Preoperative halo-gravity traction for severe spinal deformities at an SRS-GOP site in West Africa: protocols, complications, and results

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.

Clinical spine care partnerships between high-income countries and low-and-middle-income countries: A scoping review

BACKGROUND

Clinical collaboration between spine professionals in high-income countries (HICs) and low-and-middle-income countries (LMICs) may provide improvements in the accessibility, efficacy, and safety of global spine care. Currently, the scope and effectiveness of these collaborations remain unclear. In this review, we describe the literature on the current state of these partnerships to provide a framework for exploring future best practices.

METHODS

PubMed, Embase, and Cochrane Library were queried for articles on spine-based clinical partnerships between HICs and LMICs published between 2000 and March 10, 2023. This search yielded 1528 total publications. After systematic screening, nineteen articles were included in the final review.

RESULTS

All published partnerships involved direct clinical care and 13/19 included clinical training of local providers. Most of the published collaborations reviewed involved one of four major global outreach organizations with the majority of sites in Africa. Participants were primarily physicians and physicians-in-training. Only 5/19 studies reported needs assessments prior to starting their partnerships. Articles were split on evaluative focus, with some only evaluating clinical outcomes and some evaluating the nature of the partnership itself.

CONCLUSIONS

Published studies on spine-focused clinical partnerships between HICs and LMICs remain scarce. Those that are published often do not report needs assessments and formal metrics to evaluate the efficacy of such partnerships. Toward improving the quality of spine care globally, we recommend an increase in the quality and quantity of published studies involving clinical collaborations between HICs and LICs, with careful attention to reporting early needs assessments and evaluation strategies.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Medical complications and health-related quality of life in complex pediatric spine deformities exceeding 100 degrees or treated by 3CO

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To determine the incidence of medical complications in the pediatric population aged 10-20 years with baseline deformities exceeding 100 degrees or who had 3CO at surgery. Severe pediatric spine deformity poses a great challenge to the treating physician and carries a high complication rate. Pulmonary complications are among the most life threatening. The onus is on the treating surgeon to identify patients who are high risk and institute measures to mitigate the risk for successful outcomes.

METHOD

Data of 251/311pts from FOX pediatric database from 17 international sites was queried for incidence of major medical complications. Comparative analysis was done to determine the impact of such complications on HRQoL using paired t-test. Risk factors associated with medical complications were assessed using Firth logistic regression.

RESULTS

251/311pts had min 2 year f/u. 142F/109 M, average age 14.61years (10-20). Etiologies included 96 Cong,94 Idiopathic, 14-Post TB, 12-NM,12-NF,10-syndromic,8 others. Curve types included Scoliosis-121, Kyphoscoliosis 72, Kyphosis 58. Coronal and sag cobb avg 88° ± 41.47 and 91.92° ± 39.17, respectively. Deformity apices were in the thoracic region in 88% of patients. Pre-op co-morbidities included 54 (21.5%) cardiopulmonary; 7(2.79%) Genitounrinary;13 (5.18%) GI;13 (5.18%) Anxiety/depression; neurological 24 (9.56%). HGT was utilized in 103pts (41%) at an average duration of 68 days. Mean OR time was 459 min, blood loss averaged 1465 ml. VCR was performed in 120(47.81%), PSO in 16 pts (6.37%), SPO in 145pts (57.77%), Thoracoplasty in 132 pts (52.8%). 96% had blood and other blood products transfusion (FFP and platelets). There were 35 post-op medical complications occurring in 29pts (11.6%). Event-specific cumulative incidence was 24 (9.6%) pulmonary, 5(2.0%) gastrointestinal, 3(1.2%) cardiovascular, 1(0.4%) genitourinary and 1(0.4%) other complication. There was no mortality. Osteotomy grade was found to be an independent predictor of pulmonary complication. Despite significant improvement in baseline SRS total and Domain scores at 2 year FU irrespective of medical complication, the improvement in SRS scores were blunted in the complication group.

CONCLUSION

Medical complications are common among pediatric patients undergoing complex spine surgery for severe deformity. However, medical complications can be managed successfully. Although baseline HRQoL improved irrespective of medical complication status, clinical differences in the magnitude of the changes in HRQoL were observed in some domains.

First surgical experience treating scoliosis using HGT and ECMO: a case report

CASE PRESENTATION

A 13-year-old female with congenital diaphragmatic hernia-associated pulmonary hypertension presented with severe and rapidly progressing scoliosis. The patient suffered from chronic respiratory failure and high risk of hypertensive crisis with potentially life-threating consequences. The scoliosis was treated with a multidisciplinary approach combining preoperative halo-gravity traction, venoarterial extracorporeal membrane oxygenation support and posterior spinal instrumented fusion. After 2 years of follow-up, results are excellent.

