Preoperative halo-gravity traction for treatment of severe adult kyphosis and 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.

Radiological and Pulmonary Results of Surgical Treatment of Severe Idiopathic Scoliosis Using Preoperative Halo Gravity Traction Compared with Less Invasive Temporary Internal Distraction in Staged Surgery in Adolescents

Background: Severe and rigid scoliosis represents a type of spinal deformity characterized by a Cobb angle exceeding 90° and a flexibility of less than 30%. Halo spinal traction remains the established standard for managing severe scoliosis, although alternative approaches such as temporary internal distraction rods and staged surgical correction exist. The primary objective of this investigation was to compare two cohorts of patients treated using these distinct methods to ascertain any divergences in terms of surgical and radiological outcomes, pulmonary function (PF), and quality of life (QoL). Methods: This study encompassed a total of 62 pediatric patients meeting the specified criteria, which included severe idiopathic scoliosis (major Cobb curve >90) and flexibility <30%. Group 1 (G1) underwent surgical intervention involving preoperative Halo gravity traction (HGT) succeeded by posterior spinal fusion (PSF). On the other hand, Group 2 (G2) underwent a two-stage procedure starting with a less invasive temporary internal distraction technique (LITID) prior to PSF. The radiological outcomes, PF, and QoL were documented and assessed over a monitoring period ranging from 2 to 5 years. Results: The average preoperative major curves (MCs) measured 124° and 122° in G1 and G2, respectively (p < 0.426). Initial flexibility, as observed in preoperative bending films, ranged from 18% in G1 to 21% in G2 (p < 0.001). Following the ultimate surgical intervention, the MCs were corrected to 45° and 37.4° in G1 and G2, respectively (p < 0.001). The percentage correction of the MCs was higher in G2 (63% vs. 70% in G1 and G2, respectively), with significant between-group disparities (p < 0.001). The mean preoperative thoracic kyphoses (TKs) were 96.5° in G1 and 92° in G2 (p = 0.782), which were rectified to 45.8° in G1 and 36.2° in G2 (p < 0.001), equating to correction rates of 55% and 60% in the respective groups. Initially, G2 exhibited lower values for the percentage of predicted lung volume (FVC) and predicted FEV1 compared with G1 (49% and 58% vs. 54.5% and 60.8%; N.S.). Nonetheless, both groups demonstrated enhancements in their FVC and FEV1 values over the follow-up period. Conclusions: The surgical management of severe and untreated spinal curvatures in the pediatric and adolescent population can be considered safe, with a tolerable incidence of minor complications. LITID emerges as a method offering improved QoL and pulmonary function, achieving notably substantial average corrections in deformity by 70% in the coronal plane and 60% in the sagittal plane, alongside a mean increase in trunk height of 10.8 cm. Furthermore, a typical reduction of 76% in rib humps and enhancements in respiratory function, as indicated by improvements in 1 s predicted forced expiratory volume (by 25-56%) and forced vital capacity (by 35-65%), were achieved, leading to a clinically and statistically significant enhancement in QoL when evaluated using SRS-22r, without resorting to more radical, high-risk procedures.

Frontal correction assessment in severe adolescent idiopathic scoliosis surgery using halo gravity traction before to posterior vertebral arthrodesis: a multicenter retrospective observational study

PURPOSE

Preoperative preparation with halo gravity traction (HGT) has several advantages but is still controversial. A multicenter, observational, retrospective study was conducted to determine whether HGT provides better frontal correction in surgery for adolescent idiopathic scoliosis (AIS).

METHODS

Between 2010 and 2020, all patients who underwent posterior spinal fusion (PSF) AIS with a Cobb angle greater than 80° were included. The included patients who underwent HGT were compared (complications rate and radiographic parameters) to patients who did not undergo traction (noHGT). For patients who underwent HGT, a spinal front X-ray at the end of the traction procedure was performed.

