the use of SRT, a personalized digital therapy program for adults with scoliosis, resulted in a reduction in intent for spinal surgery. After using SRT for an average of 17 weeks, an 11% absolute risk reduction in intent for surgery was observed, which corresponds to a number needed to treat of 9, suggesting that one spine surgery could potentially be averted for every 9 individuals using SRT. Hence, SRT offers a promising nonoperative therapy that may decrease spinal fusions with its associated risks and economic burden.

The reduced intent in pursuing surgery with the use of SRT is consistent with other digital care programs in orthopedics, recognizing that scoliosis is a unique condition with its own clinical challenges. For a 12-week digital care program in low back pain, Shebib et al [15] demonstrated a significant reduction in surgical interest (P=.01). Similarly, Smittenaar and colleagues [16] reported a decrease in surgery intent at 3 months (P<.001) with a 12-week digital care program for chronic knee pain. Mecklenburg et al [17] also found that the self-reported likelihood of having surgery decreased over 1 year with the use of a digital care program for chronic knee pain (P=.01).

Investigators have reported conversion rates from nonoperative to operative treatment ranging from 12.7% (24/189) within 1 year to 31% (42/135) after 6 months [18,22]. Clohisy et al [18] further noted that the majority (90%) of patients crossed over from nonoperative to operative treatment due to perceived worsening of symptoms, and the remainder because the patients believed that the nonsurgical therapies were ineffective. Rhode et al [19] recently reported outcomes following 6 weeks of SRT using SRS-22r. Specifically, a significant improvement was observed in the pain (P<.001), self-image (P=.05), and mental health (P<.001) subdomains of the SRS-22r, with the improvement in the pain subdomain exceeding the minimal clinically important difference threshold. In addition, these investigators reported high satisfaction with the SRT program (9.5 out of 10, where 1=Extremely Dissatisfied and 10=Extremely Satisfied) [19]. Given that the SRT cohort reported in the study by Rhode et al (n=23) [19] is a subset of those reported herein (n=62), the statistically significant decrease in intent for surgery is consistent with the previously reported perceivable improvement in pain with the use of SRT. These consistent findings across SRT studies support the validity of using the question on surgical intent to extrapolate to the estimated cost savings.

In light of the aging population among other factors, Wadhwa and colleagues [27] reported that, among both commercial and Medicare beneficiaries, the rate of fusion for adult spinal deformity surgery doubled from 2007 to 2015. In addition, Passias et al [9] reported that the mean 2-year cost of nonoperative treatment was US $2041, and the mean 2-year cost for operative treatment was US $66,860 based on Medicare reimbursements. As such, the estimated cost savings for averted surgeries reported in the present study are likely underestimated for multiple reasons, specifically, the percentage of beneficiaries seeking medical care for scoliosis is based on data from 2013 [20], the DRG reimbursement amounts reflect only the spinal surgery hospitalization (including the global period) [13], and incentives could increase the SRT participation rate [23].

The cost analyses are based on the best available published data, recognizing that more recent trends in insurer reimbursement and technological advancements may not be reflected. The cost-savings estimates rely on several assumptions, including a 28% participation rate for intervention-focused digital wellness programs. Mattke et al [23] described the relationship between incentive structure and participation rate, noting that the use of incentives increased wellness program participation. Our analysis assumed no incentives with an intervention-focused participation rate of 28% (versus 30% if any incentives). Others have reported a 32% participation rate for physical well-being programs [28]. Hence, assuming the absence of incentives offers a conservative estimate of the participation rate.

There are several limitations of this formative research study. First, participants used SRT for an average of 17 weeks, which begs the question about whether the observed decrease in surgical intent would be sustained. That said, Smittenaar et al [16] found that the reduction in surgery interest continued for 6 months following the initiation of a digital health program for chronic knee pain (P<.001), and Mecklenburg et al [17] reported that the decreased likelihood of knee surgery with the use of a digital care program was sustained over 5 years (P=.002). Second, the self-reported survey data are subjective and participants completed both the pre- and post-SRT questions about surgical intention after initiating SRT, which potentially may be subject to recall bias. Third, the pre-post study design may be subject to confounding because it lacks an independent control or comparison group and is less rigorous than a randomized control trial; notwithstanding, each participant served as their own control. Furthermore, study participants were not blinded in that they were aware of using SRT, which may have introduced the possibility of performance bias. Lastly, although participants represented a nationwide sample of adults with scoliosis, the study included a relatively small cohort that did not permit the exploration of nuanced effects and was not ethnically diverse; therefore, the results may not be generalizable. Future studies will explore the durability of SRT use on surgical intent with a larger, more diverse cohort.

SRT is a personalized, scoliosis-specific digital health exercise program with the potential for averting 1 spinal fusion for every 9 participants, resulting in a substantial reduction in payer expenditures while improving the quality of care for commercial payer and Medicare beneficiaries. The SRT remote, digital care program holds promise as a feasible strategy to transform the nonoperative paradigm in adult spinal deformity. Digital care delivery is becoming more common with currently available health technology, and can increase patient agency and engagement, while improving overall outcomes and decreasing health care spending.