Posterior-only surgery with preoperative skeletal traction for management of severe scoliosis

Preoperative halo-gravity traction combined with one-stage posterior spinal fusion surgery following for severe rigid scoliosis with pulmonary dysfunction: a cohort study

BACKGROUND

To assess the efficacy of preoperative halo-gravity traction (HGT) in treating severe spinal deformities, evaluating radiological outcomes, pulmonary function, and nutritional status.

METHODS

This study retrospectively included 33 patients with severe spinal deformity who were admitted to our department from April 2018 to January 2022. All the patients underwent HGT prior to the posterior spinal fusion corrective surgery, with no patients having undergone anterior or posterior release procedures. The correction of deformity, pulmonary function tests (PFTs), and nutritional status data were collected and analyzed before and after HGT.

RESULTS

A total of 33 patients (9 males, 24 females) were finally included in this study with an average age of 17.79 ± 7.96 (range 12-29) years. Among them, 20 patients were aged ≤ 16 years. The traction weight started from 1.5 kg and raised to 45.2 ± 13.2% of body weight on average progressively, with the average traction duration of 129 ± 63 days. After traction, the main curve was corrected from an average of 120.66 ± 3.89° to 94.88 ± 3.35°, and to 52.33 ± 22.36° (53%) after surgery(P < 0.05). PFTs also showed a significant increase in FVC%, FEV1%, and MEF% after traction [43.46 ± 14.76% vs. 47.33 ± 16.04%, 41.87 ± 13.68% vs. 45.19 ± 15.57%, and 40.44 ± 15.87% vs. 45.24 ± 17.91%, p < 0.05]. Total protein, albumin, and BMI were used as indicators of nutritional status. TP and albumin were significantly improved after traction, from 67.24 ± 5.43 g/L to 70.68 ± 6.98 g/L and 42.40 ± 3.44 g/L 45.72 ± 5.23 g/L, respectively(P < 0.05). No significant difference was found in deformity correction and lung function improvement between patients with traction for more or less than three months (p > 0.05). Two patients developed transient brachial plexus palsy during traction.

CONCLUSIONS

Halo-gravity traction can partially correct spinal deformity, enhance pulmonary function. And HGT has been shown to facilitate an improved nutritional status in these patients. It could be used as a preoperative adjuvant treatment for severe spinal deformity. However, according to the study, a traction period longer than three months may not be necessary.

Skull-femoral traction followed by osteotomy correction is a safe and effective treatment for severe scoliosis with split cord malformation

OBJECTIVE

This study aimed to evaluate the safety and efficacy of skull-femoral traction followed by osteotomy correction in patients with severe spinal scoliosis and split cord malformation.

METHODS

We retrospectively analyzed ten cases of severe spinal scoliosis with Pang I type split cord malformation treated between August 2012 and August 2023. Patients underwent skull-femoral traction prior to osteotomy correction. We assessed changes in height, weight, coronal and sagittal Cobb's angles, and physiological indicators such as vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and blood gas levels before, during, and after treatment.

RESULTS

Traction duration ranged from 9 to 19 days, with height and weight showing significant increases post-treatment. The coronal Cobb's angle improved from pre-treatment to post-corrective surgery and remained stable at the final follow-up. Similar improvements were observed in the sagittal plane. Physiological indicators such as VC, FVC, and FEV1, as well as blood gas levels, normalized after treatment. Nutritional status, indicated by triceps skinfold thickness, albumin, and transferrin concentrations, also improved. No neurological complications or device-related complications occurred during or after treatment.

CONCLUSION

Skull-femoral traction followed by osteotomy correction is a safe and effective treatment for severe spinal scoliosis with split cord malformation, offering an alternative to high-risk procedures.

Surgical Treatment Outcomes of Anterior-Only Correction and Reconstruction for Severe Cervical Kyphotic Deformity with Neurofibromatosis-1: A Retrospective Study with a 5-Year Follow-Up

OBJECTIVES

Currently, anterior-only (AO), posterior-only, and combined anterior-posterior spinal fusions are common strategies for treating cervical kyphosis in patients with neurofibromatosis-1 NF-1. Nevertheless, the choice of surgical strategy remains a topic of controversy. The aim of our study is to evaluate the safety and effectiveness of anterior decompression and spinal reconstruction for the treatment of cervical kyphosis in patients with NF-1.

METHODS

Twelve patients with NF-1-associated cervical kyphotic deformity were reviewed retrospectively between January 2010 and April 2020. All patients underwent AO correction and reconstruction. The X-ray was followed up in all these patients to assess the preoperative and postoperative local kyphosis angle (LKA), the global kyphosis angle (GKA), the sagittal vertical axis, and the T1 slope. The visual analog scale score, Japanese Orthopedic Association (JOA) score, and neck disability index (NDI) score were used to evaluate the improvement inclinical symptoms. The results of the difference in improvement from preoperatively to the final follow-up assessment were assessed using a paired t-test or Mann-Whitney U-test.

RESULTS

The LKA and GKA decreased from the preoperative average of 64.42 (range, 38-86) and 35.50 (range, 10-81) to an average of 16.83 (range, -2 to 46) and 4.25 (range, -22 to 39) postoperatively, respectively. The average correction rates of the LKA and GKA were 76.11% and 111.97%, respectively. All patients had achieved satisfactory relief of neurological symptoms (p < 0.01). JOA scores were improved from 10.42 (range, 8-16) preoperatively to 15.25 (range, 11-18) at final follow-up (p < 0.01). NDI scores were decreased from an average of 23.25 (range, 16-34) preoperatively to an average of 7.08 (range, 3-15) at the final follow-up (p < 0.01).