CONCLUSIONS

The treatment combination reported here for the first time aims to limit surgical aggressiveness. It could be an effective and safe approach for treating severe spinal deformities in very fragile patients with high surgical risk.

The Effect of Prolonged Pre-Operative Halo Gravity Traction for Severe Spinal Deformities on the Cervical Spine Radiographs

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVE

The study sought to assess the effect of prolonged pre-operative halo gravity traction (HGT) on the c-spine radiographs.

METHODS

Data of 37 pediatric and adult patients who underwent ≥ 12wks pre-op HGT prior to definitive spine surgery from 2013-2015 at a single site in West Africa was reviewed. Radiographic assessment of the c-spine including ADI, SVA and C2-C7 Lordosis were done at pre HGT and at 4 weekly intervals. Paired T-Test was performed to evaluate changes in these parameters during HGT.

RESULTS

37pts, 18/19 (F/M). Average age 18.2yrs. Diagnoses: 22 idiopathic, 6 congenital, 3 Post TB, 2 NM and 4 NF. Average duration of HGT: 125 days. Baseline coronal Cobb:130 deg, corrected 30% in HGT; baseline sagittal Cobb:146 deg, corrected 32% post HGT. Baseline ADI (3.17 ± 0.63 mm) did not change at 4wks (P > 0.05) but reduced at 8wks (2.80 ± 0.56 mm) and 12wks (2.67 ± 0.51 mm) post HGT (P < 0.05). Baseline HGT SVA (20.7 ± 14.98 mm) significantly improved at 4wks (11.55 ± 10.26 mm), 8wks (7.54 ± 6.78 mm) and 12wks (8.88 ± 4.5 mm) (P < 0.05). Baseline C2-C7 lordosis (43 ± 20.1 deg) reduced at 4wks (26 ± 16.37 deg), 8wks (17.8 ± 14.77 deg) and 12wks (16.7 ± 11.33 deg) post HGT (P < 0.05). There was no incidence of atlanto-axial instability on flexion extension radiographs at any interval.

CONCLUSION

Prolonged HGT, while providing partial correction of severe spine deformities, also appeared to have no adverse effect on atlanto-axial stability or cervical alignment. Therefore, HGT can be safely applied for several weeks in the preoperative management of severe spine deformities in pediatric/adult patients.

Indications and Efficacy of Halo-Gravity Traction in Pediatric Spinal Deformity: A Critical Analysis Review

»

Halo-gravity traction (HGT) is a well-established technique for correcting severe spinal deformity in pediatric patients.

»

HGT induces soft-tissue relaxation and gradually lengthens the spine, and it can be used preoperatively and intraoperatively.

»

It is typically indicated for spinal deformity over 90° in any plane and medical optimization.

»

There are several complications associated with the use of HGT, and it is critical to follow a protocol and perform serial examinations to minimize this risk.

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 Efficacy of a Posterior Approach to Surgical Correction for Neglected Idiopathic Scoliosis: A Comparative Analysis According to Health-Related Quality of Life, Pulmonary Function, Back Pain and Sexual Function

BACKGROUND

This study aimed to evaluate the treatment outcomes of severe idiopathic scoliosis (IS) and hypothesized that surgical treatment would have a superior impact on the health-related quality of life (HRQoL), pulmonary function (PF), back pain, and sexual function.

METHODS

We retrospectively reviewed 195 consecutive patients with IS classified into severe (SG) and moderate groups (MG) with a minimum follow-up of two years.

RESULTS

The mean preoperative curve was 131° and 60° in the SG and MG, respectively. The mean preoperative flexibility in the bending films averaged between 22% in the SG and 41% in the MG. After definitive surgery, the main curve was corrected to 61° and 18° in the SG and MG, respectively. The mean preoperative thoracic kyphosis was 83° in the SG and 25° in the MG, which was corrected to 35° in the SG and 25° in the MG. At baseline, the percentage of predicted lung volume (FVC) was significantly lower in the SG than that in the MG (51.2% vs. 83%). The baseline percentage of the predicted FEV1 values was also significantly lower in the SG than in the MG (60.8% vs. 77%). During the two-year follow-up, the percentage of predicted FVC showed significant improvement in the SG (69.9%) (p < 0.001), and the percentage of predicted FEV1 values during the follow-up improved significantly in the SG (76.9%) (p < 0.001) compared with the MG (81%), with no statistical difference observed during the two-year follow-up. The SRS-22r showed a clinically and statistically significant improvement in the preoperative results to those of the final follow-up (p < 0.001).