RESULTS

Sixty-four in noHGT and forty-seven in HGT group were analyzed with a 31-month mean follow-up. The mean ratio of Cobb angle correction was 58.8% in noHGT and 63.6% in HGT group (p = 0.023). In HGT, this ratio reached 9% if the traction lasted longer than 30 days (p = 0.009). The complication rate was 11.7% with a rate of 6.2% in noHGT and 19.1% in HGT group (p = 0.07). In patient whose preoperative Cobb angle was greater than 90°, the mean ratio of Cobb angle correction increases to 6.7% (p = 0.035) and the complications rate increased to 14% in the no HGT group and decreased to 13% in the HGT group (p = 0.9).

CONCLUSION

HGT preparation in the management of correction of AIS with a Cobb angle greater than 90° is a technique providing a greater frontal correction gain with similar complication rate than PSF correction alone. We recommend a minimum halo duration of 4 weeks.

[Effectiveness of spinal traction in degenerative spine diseases. (A literature review)]

Back pain is one of the most urgent healthcare problems in many countries of the world. The high prevalence of the disease among persons of working age, the high disability indices and the high economic losses determine the relevance of this problem and its epidemiological and socio-economic significance.

OBJECTIVE

To analyze sources of scientific and technical literature and study materials of meta-analyses, systematic reviews on the issues of evaluation of the spinal traction effectiveness (dry and underwater, horizontal and vertical) in the treatment of patients with degenerative spine diseases.

MATERIAL AND METHODS

An analysis of 67 sources, including 54 periodical articles, 5 meta-analyses and 8 systematic reviews was conducted. The search depth was 20 years.

RESULTS

The ability of the spinal traction method to influence on the pain intensity, functional state, general improvement or return to work in patients with degenerative spine diseases has been identified. There has been a statistically significant regression of lumbar and radicular pain under the influence of «dry» horizontal tractions of the spine (13389 patients with degenerative spine diseases received them), including in combination with physiotherapy (vibration, impulse currents, laser therapy), and there has been an improvement in the motor function of the spine, a decrease in the disability rate in patients with herniated disks. These results were also obvious in short-term observation (up to 3 months after intervention). Underwater traction (5533 patients received it) had a positive impact on pain syndrome at rest and during activity, increased the activity of patients. All registered effects were related to short-term effect for up to 3 months after the intervention.

CONCLUSION

The evidence, based on the materials of meta-analyses and systematic reviews of medium and low quality, that «dry» and underwater spinal traction can be considered as a therapeutic tool for short-term (within 3 months) reducing pain and disability in patients with lumbar pain and lumbar radiculopathy, is presented.

Improvement of Pulmonary Function and Reconstructed 3-Dimensional Lung Volume After Halo-Pelvic Traction Combined With Posterior Correction for Severe Rigid Spinal Scoliosis: A Multicenter Study

BACKGROUND AND OBJECTIVES

Severe rigid spinal scoliosis (SRSS) leads to severe restrictive ventilation dysfunction. Currently, the reports about the influence of preoperative halo-pelvic traction (HPT) combined with correction surgery on pulmonary function in patients with SRSS were relatively few. This study aims to investigate (1) the influence of preoperative HPT on lung volume and pulmonary function, (2) the further influence of the following correction surgery on lung volume and pulmonary function, and (3) the relationship among deformity correction, pulmonary function test outcomes, and computed tomography-based lung volume.

METHODS

A total of 135 patients with SRSS who underwent preoperative HPT and followed low-grade osteotomy correction surgery were reviewed. Spinal parameters, including proximal thoracic curve, main thoracic curve (MTC), lumbar curve, coronal balance, thoracic kyphosis, lumbar lordosis, sagittal vertical axis, pulmonary function test outcomes (forced vital capacity [FVC], the percentage of predicted forced vital capacity [FVC%], forced expiratory volume in 1 second [FEV1], total lung capacity [TLC]), and lung volume (Vin), were analyzed before, after HPT and at the final follow-up, respectively.