CONCLUSION

Anterior-only correction and reconstruction is a safe and effective method for correcting cervical kyphosis in NF-1 patients. In fixed cervical kyphosis cases, preoperative skull traction should also be considered.

The Surgical Management of Severe Scoliosis in Immature Patient with a Very Rare Disease Costello Syndrome-Clinical Example and Brief Literature Review

BACKGROUND

Costello syndrome (CS) is a rare genetic syndrome in which, due to the occurrence of a mutation in the HRAS gene on chromosome 11 that causes the manifestation, a set of features such as a characteristic appearance, many congenital defects, intellectual disability and a genetic predisposition to cancer, friendly personality, and others can be identified. CS is very rare, with an incidence of ~1/300,000, but it belongs to one of the largest groups of congenital syndromes, called RASopathies, occurring with an incidence of 1/1000 people. Scoliosis and kyphosis, as well as other spinal defects, are common, in 63% and 58% of patients, respectively, and a study conducted among adult patients showed the presence of scoliosis in 75% of patients; there may be excessive lordosis of the lumbar section and inverted curvatures of the spine (lordosis in the thoracic section and kyphosis in the lumbar section). The aim of our study is to present a case report of treatment of severe scoliosis of 130 degrees in a 14-year-old patient with Costello syndrome, with coexisting Chiari II syndrome and syrinx in the absence of skeletal maturity. This patient underwent foramen magnum decompression 3 months before planned surgical correction for severe scoliosis. The patient was qualified for surgical treatment using magnetically controlled growing rods (MCGR). After spine surgery using MCGR, we gradually performed MCGR distraction over the next 2 years; we performed the final surgery, conversion to posterior spinal fusion (PSF) with simultaneous multi-level Ponte osteotomy, which gave a very good and satisfactory surgical result. In the perioperative period, two serious complications occurred: pneumothorax caused by central catheter and gastrointestinal bleeding due to previously undiagnosed gastrointestinal varices. This case shows that the treatment of severe and neglected scoliosis is complicated and requires special preparation and a surgical plan with other cooperating specialists. The scoliosis was corrected from 130 degrees to approximately 48 degrees, sagittal balance was significantly improved, and the surgical outcome was very pleasing, significantly improving quality of life and function for the patient.

Multi-rod posterior correction only with halo-femoral traction for the management of adult neuromuscular scoliosis (> 100°) with severe pelvic obliquity: a minimum 5-year follow-up

BACKGROUND

Many patients with neuromuscular scoliosis (NMS) experience a variety of difficult medical problems that aggravate the development effects of progressive scoliosis and pelvic obliquity (PO). The objective of the current study was to assess the safety and effectiveness of multi-rod posterior correction only (MRPCO) with halo-femoral traction (HFT) for the management of adult NMS (> 100°) with severe PO.

METHODS

From 2012 to 2017, 13 adult patients who suffered from NMS (> 100°) with severe PO underwent MRPCO with HFT. The radiography parameters in a sitting position, such as the coronal Cobb angle of the main curve, the PO and the trunk shift (TS), were measured at the preoperative, postoperative and final follow-up stages. The preoperative and final follow-up assessment of the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) was taken.

RESULTS

The average follow-up span was 68.15 ± 6.78 months. There was decreased postoperative coronal Cobb angle with an average mean of 125.24° ± 11.78° to 47.55° ± 12.10°, with a correction rate of 62.43%; the PO was reduced to 6.25° ± 1.63° from 36.93° ± 4.25° with a correction rate of 83.07%; the TS was reduced to 2.41 cm ± 1.40 cm from 9.19 cm ± 3.07 cm. There was significant improvement in all parameters compared to the preoperative data. The VAS score reduced from 4.77 ± 0.93 to 0.69 ± 0.75, and the ODI score reduced from 65.38 ± 16.80 to 28.62 ± 12.29 at the final follow-up.

CONCLUSIONS

Treatment of adult NMS (> 100°) with severe PO could be safe and effective with MRPCO with HFT. In order to obtain the optimum sitting balance, this could reduce the prevalence of complications and rectify the curvature and the correction of PO.

Efficacy of Routine Intraoperative Cranio-Femoral Traction in Surgical Treatment of Adolescent Idiopathic Scoliosis Curves Measuring Between 50° and 90°

STUDY DESIGN

Retrospective Comparative Study, Level III.

OBJECTIVE

In patients with scoliosis >90°, cranio-femoral traction (CFT) has been shown to obtain comparable curve correction with decreased operative time and blood loss. Routine intraoperative CFT use in the treatment of AIS <90° has not been established definitively. This study investigates the effectiveness of intraoperative CFT in the treatment of AIS between 50° and 90°, comparing the magnitude of curve correction, blood loss, operative time, and traction-related complications with and without CFT.

METHODS

73 patients with curves less than 90° were identified, 36 without and 37 with cranio-femoral traction. Neuromuscular scoliosis and revision surgery were excluded. Age, preoperative Cobb angles, bending angles, and curve types were recorded. Surgical characteristics were analyzed including number of levels fused, estimated blood loss, operative time, major curve correction (%), and degree of postoperative kyphosis.

RESULTS

Patients with traction had significantly higher preoperative major curves but no difference in age or flexibility. Lenke 1 curves had significantly shorter operative time and improvement in curve correction with traction. Among subjects with 5 to 8 levels fused, subjects with traction had significantly less EBL. Operative time was significantly shorter for subjects with 5-8 levels and 9-11 levels fused. Curves measuring 50°-75° showed improved correction with traction.

CONCLUSION

Intraoperative traction resulted in shorter intraoperative time and greater correction of major curves during surgical treatment of adolescent idiopathic scoliosis less than 90°. Strong considerations should be given to use of intraoperative CFT for moderate AIS.