CONCLUSIONS

Surgical treatment of severe scoliosis can be safe. It provided a mean correction of the deformity for 59% of patients and significantly improved respiratory function, with the percentage of predicted forced expiratory volume in 1 s improving by 60% and the forced vital capacity improving by 50%, resulting in clinically and statistically significant improvements in the SRS-22r, HRQoL outcome scores, and back pain (reduced from 36% to 8%), as well as improved sexual function. The planned surgical treatment can achieve a very significant deformity correction with a minimal risk of complications. The surgical treatment has a superior impact on the quality of life patients with severe spinal deformities and significantly improves function in every sphere of life.

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.

Understanding the Ghanaian Neurosurgical Literature: A Scoping Review and Bibliometric Analysis

BACKGROUND

Research serves to bolster clinical neurosurgery by critically assessing various disease pathologies, while identifying important challenges and opportunities. However, there is limited information on the landscape of the Ghanaian neurosurgical literature.

METHODS

A scoping review and bibliometric analysis was conducted in accordance with PRISMA guidelines. PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched from inception until December 21, 2021 for English language articles about neurosurgery in Ghana.

RESULTS

927 articles were identified and 66 were ultimately included in the analysis. A majority of them, 42.4%, were retrospective cohort studies, with 62.1% published after 2010. There were no randomized controlled or basic science studies. Most articles were published in the West African Journal of Medicine (24.2%) and non-infectious/non-traumatic spinal pathology was the most commonly discussed topic (22.7%); 66.7% of articles included only authors affiliated with Ghanaian institutions, and international collaborators frequently originated from the United States (15.9%). Only 22.7% of the manuscripts reported a funding source. Commonly reported challenges included limited sample sizes, delays in diagnosis and treatment, and lack of proper diagnostic tools and specialized care.

CONCLUSIONS

This review revealed that while the Ghanaian academic neurosurgery output has been increasing over time, these have been limited to cohort studies largely assessing spine pathology. The Ghanaian neurosurgical research environment may be bolstered by an increase in research funding, the establishment of longitudinal clinical databases, training in research methodology, increased incentives for researchers, strengthening of research collaborative networks, and increased engagement of neurosurgical trainees in research.

Risk factors for proximal junctional kyphosis after pediatric spinal deformity surgery with halo gravity traction

PURPOSE

To determine risk factors for proximal junctional kyphosis (PJK) in pediatric patients with scoliosis undergoing halo gravity traction (HGT) prior to posterior spinal fusion (PSF).

METHODS

Data from consecutive patients who underwent PSF after HGT with 2-year follow-up were retrospectively collected from a single center. Patients were divided into two groups: PJK vs. no PJK.

RESULTS

Twenty-five patients (age 13.6 ± 3.1 years) underwent HGT for a mean of 42 ± 37 days. Eight patients (32%) developed radiographic PJK and 1 (4%) developed proximal junctional failure. PJK patients had greater loss of cervical lordosis (-17.4 ± 23.2 vs. 2.7 ± 16.2°, p < 0.05), greater increase in lumbar lordosis (9.3 ± 19.5 vs. -2.8 ± 12.8°; p = 0.034) during traction, and smaller overall major coronal curve angle correction (-16.8 ± 30.6 vs. -36.6 ± 16.4°; p = 0.026). From postoperative to last follow-up, PJK patients had a greater increase in upper end vertebrae (UEV) slope (3.3 ± 7.8 vs. -4.0 ± 7.7°; p = 0.004). Selection of UIV based on which vertebra was most level either pre-traction or in-traction was not associated with PJK development (p > 0.05).

CONCLUSION

In-traction radiographic changes of decreased cervical lordosis, decreased major coronal curve, increased lumbar lordosis, and disruption of cervical sagittal balance at last follow-up may have implications for level selection and risk of PJK.

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.

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.

Postoperative Pulmonary Complications in Complex Pediatric and Adult Spine Deformity: A Retrospective Review of Consecutive Patients Treated at a Single Site in West Africa

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVES

This study sought to assess the incidence, risk factors, and outcomes of pulmonary complication following complex spine deformity surgery in a low-resourced setting in West Africa.

METHODS

Data of 276 complex spine deformity patients aged 3 to 25 years who were treated consecutively was retrospectively reviewed. Patients were categorized into 2 groups during data analysis based on pulmonary complication status: group 1: yes versus group 2: no. Comparative descriptive and inferential analysis were performed to compare the 2 groups.