RESULTS

The mean FVC, FVC%, FEV1, and TLC increased from 1.67 L, 51.13%, 1.47 L, and 2.37 L to 1.95 L, 64.35%, 1.75 L, and 2.78 L, respectively, after HPT and further improved to 2.22 L, 72.14%, 1.95 L, and 3.15 L, respectively, at the final follow-up. The mean Vin increased from 1.98 L to 2.42 L after traction and further increased to 2.76 L at the final follow-up. The variation of MTC was correlated with the improvement of FVC (r = 0.429, P = .026), FVC% (r = 0.401, P = .038), FEV1 (r = 0.340, P = .043), and TLC (r = 0.421, P = .029) and the variation of Vin (r = 0.425, P = .015) before HPT and after surgery.

CONCLUSION

Preoperative HPT can improve preoperative pulmonary function and enhance the preoperative lung volume. There were significant correlations among the variations of MTC, pulmonary function indexes, and lung volume before HPT and after surgery in patients with SRSS.

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.

Evaluation of outpatient halo-gravity traction in patients with severe scoliosis: development of a monitoring device

INTRODUCTION

Patients with severe spinal deformities represent a major clinical and surgical challenge. Halo-gravity traction (HGT) is a traditional method to correct the deformity prior to surgery. Typically, children undergoing HGT remain in the hospital until surgery. Therefore, it has been suggested to treat these children at lower level healthcare centers or even at home. The aim of this study was to develop a tool to assess patient adherence to HGT together with a program to analyze traction results.

MATERIALS AND METHODS

An original recording system was designed with an Arduino Nano^®. The data extracted from the memory card were compiled into a text file and then analyzed with the MatLab R2018a MathWorks^®.

RESULTS

Five patients receiving HGT for severe scoliosis were asked to use the device both in the wheelchair and in bed to evaluate its usefulness.

CONCLUSIONS

A device was developed to monitor the use of HGT at home. The device provides information on the time of HGT use and the traction weight placed throughout the day, as well as on the correct functioning of the system in bed and in the wheelchair.

The pre-surgical role of halo-traction in patients with cervical infection associated with refractory kyphosis: a retrospective study

To minimize surgical complications and staged procedures halo-traction is often used during deformity corrections. But the use of halo-traction in the treatment of refractory cervical kyphosis secondary to infections has never been reported. This study investigated the role of halo-traction in the treatment of cervical infection patients associated with refractory kyphosis. We retrospectively reviewed 48 patients with cervical infection associated with refractory kyphosis who were treated in our spine department. Patients were divided into two groups, the traction group (A) and the non-traction group (B). Group A underwent preoperative halo-traction followed by surgery, while group B underwent surgery alone. Between the two groups, we analyzed the kyphosis deformity correction, level of fusions, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), functional improvement by Neck disability index (NDI) score, and complications. Group A had a better correction of kyphosis deformity compared to group B (27.01 ± 11.54)⁰ versus (18.08 ± 10.04)⁰ (P = 0.01, Z =  - 2.44). No statistically significant differences between the two groups in terms of functional improvement, level of fusions, ESR and CRP. Group B had 3 revision surgery cases. Preoperative halo-traction followed by surgery is superior in kyphosis correction in the treatment of patients with cervical infections with refractory kyphosis.

Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery

PURPOSE

To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits.

METHODS

Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%.

RESULTS

Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines.

CONCLUSION

A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients.

LEVEL OF EVIDENCE

Level V.

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.

Does Preoperative Halo-Gravity Traction Reduce the Degree of Deformity and Improve Pulmonary Function in Severe Scoliosis Patients With Pulmonary Insufficiency? A Systematic Review and Meta-Analysis

Background: Halo-gravity traction is a commonly used clinical intervention to reduce surgical risk in patients with scoliosis before surgical correction. Some previous studies have focused on the application of halo-gravity traction on patients with severe spinal deformity and pulmonary insufficiency, but the overall effect of halo-gravity traction has not been fully understood. The object of the present study was to perform a meta-analysis exploring the efficacy of preoperative halo-gravity traction on radiographic measurement and pulmonary function in severe scoliosis patients with pulmonary insufficiency.