No Benefits in Using Magnetically Controlled Growing Rod as Temporary Internal Distraction Device in Staged Surgical Procedure for Management of Severe and Neglected Scoliosis in Adolescents

BACKGROUND

Severe spinal curvatures (SSCs) in children and adolescents have long been treated with preoperative Halo traction, in its various variations. There are also several radical techniques available for the management of neglected SSCs, such as osteotomies; however, these can be risky. Comparing the treatment outcomes when using preoperative Halo Gravity Traction (HGT) against the use of a Magnetically Controlled Growing Rod (MCGR) as a temporary internal distraction (TID) device, we evaluated the differences in surgical and radiological outcomes.

METHODS

We conducted a retrospective study of 30 patients with SSCs, treated with HGT followed by posterior spinal fusion (PSF; Group 1, n = 18) or treated using a temporary MCGR as a TID followed by PSF (Group 2, n = 12). All patients underwent surgical treatment between 2016 and 2022. The inclusion criteria were SSC > 90°, flexibility < 30%, and the use of preoperative HGT followed by PSF or the two-stage surgical procedure with initial TID rod placement (Stage 1) followed by PSF (Stage 2). The evaluated parameters were as follows: rib hump, trunk height, and radiographic outcomes. All parameters were collected preoperatively, after the initial surgery, after final correction and fusion, and during the final follow-up.

RESULTS

In Group 1, we evaluated 18 patients with a mean age of 15.5 years; in Group 2, we evaluated 12 patients with a mean age of 14.2 years. The interval between the staged procedures averaged 32.7 days. The mean preoperative main curves (MC) were 118° and 112° in Group 1 and Group 2, respectively. After definitive surgery, the MC was corrected to 42° and 44° in G1 and G2, respectively. The mean percentage correction of the MC was similar in both groups (65% vs. 61% in G1 and G2, respectively). The mean preoperative thoracic kyphosis was 92.5° in G1 and 98° in G2, corrected to 43.8° in G1 and 38.8° in G2. Trunk height increased by 9 cm on average.

CONCLUSIONS

There are no benefits in using a MCGR as a temporary internal distraction device in the management of neglected scoliosis in adolescents. Surgical treatment of severe scoliosis may be safe, with a reduced risk of potential complications, when using preoperative HGT. A specific intraoperative complication when using a MCGR as a temporary internal distraction device was a 50% risk of transient neuromonitoring changes, due to significant force applied to the spine and radical distraction of the spine. We achieved similar clinical, radiographic, and pulmonary function outcomes for both techniques. The use of HGT causes less blood loss with a shorter overall time under anesthesia. Partial correction significantly aids the subsequent operation by facilitating a gradual reduction in the curvature, thereby reducing the difficulty of surgical treatment and the risk of neurological deficits.

Paediatric Spinal Deformity Surgery: Complications and Their Management

Surgical correction of paediatric spinal deformity is associated with risks, adverse events, and complications that must be preoperatively discussed with patients and their families to inform treatment decisions, expectations, and long-term outcomes. The incidence of complications varies in relation to the underlying aetiology of spinal deformity and surgical procedure. Intraoperative complications include bleeding, neurological injury, and those related to positioning. Postoperative complications include persistent pain, surgical site infection, venous thromboembolism, pulmonary complications, superior mesenteric artery syndrome, and also pseudarthrosis and implant failure, proximal junctional kyphosis, crankshaft phenomenon, and adding-on deformity, which may necessitate revision surgery. Interventions included in enhanced recovery after surgery protocols may reduce the incidence of complications. Complications must be diagnosed, investigated and managed expeditiously to prevent further deterioration and to ensure optimal outcomes. This review summarises the complications associated with paediatric spinal deformity surgery and their management.

Surgical treatment of severe adolescent idiopathic scoliosis through one-stage posterior-only approach: A systematic review and meta-analysis

The aim of this meta-analysis was to analyze the results of one-stage all-posterior spinal fusion for severe adolescent idiopathic scoliosis (AIS). A systematic search of articles about one-stage posterior spinal fusion for severe AIS was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about population, pre-and postoperative radiographical data, surgical procedure details, and complications were extracted. Meta-analyses were performed when possible. Fourteen studies (640 patients) were included. The mean Cobb angle of the major curve varied from 80.0 ± 7.3 to 110.8 ± 12.1. The meta analysis showed a comprehensive coronal correction rate of the major curve of 58.6%, a comprehensive operative time of 274.5 min, and a comprehensive estimated intraoperative blood loss of 866.5 mL (95% confidence interval: 659.3-1073.6, I 2 ≈ 0%). A total of 48 complications (5.4%) were reported. Overall, the meta-analysis showed a major complication rate of 4%. In seven cases, revision surgery was needed. Posterior-only approach is effective enough to correct severe curves and can spare the patient possible adverse events due to anterior approach. However, when choosing this approach for severe AIS, screw density needs to be high and posterior column osteotomies may need to be planned to mobilize the spine and maximize correction.

Pulmonary function in children and adolescents with untreated idiopathic scoliosis: a systematic review with meta-regression analysis

BACKGROUND CONTEXT

One of the controversies in untreated idiopathic scoliosis is the influence of curve size on respiratory function. Whereas scoliosis patients with curves over 90 to 100 degrees are agreed to be at risk for cardiorespiratory failure in later life, the impairment of curves below 90 degrees is generally considered mild. Although various studies showed that pulmonary function is affected in patients with scoliosis, quantification of the relation between curve size and pulmonary function is lacking.