RESULTS

The incidence of pulmonary complication was 17/276 (6.1%) in group 1. A total of 259 patients had no events (group 2). There were 8 males and 9 females in group 1 versus 100 males and 159 females in group 2. Body mass index was similar in both groups (17.2 vs 18.4 kg/m², P = .15). Average values (group 1 vs group 2, respectively) were as follows: preoperative sagittal Cobb angle (90.6° vs 88.7°, P = .87.), coronal Cobb angle (95° vs 88.5°, P = .43), preoperative forced vital capacity (45.3% vs 62.0%, P = .02), preoperative FEV₁ (forced expiratory volume in 1 second) (41.9% vs 63.1%, P < .001). Estimated blood loss, operating room time, and surgery levels were similar in both groups. Thoracoplasty and spinal osteotomies were performed at similar rates in both groups, except for Smith-Peterson osteotomy. Multivariate logistic regression showed that every unit increase in preoperative FEV₁ (%) decreases the odds of pulmonary complication by 9% (OR = 0.91, 95% CI 0.84-0.98, P = .013).

CONCLUSION

The observed 6.1% incidence of pulmonary complications is comparable to reported series. Preoperative FEV₁ was an independent predictor of pulmonary complications. The observed case fatality rate following pulmonary complications (17%) highlights the complexity of cases in underserved regions and the need for thorough preoperative evaluation to identify high-risk patients.

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.

One-stage multiple posterior column osteotomies and fusion and pre-op halo-gravity traction may result in a comparative and safer correction of complex spine deformity than vertebral column resection

STUDY DESIGN

A retrospective review of prospectively collected from patients recruited at a single center.

PURPOSE

To test whether safe and optimal correction can be obtained with preoperative halo-gravity traction and posterior spinal fusion with adjunctive procedures but without VCR. Posterior vertebral column resection(VCR) is gaining popularity for correction of severe spinal deformity. However, it is a highly technically demanding procedure with potential risk for complications and neurological injury.

METHODS

In total, 72 patients with severe spinal deformity (Cobb angle > 100º) who underwent HGT followed by definitive PSF with PCO, with or without concave rib osteotomy and thoracoplasty. Demographic and surgical data were collected. Conventional coronal and sagittal radiographic measurements were obtained pre-traction, post-traction, post-op and at follow-up to determine the final deformity correction. Postoperative neurological and major complications were reviewed. We used Chi-square to compare proportion between groups and t test to compare groups in quantitative/ordinal variables.

RESULTS

There were 72 patients (35 females, 37 males). The etiology was congenital (21),idiopathic (45), neurofibromatosis (2) and neuromuscular (4). The mean was: age 18 ± 4.6 years; duration of HGT 103 ± 35 days; coronal Cobb angle before traction 131.5 ± 21.4º vs 92. ± 15.9º after HGT (30% correction) and 72.8 ± 12.7º after fusion (47% correction); kyphosis angle before traction 134.7 ± 32.3º vs 97.1 ± 22.4º after HGT and 73.7 ± 21.3º post-fusion. Number of fusion levels 14 ± 1; EBL 1730 ± 744 cc; number of PCOs done 5 ± 2; number of concave rib osteotomies (2 ± 2). There were 16 patients with postoperative complications (22.2%), 10 medical, one wound infection, 2 implant related and 3 post-op neuro-deficits (all of whom recovered at follow-up). There was one death (cardiac arrest).

CONCLUSION

HGT and one-stage posterior fusion with PCO, with or without concave rib resection and thoracoplasty, without VCR, achieved satisfactory correction of rigid complex spine deformity with minimal neurological complications. The results compare favorably with previous reports of similar deformities treated with VCR.

LEVEL OF EVIDENCE

III.

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.

Perioperative outcome of severe rigid idiopathic scoliosis: Single-staged posterior spinal fusion utilizing a dual attending surgeon strategy. A report of 41 patients

PURPOSE

Various surgical strategies including combined approach and spinal osteotomies in severe rigid scoliosis had been reported with significant perioperative complication rates. The use of single-staged posterior spinal fusion (PSF) utilizing a dual attending surgeon strategy for severe rigid scoliosis has not been widely reported.

METHODS

This was a retrospective study aimed to evaluate the perioperative outcome of single-staged PSF in severe rigid idiopathic scoliosis patients (Cobb angle ≥90° and ≤30% flexibility). Forty-one patients with severe rigid idiopathic scoliosis who underwent single-staged PSF were included. The perioperative outcome parameters were operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, preoperative and postoperative hemoglobin, transfusion rate, patient-controlled anesthesia morphine usage, length of postoperative hospital stay, and perioperative complications. Radiological parameters included preoperative and postoperative Cobb angle, correction rate, side-bending flexibility, and side-bending correction index.

