X-ray image of adult patient spine showing scoliosis surgery. Scoliosis surgeries are effective but expensive.
getty
A groundbreaking scoliosis study, recently published in the Journal of the American Medical Association and presented at the 2025 Scoliosis Research Society Annual Meeting in Charlotte, North Carolina, addresses a critical question: Do patients with scoliosis experience long-term benefits from major reconstructive surgery?
It’s a simple but difficult question.
Scoliosis can cause substantial pain and functional impairment, yet the surgical interventions designed to correct it remain highly invasive and financially burdensome. This longitudinal study followed adult patients with scoliosis—defined by a lateral curvature of the spine—over an eight-year period.
At its core, the authors pose a critical question: given that complex spinal reconstruction can cost as much as $125,000, is the procedure truly worth the investment?
What Is Adult Symptomatic Lumbar Scoliosis?
Adult symptomatic lumbar scoliosis (ASLS) poses a complex challenge in spinal care, profoundly impacting quality of life through pain, disability, and spinal deformity. This condition, characterized by lateral curvature in the lumbar spine of adults, differs from pediatric scoliosis. While pediatric scoliosis typically arises during growth, ASLS often results from degenerative changes in the lower back. Pain is a primary symptom in most adult cases, unlike the majority of pediatric cases. Additionally, because adult spines are less flexible, surgical interventions often require more invasive techniques, such as osteotomies or bone cuts, to achieve spinal alignment.
What Is The Groundbreaking Scoliosis Study?
The pivotal study, Long-Term Outcomes of Surgical Versus Nonsurgical Management for Adult Symptomatic Lumbar Scoliosis (ASLS II), provides insights into the long-term effectiveness of surgical interventions for adult scoliosis.
Patient who had surgery did better than those who did not.
The ASLS II study, a continuation of the Adult Symptomatic Lumbar Scoliosis 1 (ASLS-1) study, extends the prospective, multicenter investigation to evaluate the durability of surgical versus nonsurgical treatments over an eight-year period.
Study Design And Methodology
The ASLS II study combined data from cohorts across nine North American centers. It enrolled 286 adults aged 40 to 80 years with symptomatic lumbar scoliosis, comprising 182 surgical and 104 nonsurgical patients. Data collection and analysis occurred between November 2023 and July 2024, with a follow-up rate 72% at 8 years. This meticulous effort to track patients, including those who opted for nonsurgical management, is noteworthy for its rigor and scope.
Key Findings
The study compared outcomes using validated measures, including the Oswestry Disability Index (ODI) and Scoliosis Research Society-22 (SRS-22) scores, which provide objective assessments of disability and quality of life. Surgical patients demonstrated significantly better outcomes than nonsurgical patients at 2, 5, and 8 years. Notably, even surgical patients who experienced one adverse event or complication showed greater improvements compared to nonsurgical patients, underscoring the robustness of surgical benefits despite potential risks. These findings offer evidence-based guidance for patients and clinicians navigating this complex condition.
Why Is ASLS II A Groundbreaking Study?
The ASLS II study is considered transformative because it established that the benefits of surgery for adult scoliosis are not ephemeral. Patients who underwent operative treatment experienced not only short-term improvements but also sustained, clinically meaningful gains in pain relief, functional capacity, and quality of life across an unprecedented eight-year follow-up period.
Conducted across nine leading U.S. institutions, with 23 distinguished surgeons serving as co-authors, and supported by the Scoliosis Research Society, this multicenter investigation carries exceptional credibility. The durability of its outcomes is particularly noteworthy, confirming that patients who undergo high-risk reconstructive surgery for adult scoliosis achieve lasting benefit, validated with a high level of scientific rigor.
Equally impressive was the trial’s ability to maintain strong follow-up rates, especially within the nonsurgical cohort. Retaining such patients over nearly a decade is notoriously difficult—comparable to surveying individuals about a university they were accepted to but chose not to attend, eight years after the fact. This methodological strength significantly enhances the reliability of the data.
The implications of ASLS II extend well beyond the clinical sphere. Although surgical interventions entail high upfront costs, the demonstrated long-term benefits suggest potential reductions in cumulative healthcare expenditures by decreasing reliance on chronic nonsurgical management. As such, this evidence carries considerable weight for both clinical decision-making and health policy formulation in the management of adult symptomatic lumbar scoliosis.