PURPOSE

This systematic review with meta-regression analysis aims to characterize the relation between pulmonary function tests and scoliosis severity in children and adolescents with idiopathic scoliosis.

STUDY DESIGN

Systematic review with meta-regression analysis.

METHODS

Pubmed, Embase, Cochrane, and CINAHL were systematically searched until November 3, 2020, for original articles that reported (1) severity of scoliosis quantified in Cobb angle, and (2) pulmonary function tests in children and adolescents with untreated idiopathic scoliosis. Exclusion criteria were other types of scoliosis, non-original data, post-treatment data, and case reports. All study designs were included, and relevant study details and patient characteristics were extracted. The primary outcome was the effect of Cobb angle on pulmonary function as expressed by the slope coefficient of a linear meta-regression analysis.

RESULTS

A total of 126 studies, including 8,723 patients, were retrieved. Meta-regression analysis revealed a statistically significant inverse relation between thoracic Cobb angle and absolute and predicted forced vital capacity in 1 second, forced vital capacity, vital capacity, and total lung capacity. For these outcomes, the slope coefficients showed a decrease of 1% of the predicted pulmonary function per 2.6 to 4.5 degrees of scoliosis. A multivariable meta-regression analysis of potential confounders (age, year of publication, and kyphosis) hardly affected the majority of the outcomes.

CONCLUSION

This meta-regression analysis of summary data (means) from 126 studies showed an inverse relationship between the thoracic Cobb angle and pulmonary function. In contrast to previous conclusions, the decline in pulmonary function appears to be gradual over the full range of Cobb angles between <20 and >120 degrees. These findings strengthen the relevance of minimizing curve progression in children with idiopathic scoliosis.

Posterior-only surgical correction with heavy halo-femoral traction for the treatment of extremely severe and rigid adolescent idiopathic scoliosis (> 130°)

INTRODUCTION

The treatment of extremely severe and rigid spinal deformities was a great surgical challenge. Pulmonary impairment often occurred, which increased the challenges to already daunting surgical approaches. The present study was performed to evaluate the safety and efficacy of posterior-only surgical correction with heavy halo-femoral traction (HFT) for the treatment of extremely severe and rigid adolescent idiopathic scoliosis (AIS) of more than 130°.

MATERIALS AND METHODS

From 2010 to 2017, 11 patients suffered from extremely severe and rigid AIS of more than 130° underwent posterior-only surgical correction with HFT. The preoperative mean coronal Cobb angle of major curve was 139.01° ± 5.83°, and the mean flexibility was 17.21% ± 3.33%; the mean angle of thoracic kyphosis (TK) and lumbar lordosis (LL) were 65.02° ± 7.21° and 39.05° ± 4.08°, respectively; the mean trunk shift (TS) and sagittal vertical axis (SVA) were 3.3 ± 0.97 cm and 3.97 ± 1.16 cm, respectively; moreover, the percent forced vital capacity (FVC%) and percent forced expiratory volume in 1 s (FEV1%) were 50.08% ± 6.07% and 53.46% ± 5.96%, respectively; the mean body height and weight were 140.09 ± 4.95 cm and 37 ± 4.34 kg, respectively.

RESULTS

The mean duration of surgery was 335.91 ± 48.31 min and blood loss was 1590 ± 520.1 ml. The average period of follow-up was 32.18 ± 8.17 months. After heavy HFT, the mean coronal Cobb angle of major curve was reduced to 82.98° ± 6.91° with correction rate of 40.39%. After posterior-only surgical correction, the mean coronal Cobb angle was further reduced to 51.17° ± 5.4° with correction rate of 63.27%. The postoperative mean TK, LL, TS and SVA were improved to 23.85° ± 5.14°, 44.95° ± 2.26°, 1.32 ± 0.72 cm and 1.42 ± 0.83 cm, respectively. At the final follow-up, the corrective loss rate of Cobb angle was only 0.72%; moreover, the mean FVC% and FEV1% were increased to 65.45% ± 5.29% and 69.08% ± 5.32% with improvement of 15.36% and 15.62%, respectively; the mean body height and weight were increased to 154.45 ± 5.32 cm and 45 ± 4.02 kg with improvement of 14.36 cm and 8 kg, respectively. The spinal cord function was stable, and there were no new neurological symptoms after correction.

CONCLUSIONS

Posterior-only surgical correction with heavy HFT could be safe and effective for the treatment of extremely severe and rigid AIS of more than 130° in reducing the incidence of complications and greatly improving curve correction.

Effects of combined adjustable Halo-pelvic fixation brace on cervical spine alignment in patients with severe rigid spinal deformity

Objective

To evaluate the effect of continuous traction with a combined adjustable Halo-pelvic fixation brace on the cervical spine alignment in patients with severe rigid spinal deformity and analyze its related factors.

Methods

We conducted a retrospective cohort study of 21 patients with severe rigid spinal deformity treated in our department between 2015 and 2019. All subjects received combined adjustable Halo-pelvic fixation brace traction before secondary orthopedic surgery. The influence of the Halo-pelvic fixation brace on the cervical spine alignment was evaluated by measuring the parameters of lateral cervical X-ray at three time points: before traction, at the end of traction, and 6 months after orthopedic surgery. The correlation between parameter changes and total traction duration was analyzed to explore factors influencing cervical alignment.

Results

The C2L-C7L angle was 22.40 ± 15.91° before traction, which decreased to 5.91 ± 6.78° at the end of traction but increased to 14.51 ± 10.07° after orthopedic surgery (BT vs ET p < 0.005, ET vs AOS p < 0.005, BT vs AOS p < 0.005). Accordingly, C2L-C7U angle, C2L-C6L angle, C2L-C6U angle, C2L-C5L angle, C7 or T1 slope, C2-C7 SVA, SCA, C2-T1 Ha, C0 slope, and C0-C2 angle also changed similarly to C2L-C7L angle. Furthermore, moderate correlation was observed between C2L-C7L angle and total traction volume (r = 0.563, p = 0.008) and SCA and traction duration (r = 0.525, p = 0.015). However, no significant correlation was found between other cervical alignment parameters and total traction volume and traction duration.