RESULTS

The mean age was 16.9 ± 5.6 years. The mean preoperative Cobb angle was 110.8 ± 12.1° with mean flexibility of 23.1 ± 6.3%. The mean operation duration was 215.5 ± 45.2 min with mean blood loss of 1752.6 ± 830.5 mL. The allogeneic blood transfusion rate was 24.4%. The mean postoperative hospital stay was 76.9 ± 26.7 h. The mean postoperative Cobb angle and correction rate were 54.4 ± 12.8° and 50.9 ± 10.1%, respectively. The readmission rate in this cohort was 2.4%. Four perioperative complications were documented (9.8%), one somatosensory evoke potential signal loss, one superficial infection, one lung collapse, and one superior mesenteric artery syndrome.

CONCLUSIONS

Severe rigid idiopathic scoliosis treated with single-staged PSF utilizing a dual attending surgeon strategy demonstrated an average correction rate of 50.9%, operation duration of 215.5 min, and postoperative hospital stay of 76.9 h with a 9.8% perioperative complication rate.

Characterization of complex vertebral transposition (gamma deformity) > 180 degrees: clinical and radiographic outcomes of halo gravity traction and vertebral column resection (VCR)

STUDY DESIGN

Prospective case series OBJECTIVE: Results of surgical treatment of complex vertebral transposition "Gamma Deformity" > 180 degrees with halo gravity traction (HGT) and vertebral column resection (VCR). We recently published a novel classification system for complex spine deformities of which complex vertebral transposition > 180 degrees (Gamma; type 3) was described. Halo gravity traction (HGT) has been shown to mitigate surgical risk in complex spine deformity correction and in some cases obviates the need for three-column osteotomy. However, we are not aware of report of its utilization in treating Gamma deformities with or without vertebral column resection (VCR).

METHODS

A consecutive series of 13 patients with Gamma deformity (GD) were prospectively enrolled at a single site in West Africa. Standard radiographs and 3D computerized tomography (CT) were done to assess coronal and sagittal vertebral transposition (CVT and SVT). The HGT with 50% of body weight was applied over several weeks followed by VCR. Demographics, operative data, radiographic parameters, and complications data were collected.

RESULTS

13 pts with GD underwent HGT for an avg of 110 days prior to definitive surgery. Etiologies were Congenital-11 pts and Neurofibromatosis-2 pts. Average age: 17.8 years; Pts were reviewed at 3 months post-op and at minimum 2-year follow-up. Preop myelopathy was present in five patients. Pre-op CVT avg 75% and was corrected in all cases post-op. SVT avg 211 deg and improved with HGT by 36% and corrected to 53 deg (74% correction) post-op. Thoracic kyphosis avg -42 deg and averaged 48 deg post-op. Intra-op spinal cord monitoring (SCM) alerts occurred in 8 pts (61%). Post-operative LEM deficits occurred in 5 pts: 2 fully recovered by 3 months and 2 year follow-up, while the remaining 3 improved but had residual motor deficits at final follow-up. There was one post-operative mortality.

CONCLUSION

The management of complex vertebral transposition (Gamma deformity) > 180 degrees with HGT prior to VCR is not only effective in some patients, but also associated with high SCM alerts and neurologic injury rates. Myelopathic patients with thoracic deformities are at higher risk of developing permanent neurologic deficits. Surgeons should be aware of this rare and unusual deformity and consider HGT and VCR bearing in mind the technical challenges and high complication rate.

Preoperative Halo-Gravity Traction for Patients with Severe Focal Kyphosis in the Upper Thoracic Spine: A Safe and Effective Alternative for Three-Column Osteotomy

STUDY DESIGN

Retrospective review.

OBJECTIVE

To evaluate the effect of preoperative Halo-gravity traction (HGT) in the treatment of severe focal kyphosis in the upper thoracic spine (UTS), and to propose the indications that HGT could serve as an alternative for three-column osteotomy (3CO) among these patients.

SUMMARY OF BACKGROUND DATA

The HGT has been proven to be effective for severe kyphoscoliosis secondary to multiple etiologies. However, the safety and efficacy of HGT in severe focal kyphosis in UTS was still unclear.

METHODS

Patients with focal kyphosis in UTS undergoing HGT and without 3CO operation were reviewed. The sagittal focal kyphosis was measured at pre-, posttraction, and postoperation. The neurologic function at pretraction, posttraction, and postoperation were assessed according to the American Spinal Injury Association (ASIA) grading. The complications during HGT, operation, and follow-up were recorded. The comparison between pretraction and posttraction was performed using paired samples t test.

RESULTS

A total of 19 patients were included in this study, with a mean age of 13.2 ± 5.8 years. The average duration of HGT was 62.6 ± 8.4 days, during which the average kyphosis decreased from 95.3 ± 16.4° to 64.1 ± 19.2° (P < 0.001). After HGT, the ASIA grade improved from C to D in three patients and from C to E in three patients, from D to E in seven patients, from B to D in one patient. No deterioration in neurologic function was observed during HGT. The neurological status in one patient improved from ASIA C at pretraction to ASIA E at postoperation, but deteriorated to C at 4 years follow-up.

