Feasibility, Acceptability, and Preliminary Effects of Virtual Reality for Pain, Anxiety and Recovery Enhancement of Children Post-Scoliosis Surgical Repair: A Pilot Randomized Controlled Parallel Trial (VR-SPINE)

BACKGROUND Adolescent idiopathic scoliosis is a three-dimensional spinal deformity of unknown cause. It is often called 'adolescent' because it is most commonly diagnosed during adolescence. However, scoliosis can be viewed as a condition that exists from birth through adulthood and can be identified at any age. Idiopathic scoliosis is the most common spinal deformity seen in adolescents over 10 years old, accounting for about 80% of cases. This deformity is characterized by a Cobb angle greater than 10 degrees when measured on an anterior-posterior radiograph. Its prevalence among patients aged 10 to 18 years ranges from 2% to 4%.

Scoliosis management entails observation for small curvature (10 - 25 degrees), bracing for moderate curvature and surgical stabilization for curvature greater than 45 degrees. Although the incidence of surgical management is small, it is associated with substantial acute postoperative pain and notable psychological distress, including anxiety and depressive symptoms, for a significant subset of patients. Prospective trajectory studies show that many adolescents report moderate to severe pain in the immediate postoperative period that gradually declines over weeks, yet a non-trivial minority experience persistent postsurgical pain and pain-related interference. Anxiety and depression are more prevalent in AIS than in the general adolescent population and are linked with longer hospital length of stay after posterior spinal fusion. Qualitative work also indicates that concerns about body image, treatment efficacy, and loss of control around the time of surgery contribute to heightened anxiety in adolescents with AIS.

Preoperative pain and anxiety are strong predictors of both acute and longer-term postoperative pain in AIS, forming a continuum from pre- to postsurgical experiences. Higher baseline pain, anxiety, and pain catastrophizing are associated with more intense early postoperative pain, greater risk of persistent postsurgical pain at 6-12 months, and poorer health-related quality of life. Sex differences appear relevant: girls constitute the majority of AIS cases and tend to exhibit higher emotional distress and more tightly interconnected anxiety-depression symptom networks than boys. After posterior spinal fusion, female adolescents report higher average pain scores in the first 48 hours and at initial physical therapy compared with males, despite similar surgical characteristics and analgesic regimens, suggesting that female patients may require more proactive perioperative pain and psychological support.

Early postoperative mobilization, embedded within multimodal "rapid recovery" pathways, plays an important role in modulating pain, anxiety, and overall recovery after AIS surgery. Protocols that promote sitting, standing, and assisted ambulation within the first 24 hours, combined with scheduled non-opioid and rescue opioid analgesia, have been associated with reduced daily pain scores, fewer opioid-related side effects, earlier functional recovery, and shorter length of stay, without worsening pain or increasing readmissions. Given that opioids are commonly associated with adverse effects such as nausea, constipation, pruritus, drowsiness, and, less frequently, respiratory depression, multimodal and opioid-sparing regimens in AIS aim to reduce both pain intensity and opioid-related morbidity to facilitate earlier mobilization and recovery. By helping adolescents safely resume movement, early mobilization can lessen fear of movement and perceived fragility and may indirectly reduce anxiety and depressive symptoms that otherwise prolong hospitalization. Clinical pathways now explicitly list early mobilization as a key objective to standardize care, minimize opioid exposure, and support both physical and psychological recovery after AIS fusion.

Considering the familiarity that adolescents have with immersive gaming, VR-based interventions may help adolescents with AIS better tolerate early postoperative mobilisation by concurrently targeting pain and anxiety. Guided-relaxation and distraction-based VR sessions have shown transient reductions in postoperative pain intensity, pain unpleasantness, and anxiety in children and adolescents, with the greatest benefit in those with higher anxiety sensitivity. Systematic reviews and meta-analyses in pediatric populations indicate that VR distraction during medical procedures produces moderate-to-large reductions in pain and anxiety, supporting its use as a non-pharmacological tool alongside multimodal analgesia. Emerging perioperative trials suggest that integrating VR into early mobilization or physiotherapy can facilitate engagement, preserve or improve respiratory and functional parameters, and address fear of movement (kinesiophobia), which are all relevant to optimizing early post-fusion recovery in AIS.