Conclusions

The continuous traction of a combined adjustable Halo-pelvic fixation brace can affect the cervical spine alignment of patients with severe rigid spinal deformity and straighten the physiological curvature of the cervical spine. However, the sagittal alignment gradually recovers after the traction, without any adverse effects on the orthopedic surgery and global balance after the operation; therefore, this apparatus is worthy of wide application.

Halo Gravity Traction for the Correction of Spinal Deformities in the Pediatric Population: A Systematic Review and Meta-Analysis

OBJECTIVE

Halo gravity traction (HGT) is an effective way of managing pediatric spinal deformities in the preoperative period. This study comprehensively reviews the existing literature and evaluates the effect of HGT on various radiographic parameters regarding spinal correction and, secondarily, evaluates the improvement in pulmonary function as well as nutritional status.

METHODS

In accordance with PRISMA guidelines, a comprehensive search was conducted for articles on HGT in the treatment of spinal deformity. Spinal deformity after traction and surgery, change of pulmonary function, nutritional status, and prevalence of complications were the main outcome measurements. All meta-analyses were conducted using random models according to the between-study heterogeneity, estimated with I².

RESULTS

A total of 694 patients from 24 studies were included in this review. Compared with pretraction values, the average coronal Cobb angle reduction after traction was 27.66° (95% confidence interval [CI], 23.41-31.90; P < 0.001) and 47.43° (95% CI, 39.32-55.54; P < 0.001) after surgery. The sagittal Cobb angle reduction after HGT and surgery was 27.23° (95% CI, 22.83-31.62; P <0.001) and 36.77° (95% CI, 16.90-56.65; P < 0.001), respectively. There was a statistically significant improvement in the overall pulmonary function, as evident by an increase in a forced vital capacity of 8.44% (95% CI, -5.68 to -11.20; P < 0.001), and an increase in nutritional status, with a percentage correction of body mass index by 1.58 kg/m² (95% CI, -2.14 to -1.02; P < 0.001) after HGT application.

CONCLUSIONS

HGT has been shown to significantly improve coronal deformities, sagittal deformities, nutritional status, and pulmonary function in the preoperative period.

Preoperative Halo-Femoral Traction With Posterior Surgical Correction for the Treatment of Extremely Severe Rigid Congenital Scoliosis (Cobb Angle >120°)

INTRODUCTION

To evaluate the effectiveness and safety of preoperative halo-femoral traction (HFT) with posterior surgical correction for the treatment of extremely severe rigid congenital scoliosis (>120°).

METHODS

We reviewed the records of all patients with extremely severe rigid congenital scoliosis (>120°) treated with preoperative HFT from 2010 through 2018. Radiographic measurements were performed. The period of traction, blood loss, operation time, complications, and pulmonary function test results were recorded.

RESULTS

A total of 11 patients were included in the study. All patients underwent preoperative HFT with posterior surgical correction. The mean preoperative main curve Cobb angle was 127.9° ± 4.4°, and the average correction rate was 33.5% posttraction, 54.8% postoperation, and 55.3% at the latest follow-up. Pulmonary function improved significantly after traction, and forced vital capacity and forced expiratory volume in 1 second increased from 34.7% and 33.4% to 48.1% and 48.5%, respectively. Only one patient experienced halo pin infection during HFT. No patients experienced permanent neurologic deficits or death.

CONCLUSION

For extremely severe rigid congenital scoliosis with a Cobb angle greater than 120°, preoperative HFT with posterior surgical correction offers an effective and safe corrective option. The perioperative complication rate can be partially reduced.

STUDY DESIGN

Retrospective study.

Halo-pelvic traction for thoracic spine dislocation in neurofibromatosis type 1: a case series

PURPOSE

To present a case series of 6 patients with Neurofibromatosis type 1 (NF-1) who had severe kyphoscoliosis with vertebral dislocation, and were treated with halo-pelvic traction (HPT) and posterior fusion. To discuss the pathological characteristics of this rare entity, and report our experience using HPT to manage the condition.

METHODS

From March, 2016 to September, 2017, 6 patients with severe kyphoscoliosis with vertebral dislocation were admitted for HPT and posterior surgery, and were followed for 2 years.

RESULTS

The 6 patients received HPT for an average of 42 days. The average scoliosis Cobb angle was 131.2° before HPT, 69.9° after HPT, 52.7° after posterior surgery, and 51.7° at the 2-year follow-up. The average 2-year correction rate was 61.7%. The average kyphosis Cobb angle was 125.2° before HPT, 62.9° after HPT, 62.2° after posterior surgery, and 64.9° at the 2-year follow-up. The average 2-year correction rate was 46.5%. Proximal screw pull-out was found in one patient at the 3-month follow-up visit, but revision surgery was not needed. No patients experienced permanent neurological deficits or death. No screw malposition occurred in any patient.

CONCLUSION

HPT is a viable treatment option for vertebral dislocation in NF-1. After 6 weeks of traction, the vertebral dislocation, scoliosis, and kyphosis can be dramatically reduced, and thus the conditions for corrective surgery can be improved.