CONCLUSION

Preoperative HGT could help to correct deformity and improve neurological deficit. 3CO procedure might be unnecessary in patients with severe focal kyphosis in UTS with the utilization of HGT.Level of Evidence: 4.

Application of a Halo Fixator for the Treatment of Pediatric Spinal Deformity

Background

In spine surgery, the halo fixator was initially utilized to stabilize cervical fusions in patients with poliomyelitis. More recently, the indications for halo fixation have evolved to include stabilization and definitive treatment for upper cervical spine injuries (Jefferson fractures, atlanto-occipital dissociations, odontoid fractures, etc.), treatment of atlantoaxial rotatory subluxation, stabilization of long cervical fusions, and preoperative traction. In the realm of pediatric spinal deformity, halo fixation has proved to be a valuable resource for severe or neglected spinal deformities. In this video article, we demonstrate the application of a halo fixator in a pediatric patient with severe scoliosis.

Description

The procedure includes appropriate pin placement in the safe zones of the skull performed under either general anesthesia or local anesthesia. Pins are secured to a halo frame that is sized to be 2 cm larger than the circumference of the skull and are tightened according to age-specific torque guidelines.

Alternatives

Alternative treatments vary from cervical spine immobilization to definitive surgical treatment in the spine, or even spinal osteotomies, depending on the underlying spinal pathology.

Rationale

The halo fixator works by limiting motion of the cervical spine in flexion, extension, and axial rotation. The halo is also able to control and correct translational injuries of the cervical spine. In the setting of spinal deformity, the halo fixator can also be utilized to overcome the effects of gravity and lengthen the spine.

Expected Outcomes

For spinal deformities, the halo fixator can be expected to lengthen the spine and increase deformity flexibility prior to definitive surgical treatment in the spine or growth-friendly spinal instrumentation.

Important Tips

Correct identification of safe zones for pin placement is vital to correct pin placement.For pediatric patients, it is important to obtain fixation with a minimum of 6 to 8 pins.Pins should be tightened with use of a torque-limiting wrench, up to no more than 1 in/lb (55.9 mm/kg) per year of age, up to a maximum of 8 in/lb (447.9 mm/kg).Applied traction should be a maximum of 50% of the body weight of the patient.Neurovascular examination is vital following application of weight.

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.

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.

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.

Inpatient versus outpatient halo-gravity traction in children with severe spinal deformity

STUDY DESIGN

A retrospective, comparative study.

OBJECTIVE

To compare the results, complications, and costs of preoperative halo-gravity traction in in- and outpatient settings.

BACKGROUND DATA

Surgical management of severe spinal deformities remains complex and controversial. Preoperative halo-gravity traction results in a decreased need for aggressive surgical techniques, lower incidence of intraoperative neurologic complications, and improvement of nutritional parameters and preoperative cardiopulmonary function.

METHODS

Twenty-nine patients younger than 18 years with kyphoscoliosis undergoing preoperative halo-gravity traction were divided into two groups: inpatients (n: 15) and outpatients (n: 14, home care or care at the Foundation). Traction time (weeks), traction weight (kg), radiographic curve correction, complications, and costs were compared. For statistical analysis, t test and odds ratio were calculated with a significance of p < 0.05.

RESULTS

Mean traction time was 6 weeks for in- and 4 weeks for outpatients (p = 0.038). Initial traction weight was 6 kg in both groups, while final traction weight was 13 kg for in- and 15 kg for outpatients (p = 0.50). At the end of the traction period, coronal correction was 24° in in- and 28° in outpatients (p = 0.5), while sagittal correction was 27° and 29°, respectively (p = 0.80). Pin loosening was observed in 2 patients in each group, of whom 1 outpatient developed pin-site infection. In each group, one patient developed transient neurologic complications (odds ratio 1.091). Mean treatment cost per patient was 2.8-fold higher in inpatients.

CONCLUSIONS

Considering complications and costs, our results show that preoperative halo-gravity traction in an outpatient setting is an option to be taken into account.

LEVEL OF EVIDENCE

Grade III.

Management of Proximal Thoracic Kyphoscoliosis with Early Myelopathy in a Young Adult with Neurofibromatosis Type 1: A Case Report and Review of Literature

INTRODUCTION

Neurofibromatosis (NF) 1 is associated with skeletal deformities. Scoliosis is seen in about 10-64% of NF-1 patients. NF-1 may be associated with dystrophic or non-dystrophic type of curve. There are technical difficulties in treating large dystrophic curve with proximal thoracic kyphoscoliosis in NF-1. This case report and subsequent review of literature attempts to provide a line of management for such difficult lesions.