Methods: We searched the medical works of literature completed before January 17, 2021, in the databases of Pubmed, Embase, and Cochrane Library. Studies that quantitatively analyzed the effects of halo-gravity traction on the deformity and pulmonary functions of patients with severe scoliosis were included. Two researchers independently conducted the literature search, data extraction, and quality assessment. We used the Review Manager Software (version 5.4) for statistical analysis and data analysis. Mean difference (MD) with 95% confidence intervals (CIs) were calculated to evaluate the effects of halo-gravity traction.

Results: Seven studies involving 189 patients received halo-gravity traction therapy preoperatively were analyzed in our study. Preoperative halo-gravity traction significantly ameliorated the degree of deformity in severe scoliosis patients with pulmonary insufficiency, especially reduced coronal Cobb angle and sagittal Cobb angle effectively [mean deviation (MD) = 2 7.28 (95%CI 21.16–33.4), p < 0.001; MD = 22.02 (95%CI 16.8–27.23), p < 0.001]. Preoperative halo-gravity traction also improved the pulmonary functions in patients, especially increasing %FVC and %FEV1 [MD = −0.0662 (95%CI −0.0672–−0.0652), p < 0.001; MD = −0.0824 (95%CI −0.0832–−0.081), p < 0.001].

Conclusions: Preoperative halo-gravity traction for severe scoliosis patients shows significant improvement in the degree of deformity and pulmonary functions. Halo-gravity traction is an effective method to improve the tolerance of patients to surgery in the perioperative period.

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.

Investigation of Preoperative Traction Followed by Percutaneous Kyphoplasty Combined with Percutaneous Cement Discoplasty for the Treatment of Severe Thoracolumbar Osteoporotic Vertebral Compression Fractures

Objective

To evaluate the feasibility, clinical efficacy and imaging results of preoperative traction (PT) followed by percutaneous kyphoplasty (PKP) combined with percutaneous cement discoplasty (PCD) for treating severe thoracolumbar osteoporotic vertebral compression fractures (OVCFs).

Methods

A total of 13 patients with severe thoracolumbar OVCFs treated by PT followed by PKP combined with PCD were enrolled. General information, PT time, operation time, postoperative hospital stay, perioperative complications, visual analog scale (VAS) score, Oswestry disability index (ODI) score, local kyphosis angle, intervertebral angle (IVA), anterior vertebral height (AVH) and posterior vertebral height (PVH) were recorded.

Results

The average VAS score at admission was 7.4±3.5, decreased to 4.3±1.7 after PT and 2.3±0.7 three days after operation, and 1.5±0.9 at last follow-up. The average ODI score was 73.7±21.4 before operation, decreased to 26.6±9.3 three days after operation and 13.7±7.1 at last follow-up. Compared to VAS and ODI scores at admission, these at the third day after operation and last follow-up were significantly different. At admission, the IVA was 3.4°±6.8°, the disc height was 5.7±1.2mm, the AVH was 10.7±3.2mm, and the PVH was 25.7±4.2 mm, which, after PT, changed to 8.1°±7.3°, 8.6±2.6mm, 18.5±2.8mm, and 26.2±7.1mm, respectively, and the differences were significant. The average kyphotic angle was 43.4°±17.8° at admission, and decreased to 26.3°±6.7° after PT, 17.5°±8.4° three days after operation and 19.1°±10.3° at last follow-up, and the differences were significant.

Conclusion

PT followed by PKP combined with PCD for the treatment of severe thoracolumbar OVCFs was an effective and simple procedure with satisfactory short-term clinical outcomes by relieving pain and improving kyphosis.

[Spinal deformity in neurofibromatosis type 1]

BACKGROUND

With a prevalence of up to 60%, spinal deformity represents the most common skeletal manifestation of neurofibromatosis type 1. The deformity can occur as a non-dystrophic or as a less common dystrophic type. This distinction is of great relevance because the therapeutic strategy is completely different in each case.