THE USE OF CRANIAL HALO TRACTION VERSUS TEMPORARY INTERNAL DISTRACTION IN STAGED SURGERY FOR SEVERE SCOLIOSIS: A COMPARATIVE STUDY

ABSTRACT Objective: To determine which method is more effective – cranial halo traction or temporary internal distraction – in staged surgeries for patients with severe (≥ 100°) and stiff (<25% flexibility) scoliosis. Methods: A sample of 12 patients with traction and 7 patients without traction, operated on between January 2013 and December 2017. The patients’ demographic data, the type of surgery performed, complications, and coronal and sagittal alignment parameters were recorded before surgery and in the final follow-up. The data were processed in SPSS 20.0. Comparisons were made between the means (Student's t-test) and the clinical and procedure-related characteristics (likelihood ratio and Fisher's Exact tests), at a confidence level of 0.05. Results: There were no significant intergroup differences for clinical characteristics, complications or degree of correction. However, more patients in the group submitted to temporary internal distraction required vertebral resection osteotomies during definitive surgery (p<0.05). Conclusions: Based on the results, it was not possible to establish which is the most effective method, but it is suggested that staged traction may be more effective, and safer, particularly when the surgeon is less experienced, during surgery on patients with severe and stiff scoliosis. Level of evidence IV; Vase series.

Halo traction combined with posterior-only approach correction for cervical kyphosis with Neurofibromatosis-1: minimum 2 years follow-up

Background

Surgical management of cervical kyphosis in patients with NF-1 is a challenging task. Presently, anterior-only (AO), posterior-only (PO) and combined anterior-posterior (AP) spinal fusion are common surgical strategies. However, the choice of surgical strategy and application of Halo traction remain controversial. Few studies have shown and recommended posterior-only approach for cervical kyphosis correction in patients with NF-1. The aim of this study is to evaluate the safety and the effectiveness of halo Traction combined with posterior-only approach correction for treatment of cervical kyphosis with NF-1.

Methods

Twenty-six patients with severe cervical kyphosis due to NF-1 were reviewed retrospectively between January 2010 and April 2018. All the cases underwent halo traction combined with posterior instrumentation and fusion surgery. Correction result, neurologic status and complications were analyzed.

Results

In this study, cervical kyphosis Cobb angle decreased from initial 61.3 ± 19.7 degrees to postoperative 10.6 ± 3.7 degrees (P<0.01), with total correction rate of 82.7%, which consist of 45.8% from halo traction and 36.9% from surgical correction. JOA scores were improved from preoperative 13.3 ± 1.6 to postoperative 16.2 ± 0.7 (P<0.01). Neurological status was also improved. There was no correction loss and the neurological status was stable in mean 43 months follow-up. Three patients experienced minor complications and one patient underwent a second surgery.

Conclusion

Halo traction combined with PO approach surgery is safe and effective method for cervical kyphosis correction in patients with NF-1. A satisfied correction result, and successful bone fusion can be achieved via this procedure, even improvement of neurological deficits can also be obtained. Our study suggested that halo traction combined with PO approach surgery is another consideration for cervical kyphosis correction in patients with NF-1.

Halo-gravity traction followed by definitive fusion in severe early onset scoliosis: results of a trunk analysis based on biplanar 3D reconstructions

PURPOSE

Definitive fusion can be considered in early onset scoliosis (EOS) around triradiate cartilage closure. Halo-gravity traction (HGT) is an old strategy that can help lengthen and balance the spine before fusion. The postoperative changes of the trunk have never been investigated to date with modern imaging. The goal of this study was to analyze the 3D radiological outcomes, and the associated pulmonary function, of a cohort of severe EOS patients treated by definitive posterior fusion prepared by HGT.

METHODS

All consecutive EOS patients with severe (> 85°) and stiff (flexibility < 25%) curves, treated by HGT followed by posterior fusion, were followed. 3D radiological measurements and pulmonary function were assessed.

RESULTS

Forty-nine EOS patients underwent fusion, with a mean follow-up of 4 years (± 1). Age at surgery averaged 13.5 years old. HGT protocol reached on average 41% of body weight. Mean preoperative 3D Cobb angle was 95° (± 10) and final correction averaged 68.4% after surgery. 3D T4T12 kyphosis was reduced after surgery (11°, p < 0.01), while the apical vertebral rotation was improved by 27.8% (p = 0.06). 3D thoracic volume increased after surgery (p = 0.02), with a 3D T1T12 height gain averaging 3.7 cm (± 2). Both parameters were significantly correlated with total lung capacity improvement. Seven complications (14.2%) were reported, and 5 patients (10.6%) underwent unplanned revision.

CONCLUSION

HGT is a safe and efficient strategy to prepare posterior fusion in severe EOS patients. The 3D trunk analysis demonstrated significant postoperative gains in thoracic and spinal lengths, as well as in thoracic volume.

LEVEL OF EVIDENCE

IV.

How helpful is the halo-gravity traction in severe spinal deformity patients?: A systematic review and meta-analysis

PURPOSE

This study sought to evaluate the complications and clinic outcome in radiographic parameters, pulmonary function, and nutritional status of halo-gravity traction (HGT) in treating severe spinal deformity.

METHODS

Embase, PubMed, Cochrane, Web of Science databases were searched comprehensively for relevant studies from inception to February 2021, by using combined text and MeSH terms and English language restriction was used. The data, including radiographic parameters, pulmonary function (FVC %), and nutritional status (BMI) was extracted from included studies. All meta-analyses were conducted using random or fixed-effects models according the between-study heterogeneity, estimated with I².