MATERIALS AND METHODS

We present a case of 22-year-old male with NF-1 who came to us with gradually progressive upper back deformity and signs of early myelopathy for 2-3 months. The patient had a 100° proximal thoracic kyphosis and 100° scoliosis with no neurological deficit and brisk reflexes. A single stage posterior fixation with three column osteotomy at the apex of the curve was performed.

RESULTS

The kyphosis was corrected to 65° from 100, the scoliosis was corrected to 60° from 100. Clinically, the hump in the upper back was visibly reduced. At 1-year follow-up, the patient remained asymptomatic with no loss of correction and implant breakage on X-ray.

CONCLUSION

Large dystrophic proximal thoracic kyphoscoliosis is a difficult lesion to treat and can be managed with an all posterior approach, achieving good cosmetic and neurological outcomes, as demonstrated by this case.

Perioperative Halo-Gravity Traction in the Treatment of Scoliosis with Intraspinal Anomalies

OBJECTIVE

To investigate the efficacy and safety of preoperative halo-gravity traction and 1-stage posterior surgery for the treatment of scoliosis with intramedullary anomalies.

METHODS

A total of 11 patients with scoliosis with intramedullary anomalies were evaluated. All patients were treated with preoperative halo-gravity traction and 1-stage posterior surgery. The average age was 11.4 years (range, 7-21 years). All patients were followed-up for at least 2 years (mean, 3.5 years; range, 2-5 years). Their radiologic presentations and complications were reviewed.

RESULTS

The operating time was 7.9 hours, and the intraoperative bleeding amount was 1890 mL. Both the Cobb angle of scoliosis and kyphosis were significantly improved after halo-gravity traction and the operation (P < 0.05). Tethered cords were released, and intraspinal masses (neurofibromatosis and lipoma) were excised. Syringomyelia and split spinal cord malformations were left untreated. None of the patients experienced deterioration in their neurologic status after surgery. No severe complications, such as infection, cerebrospinal fluid leakage, failed internal fixation, or fractured pedicle screws or rods occurred after the operation. There was no deterioration of neurologic function, delayed infection, or pseudoarthrosis during the follow-up visits.

CONCLUSIONS

Preoperative halo-gravity traction and 1-stage posterior surgery provided patients who had scoliosis and intramedullary anomalies an effective and safe treatment option with few complications.

Outcome of Posterior-Only Approach for Severe Rigid Scoliosis: A Retrospective Report

BACKGROUND

The management of severe scoliosis may lead to significant complications, and adequate mobilization is a key step to achieve maximal correction, usually requiring extensive approaches. There is still no consensus on the management of these severe and rigid curves. In this study we evaluated the clinical and radiologic outcome of a posterior-only approach with multilevel asymmetric Ponte osteotomy with a minimum of 2 years' follow-up.

METHODS

In this retrospective study, 23 patients with severe and rigid adolescent idiopathic scoliosis who underwent surgery with a single-staged posterior-only approach were included. The surgical procedures in these patients were excision of posterior ligaments and spinous process, partial laminectomy in caudal part of lamina, excision of the ligamentum flavum, facetectomies, and multilevel asymmetric posterior column osteotomies (Ponte) followed by instrumented fusion. Clinical records-including demographic data; operating time; hospitalization time; blood loss; number of segments instrumented, fused, and osteotomized; functional improvement; follow-up duration; and complications-were recorded.

RESULTS

The mean preoperative Cobb angle of major curve in coronal plan was 97.5° (range, 82°-131°) with the mean flexibility of 21.4° (range, 10°-25°) on bending radiography. The mean immediate postoperative Cobb angle of major curve was 34.8° (range, 17°-61°), showing a 64.2% correction. The mean preoperative coronal and sagittal imbalances of 3.8 and 4.2 cm were improved to 1.0 and 1.3 cm at postoperative measurements, respectively. A mean of 6.1 (range, 5-9) vertebral segments were osteotomized. We experienced no major complications.

CONCLUSIONS

We found that a posterior-only procedure in patients with severe and rigid adolescent idiopathic scoliosis could provide correction rate, coronal and sagittal balance, and clinical outcomes comparable with other procedures. Using this technique can eliminate the need for the anterior release, with the associated complications related to anterior surgery, in the treatment of severe rigid scoliosis.

Halo-gravity traction for the treatment of pediatric cervical spine disorders

OBJECTIVE

Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities.

METHODS

Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2-24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications.

RESULTS

The mean duration of HGT was 25 days (IQR 13-29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%-40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°-122°) to 56° ± 17.6° (range 32°-96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%-57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17-43 days).Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24-48 hours.