NON-DYSTROPHIC TYPE

The non-dystrophic type can be treated like idiopathic scoliosis due to the comparable behavior of both entities. However, care must be taken regarding the so-called modulation. Modulation describes the formation of dysplasias of the spine. This will result in a progression behavior as known from the dystrophic type.

DYSTROPHIC TYPE

For the dystrophic type, different spinal dysplastic changes are typical. These lead to a rapid progression of deformity and a lack of response to conservative treatment. If untreated, severe and grotesque deformities can arise. This type of deformity requires early surgical intervention, even in childhood. The knowledge about the peculiarities of this disease in general, as well as the typical changes of the spine are prerequisites to managing these often-challenging situations.

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.

The radiographic, pulmonary, and clinical outcomes of patients with severe rigid spinal deformities treated via halo-pelvic traction

Background

The severe rigid deformity patients with pulmonary dysfunction could not tolerate complicated corrective surgery. Preoperative traction are used to reduce the curve magnitude and improve the pulmonary function before surgery, including halo-gravity traction (HGT) and halo-pelvic traction (HPT). The present study aimed to retrospectively compare the radiographic, pulmonary and clinical outcomes of preoperative HGT and HPT in severe rigid spinal deformity with respiratory dysfunction.

Methods

81 cases of severe rigid kyphoscoliosis treated with preoperative traction prior to corrective surgery for spinal deformity between 2016 and 2019 were retrospectively reviewed. Two patient groups were compared, HPT group (N = 30) and HGT group (N = 51). Patient demographics, coronal and sagittal Cobb angles and correction rates, pulmonary function, traction time, osteotomy grade, and postoperative neurological complications were recorded for all cases.

Results

The coronal Cobb angle was corrected from 140.67 ± 2.63 to a mean of 120.17 ± 2.93° in the HGT group, and from 132.32 ± 4.96 to 87.59 ± 3.01° in the HPT group (mean corrections 15.33 ± 1.53 vs. 34.86 ± 3.11 %) (P = 0.001). The mean major sagittal curve decreased from 134.28 ± 3.77 to 113.03 ± 4.57° in the HGT group and from 129.60 ± 8.45 to 65.61 ± 7.86° in the HPT group (P < 0.001); the mean percentage corrections were 16.50 ± 2.13 and 44.09 ± 9.78 % (P < 0.001). A significant difference in the pulmonary function test results was apparent between the two groups; the mean improvements in the FVC% of the HGT and HPT groups were 6.76 ± 1.85 and 15.6 ± 3.47 % (P = 0.024). The HPT group tended to exhibit more FEV% improvement than the HGT group, but the difference was not significant (5.15 ± 2.27 vs. 11.76 ± 2.22 %, P = 0.91).

Conclusions

Patients with severe rigid kyphoscoliosis who underwent preoperative HPT exhibited better radiographic correction of the deformity, and pulmonary function, and required fewer osteotomies compared to the HGT group. Thus, HPT may be useful for severe rigid spinal deformity patients with pulmonary dysfunction.

Staged Management of Cervicothoracic Lordosis and Scoliosis in an Emery-Dreifuss VI Muscular Dystrophy Patient: A Case Report

CASE

We report the case of an 18-year-old man with extreme cervicothoracic lordosis and a progressive scoliosis secondary to Emery-Dreifuss Type VI muscular dystrophy. In a staged fashion, the patient underwent posterior cervical muscle release, halo-gravity traction, and posterior instrumented spinal fusion from C3-L4 with multiple posterior column osteotomies. The patient was followed over 2 years postoperatively with restoration of normal spinal alignment in both the coronal and sagittal profiles.

CONCLUSION

This is the first reported case illustrating the gradual correction of severe lordoscoliosis in this patient population.