RESULTS

Four hundred and forty-six studies were identified and twelve studies with a total of 372 patients were included in this review. Compared with pre-traction values, there were reduction in cobb angle of 28.12° [95% CI (22.18, 34.18)], decrease in thoracic kyphosis of 26.76°[95% CI (20.73, 32.78)], improvements in spine height[SMD = -0.89, 95% CI (- 1.56, - 0.21)] and in coronal balance[WMD = - 0.03, 95% CI (- 1.56, - 0.21), P = 0.84] with preoperative halo-gravity traction for severe spinal deformity patients. Besides, our pooled analysis showed the improvement in pulmonary function (FVC %) [WMD = - 9.56, 95% CI (- 1.56, - 0.21)] and increase in nutritional status (BMI) [WMD = - 0.50, 95% CI (- 1.56, - 0.21)].

CONCLUSION

Partial correction can be achieved by preoperative HGT, thereby reducing the difficulty of the operation and the risk of neurologic injury caused by excessive correction. Moreover, preoperative HGT can improve pulmonary function and nutritional status and, thus, increase patients' tolerance to surgery.

Preoperative skull tongs-femoral traction versus cotrel longitudinal traction for rigid and severe scoliosis: Cohort study

Background

To compare two methods of preoperative traction (Cotrel traction exercises and skull tongs femoral traction) in severe scoliosis treatment.

Methods

We collected retrospective data of severe (>80°) and rigid scoliosis patients who underwent preoperative traction before correction surgery from 2016 to 2018. The first group consisted of patients who underwent Cotrel traction exercises and second group underwent continuous-progressively increasing Skull Tongs Femoral Traction (STFT) traction. Posterior fusion was performed in all patients. Intraoperative parameters (blood loss, operation time and level instrumented) and radiologic change (initial, post-traction and postoperative Cobb Angle) was evaluated and analyzed.

Results

Thirty consecutive case of severe and rigid scoliosis were included (15 in each group). Despite Cotrel group having larger initial Cobb angle, the amount of post traction correction was statistically similar in both groups (16.4° and 11.8°, in STFT and Cotrel group respectively). Mean traction duration was 14.0 days for Cotrel group and 12 days for STFT. There were also no significant differences in postoperative curve correction rate between two groups, although STFT group had a slightly higher correction rate (69.3° vs 55.0°). No major/neurologic complication were found in our series.

Conclusions

Both preoperative traction methods were found safe and beneficial to reduce preoperative curve degree before definitive scoliosis correction surgery. Although, no statistical difference were found between two methods, STFT may provide better correction rate.

Level of evidence

3.

•

Compare two preoperative traction methods in severe scoliosis.

•

Preoperative traction were safe and beneficial to reduce preoperative curve degree.

•

Skull Tongs Femoral Traction may provide better correction rate.

Preoperative Halo Traction for Severe Scoliosis

STUDY DESIGN

Retrospective case control study.

OBJECTIVE

The aim of this study was to analyze the appropriate traction period and preoperative halo traction (HT)-related factors in severe scoliosis SUMMARY OF BACKGROUND DATA.: HT can reduce risks involved in severe scoliosis treatment, and its safety and efficacy are well known. However, a lack of evidence exists in guiding the appropriate traction period and other factors involved in HT.

METHODS

We retrospectively reviewed 59 patients who underwent preoperative HT, analyzed correction rate changes over time using HT, and assessed other factors by dividing the patients into two groups according to differences between the post-bending correction angle (PBC) and post-halo traction correction angle (PTC): group A (PBC ≒ PTC) and group B (PBC < PTC). The grouping was determined by whether the difference between PBC and PTC was >8°, the maximum measurement error when measuring the Cobb angle.

RESULTS

The mean Cobb angle improved from 96.9° preoperatively to 72.9° post-bending to 63.3° post-traction and 32.5° postoperatively. The coronal correction of the major curve (change in curve from the start to each week/total change in curve after traction) was 28.2% at 1 week (n = 59), 34.0% at 2 weeks (n = 58), 33.8% at 3 weeks (n = 41), and 32.2% at 4 weeks (n = 13); a difference was noted between the first and second weeks (P < 0.001, <0.001, 0.244, and 0.082, respectively). Compared with group A, group B had a lower height (154.9 vs. 144.4 cm, P = 0.029), lower body weight (49.1 vs. 39.4 kg, P = 0.017), higher traction/body weight ratio (0.41 vs. 0.47, P = 0.025), and more halo-femoral traction (0 vs. 6, P = 0.018).

CONCLUSION

Traction for ≥3 weeks was unnecessary for optimal traction. In patients with low height and weight, halo-femoral traction with a heavy traction weight was effective.

LEVEL OF EVIDENCE

4.

A Retrospective Study to Compare the Efficacy of Preoperative Halo-Gravity Traction and Postoperative Halo-Femoral Traction After Posterior Spinal Release in Corrective Surgery for Severe Kyphoscoliosis

Background

This retrospective clinical study aimed to compare the efficacy of preoperative halo-gravity traction with postoperative halo-femoral traction after posterior spinal release in corrective surgery for patients with severe kyphoscoliosis.

Material/Methods

A retrospective clinical study included patients who underwent elective corrective surgery for severe kyphoscoliosis (N=60) between 2013 and 2015. Two patient groups were compared, the postoperative halo-femoral traction after posterior spinal release (R-HF) group (N=30) and the preoperative halo-gravity traction (HGT) group (N=30). Demographic and clinicopathological data included age, gender, Cobb angle, degree of spinal curvature, history of osteotomy, and etiological factors. Patients in the two study groups were matched. Postoperative surgical outcome was evaluated by the radiographic coronal Cobb angle, global kyphosis, coronal balance, and the sagittal vertical axis (SVA). Clinical outcome was assessed using the Scoliosis Research Society Outcomes Questionnaire (SRS-22).