What Are Surgeons Saying?
Justin Smith, MD, PhD, a lead author of the Long-Term Outcomes of Surgical Versus Nonsurgical Management for Adult Symptomatic Lumbar Scoliosis study, presented the findings at the Scoliosis Research Society Annual Meeting and was interviewed for this article.
Context Of The Study
The context of this study is critical: an aging global population will inevitably increase the prevalence of adult spinal deformity. Both surgeons and policymakers must determine the most effective treatment strategies for this condition. Dr. Smith emphasizes this point:
“The great majority of adult spinal deformity occurs through degenerative changes that accumulate with the aging process, and these deformities can have profound impact on the quality of life of those affected. With an aging global population, the prevalence of adult spinal deformity will continue to markedly increase.”
This underscores the growing societal importance of developing and implementing effective treatment strategies for adult scoliosis.
Key Findings For Patients
The study equips patients and surgeons with rigorous, evidence-based data. Dr. Smith highlights:
“The adult symptomatic lumbar scoliosis (ASLS) 8-year outcomes study provides valuable data for patients and surgeons regarding the benefits of nonoperative versus operative treatment. Our findings demonstrate that surgical treatment offers significant improvement in patient-reported quality of life measures and that the treatment benefits are durable at 8-year follow-up. In contrast, nonoperative treatment provides, at best, maintenance of presenting levels of symptoms and disability.”
These findings reinforce the long-term efficacy of surgical intervention for ASLS, demonstrating not only initial improvement but also sustained benefit.
Economic Implications
The cost of scoliosis surgery carries substantial policy relevance, particularly as governments assume greater roles in healthcare financing directly or indirectly. While surgery involves higher upfront expenditures, it ultimately proves more cost-effective over time. Health economists measure this using the incremental cost-effectiveness ratio (ICER)—the additional cost of one intervention compared to another, divided by the incremental health benefit, typically expressed as cost per quality-adjusted life year (QALY) gained.
A quality-adjusted life year (QALY) integrates both the quantity and quality of life, with one QALY representing one year in perfect health. This framework enables decision-makers to evaluate whether the benefits of an intervention justify its costs. For example, if a novel drug costs $10,000 more than the standard treatment and provides 0.5 additional QALY, the ICER would be $20,000 per QALY gained.
In the case of ASLS II, the study demonstrated that operative treatment was more cost-effective than nonoperative management at eight-year follow-up. The ICER improved from $44,033 at five years to $20,569 at eight years.
Dr. Smith elaborates:
“Notably, the costs of both nonoperative and operative treatment approaches are substantial, with operative treatment having a much higher cost upfront. To address this, a subsequent published paper that focused on the same dataset demonstrated the very favorable cost-effectiveness of operative over nonoperative treatment for ASLS and that the ICER (a measure of cost-effectiveness) continued to improve with longer-term follow-up.”
These results highlight the economic advantage of surgical intervention for ASLS, supporting more informed decisions at both the clinical and policy levels.
What Are The Next Steps?
The ASLS II study provides patients with essential evidence to guide decision-making regarding complex spine reconstruction—a choice that is both significant and multifactorial. The findings demonstrate that surgical intervention for adult symptomatic lumbar scoliosis is supported by robust, long-term data, with patient-reported quality of life showing sustained improvement across an eight-year horizon. Just as importantly, the study underscores that adult scoliosis is a progressive condition: without surgical correction, symptoms and disability tend to worsen over time. These results align closely with the long-standing clinical observations of spinal deformity specialists, offering empirical validation of their experiential knowledge.
Equally critical, the study informs insurers and government agencies by presenting a rigorous, evidence-based assessment of the cost-effectiveness of complex spinal surgery. While these procedures carry substantial upfront expenditures, the durable improvements they provide translate into reduced long-term healthcare utilization, thereby offsetting initial costs. Although short-term budget cycles often shape payer decisions, the longitudinal data from ASLS II reinforce that surgical intervention for adult scoliosis is not only clinically effective but also economically advantageous.