Halo pin positioning in the temporal bone; parameters for safe halo gravity traction

INTRODUCTION

Halo gravity traction (HGT) is increasingly used pre-operatively in the treatment of children with complex spinal deformities. However, the design of the current halo crowns is not optimal for that purpose. To prevent pin loosening and to avoid visual scars, fixation to the temporal area would be preferable. This study aims to determine whether this area could be safe for positioning HGT pins.

METHODS

A custom made traction setup plus three human cadaver skulls were used to determine the most optimal pin location, the resistance to migration and the load to failure on the temporal bone. A custom-made spring-loaded pin with an adjustable axial force was used. For the migration experiment, this pin was positioned at 10 predefined anatomical areas in the temporal region of adult cadaver skulls, with different predefined axial forces. Subsequently traction force was applied and increased until migration occurred. For the load-to-failure experiment, the pin was positioned on the most applicable temporal location on both sides of the skull.

RESULTS

The most optimal position was identified as just antero-cranial to the auricle. The resistance to migration was clearly related to the axial tightening force. With an axial force of only 100 N, which corresponds to a torque of 0.06 Nm (0.5 in-lb), a vertical traction force of at least 200 N was needed for pin migration. A tightening force of 200 N (torque 0.2 Nm or 2 in-lb) was sufficient to resist migration at the maximal applied force of 360 N for all but one of the pins. The load-to-failure experiment showed a failure range of 780-1270 N axial force, which was not obviously related to skull thickness.

CONCLUSION

The temporal bone area of adult skulls allows axial tightening forces that are well above those needed for HGT in children. The generally applied torque of 0.5 Nm (4 in-lb) which corresponds to about 350 N axial force, appeared well below the failure load of these skulls and much higher than needed for firm fixation.

[Comparison of radiological changes after Halo-pelvic traction with posterior spinal osteotomy versus simple posterior spinal osteotomy for severe rigid spinal deformity]

Objective

To compare the changes of scoliosis and kyphosis angles after Halo-pelvic traction with posterior spinal osteotomy versus simple posterior spinal osteotomy for severe rigid spinal deformity.

Methods

A clinical data of 28 patients with severe rigid spinal deformity between January 2015 and November 2017 was retrospectively analyzed. Sixteen patients were treated by Halo-pelvic traction with posterior spinal osteotomy (group A) and 12 patients were treated with posterior spinal osteotomy only (group B). There was no significant difference between the two groups ( P>0.05) in gender, age, body mass index, and preoperative pulmonary function, coronal and sagittal Cobb angles, and flexibility. The operation time, intraoperative blood loss, and complications were recorded. The coronal and sagittal Cobb angles were measured on X-ray films before operation (before traction in group A), at 10 days after operation, at last follow-up in the two groups and after traction in group A. The improvement rate of deformity after traction in group A, the correction rate of deformity after operation, and the loss rate of correction at last follow-up were calculated.

Results

All patients were followed up 24-30 months (mean, 26.5 months). The operation time and intraoperative blood loss were significantly less in group A than in group B ( t=7.629, P=0.000; t=8.773, P=0.000). In group A, 1 patient occurred transient numbness of both legs during continuous traction and 2 patients needed ventilator support for more than 12 hours. In group B, 7 patients needed ventilator support for more than 12 hours, including 1 patient with deep incision infection. The incidence of complications was 18.75% (3/16) in group A and 58.33% (7/12) in group B, and the difference between the two groups was significant ( χ ²=4.680, P=0.031). The coronal and sagittal improvement rates of deformity after traction in group A were 40.47%±3.60% and 40.70%±4.20%, respectively. There was no significant difference between the two groups ( P>0.05) in the coronal and sagittal Cobb angles at 10 days after operation and at last follow-up, in the correction rate of deformity after operation, and in the loss rate of correction at last follow-up.

Conclusion

For the severe rigid spinal deformity, Halo-pelvic traction with posterior spinal osteotomy and simple posterior spinal osteotomy can obtain the same orthopedic effect and postoperative deformity correction. However, the Halo-pelvic traction can shorten operation time, reduce blood loss and incidence of perioperative complications.