Results

The preoperative Cobb angle was similar between the R+HF group and the HGT group (123.5±12.7° vs. 123.1±14.1°; P=0.909). Following postoperative traction, a significantly higher correction rate was found in the R+HF group than the HGT group (31.8±7.8% vs. 19.3±12.9%; P=0.001). The postoperative correction rate in the R+HF group was significantly higher than the HGT group (44.7±7.8% vs. 39.0±12.8%; P=0.042). In both study groups, the postoperative SRS-22 scores were significantly improved with no statistical difference between the two groups, and no neurological complications occurred.

Conclusions

Patients with severe kyphoscoliosis who underwent postoperative halo-femoral traction after posterior spinal release achieved satisfactory radiographic correction.

Stepwise Management of Severe Thoracogenic Scoliosis in Burned Child

BACKGROUND

Skin and soft tissue retraction secondary to burns of the trunk may induce severe and progressive thoracogenic spinal deformities in children. Its management is rarely described.

CASE DESCRIPTION

Our study reports a case of severe thoracic scoliosis in a 13-year-old adolescent, secondary to soft tissue retraction due to trunk burn in early childhood. The Cobb angle of the scoliosis was 100 degrees. The 3-stage surgical strategy consisted of scar excision and skin graft in the first stage, halo gravity traction in the second stage, and posterior correction and fusion of the spine in the third and final stage. The postoperative course was satisfactory, and late follow-up at 1 year showed stable correction of the spine, with satisfactory coronal and sagittal balance and good healing of skin and soft tissues.

DISCUSSION

While spinal deformities secondary to burns are rare, they require specific, sequential, and multidisciplinary medical and surgical management. Our surgical strategy was to treat skin and soft tissues retractions first and then address spinal deformity. We used halo-gravity traction between the 2 surgical stages to help improve the spine deformity correction while reducing the risk of neurologic complications.

Anterior and Posterior Fusion for Large, Rigid Idiopathic Scoliosis: Does Implant Density Matter?

BACKGROUND

Despite advancements in surgical techniques, controversy remains regarding the optimal implant density for the correction of idiopathic scoliosis. Recent evidence has suggested that equivalent radiographic and clinical outcomes can be achieved with lower implant densities for those with moderate curves and good flexibility. Among the experts, the consensus has continued that higher implant densities should be used for larger, stiffer curves. The purpose of the present study was to compare the radiographic results between high-implant density (HID) and low-implant density (LID) constructs in patients with large (>65°), rigid (<50% flexibility) curves who had undergone anterior release and posterior spinal fusion.

METHODS

We reviewed the idiopathic scoliosis cases performed at a single institution from 2006 to 2014. Only those meeting the inclusion criteria were selected. The patients were divided into HID and LID groups. The postoperative radiographs were compared for coronal correction, thoracic kyphosis, pelvic tilt, lumbar lordosis, and sagittal vertical axis.

RESULTS

A statistically significant improvement in coronal correction was detected in the HID group at all follow-up points (final follow-up: HID, 81.1% vs. LID, 70.4%; P = 0.01). When preoperative thoracic kyphosis was considered, no differences were found between the 2 groups. No differences were found in the other sagittal parameters.

CONCLUSION

In patients with large, rigid idiopathic scoliosis undergoing anterior release and posterior spinal fusion, a small, but statistically, significant improvement in the coronal Cobb angle was seen. It remains to be determined whether this small difference in radiographic correction will have any influence on the clinical outcome.

Neurologic Deficit During Halo-Gravity Traction in the Treatment of Severe Thoracic Kyphoscoliotic Spinal Deformity

Correction of severe spinal deformity is a significant challenge for spinal surgeons. Although halo-gravity traction (HGT) has been shown to be well-tolerated and safe, we report here a case of neurologic decline during treatment. A 24-year-old male presents with severe thoracic kyphoscoliosis with > 180° of 3-dimensional deformity. Magnetic resonance imaging showed his thoracic spinal cord draped across his T7-9 apex. His neurologic exam showed lower extremity myelopathy. During week 7 at a goal traction weight of 18.1 kg, his distal lower extremity exam declined from 4+/5 to 2/5. His traction weight was lowered to 11.3 kg. He subsequently sustained a ground-level fall and became paraparetic with a motor exam of 1-2/5. He subsequently underwent a T1-L4 posterior spinal instrumentation and fusion with a T7-9 vertebral column resection. Postoperatively, he was noted to have a complete return to his baseline neurologic exam. At his 4-month postoperative visit, he was now full strength in his lower extremities with complete resolution of his myelopathy. We present here a case of neurologic decline in a patient with severe kyphoscoliosis who underwent HGT and discuss the management decisions associated with this challenging scenario.

Correction using Halo Gravity Traction for Severe Rigid Neuromuscular Scoliosis: A Report of Three Cases

Severe rigid neuromuscular scoliosis is a major challenge to the spine surgeon due to the possibilities of neurological sequelae from acute correction of the deformity. Halo gravity traction has been considered as a way of reducing the deformity before correction to prevent neurological complications. Three female patients with severe neuromuscular scoliosis aged seven to 13 years with main coronal Cobb angle of 95°-128° and Kyphotic Cobb of 47°-118° having ≤35% flexibility on traction, had between 18 to 23 days of 16 hour/day of halo gravity traction and night time supine traction with 4kg weight for 7-8 hours. They had 28.9% and 18.5% of main coronal and kyphotic Cobb angle correction post-traction respectively. All had posterior instrumentation and post-operatively, they had correction of main coronal Cobb angle of 29°-58° and kyphotic Cobb angle of 30°-77° with no neurological complication. Halo gravity traction is therefore a viable option for reducing post-operative neurological complication in rigid severe scoliosis.