CONCLUSIONS

HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.

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.

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

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To assess the efficacy of preoperative halo-gravity traction (HGT) in the treatment for severe adult kyphosis and scoliosis. Preoperative HGT improves severe curve magnitude and clinical condition in pediatric spinal deformity. However, the efficacy of HGT on severe adult spinal deformity has rarely been studied.

MATERIALS AND METHODS

This study included 18 patients with severe adult kyphosis and scoliosis (age ≥ 18) who underwent a preoperative HGT (mean 4 weeks), and subsequent definitive posterior-alone corrective fusion. Etiologies were neurofibromatosis (n = 5), adult idiopathic (n = 3), multiple vertebral fractures due to osteoporosis (n = 1) and multiple myeloma (n = 1), degenerative failed back syndrome (n = 1), Scheuermann kyphosis (n = 1), Marfan syndrome (n = 1), and other genetic and connective tissue disorders (n = 5). We reviewed baseline demographics, including coronal and sagittal radiographic profiles. The changes in major curve magnitude, pulmonary function tests (PFTs), and nutritional status were assessed between pre- and post-traction and immediate post-definitive corrective surgery.

RESULTS

There were 11 male and 7 female patients, aged 18-69 years with their major coronal and sagittal curves being 92.0° ± 25.2° and 111.6° ± 40.1°, respectively. The major coronal and sagittal curves were reduced by 18.4% and 16.8% after halo-traction, and 54.7% and 44.2% after definitive fusion, respectively. PFTs showed significant increase in %FEV1 and %FVC when comparing pre- and post-traction [43.0% ± 17.4% vs. 49.6% ± 18.7%, and 44.8%. ± 16.7% vs. 54.3% ± 20.7%, respectively, p < 0.01 (n = 11)]. Effective weight gain was observed after traction (46.8 ± 14.5 vs. 49.3 ± 13.5 kg, p < 0.01).

CONCLUSION

Halo-gravity traction (HGT) for severe coronal and sagittal plane spinal deformity in adult patients significantly reduced Cobb angles, improved PFTs, and allowed for effective weight gain in the preoperative period. The use of preoperative HGT is extremely beneficial to optimize the alignment and overall health of severe adult spinal deformity patients before their spinal reconstruction.

LEVEL OF EVIDENCE

Level IV.

Posterior vertebral column resection for rigid proximal thoracic kyphoscoliosis with broken growing rods in a patient with Desbuquois dysplasia

STUDY DESIGN

Case report.

OBJECTIVE

To describe the importance of preoperative halo-gravity traction and posterior vertebral column resection (PVCR) for severe proximal thoracic kyphoscoliosis associated with Desbuquois dysplasia, after breakage of a growing rod construct. Desbuquois dysplasia is a rare, autosomal recessive chondrodysplasia characterized by short stature, joint laxity, kyphoscoliosis, and characteristic facial dysmorphism. Our 8-year-old patient developed severe, progressive, infantile-onset kyphoscoliosis and had been initially treated with Vertical Expandable Prosthetic Titanium Rib (VEPTR) rods. She subsequently underwent growing rod placement, but the eventual rod fracture resulted in a severe angular kyphosis.

METHODS

Clinical and radiographic case review.

RESULTS

The broken implants were removed, and she was treated with 2.5 months of preoperative halo-gravity traction. She then underwent a T4 PVCR and C7-L4 instrumented posterior spinal fusion. The patient had an uneventful postoperative course without any neurologic problems. Two years postoperatively, correction was well maintained with appropriate alignment and balance without implant breakage.

CONCLUSION

To our knowledge, this is the first report of treatment of spinal deformity associated with Desbuquois dysplasia. Our results suggest that preoperative halo-gravity traction and PVCR are safe and efficacious techniques for severe rigid kyphoscoliosis in the cervicothoracic region associated with broken growing rods in a patient with Desbuquois dysplasia.

LEVEL OF EVIDENCE

Level IV.

The Use of Halo Gravity Traction in the Treatment of Severe Early Onset Spinal Deformity

STUDY DESIGN

Retrospective Review of Prospective cohort.

OBJECTIVE

To describe the feasibility of preoperative halo gravity traction (HGT) with subsequent growing rod/guided growth (GR/GG) placement in early onset spinal deformity (EOSD).

SUMMARY OF BACKGROUND DATA

In children with severe EOSD, primary implantation of GR/GG constructs is not always possible. We describe a staged protocol with preoperative HGT followed by GR/GG implantation.

METHODS

EOSD patients treated with HGT prior to GR/GG implantation were included. HGT used traction up to 50% body weight for 4 to 29 weeks. Pulmonary function tests (PFTs) were performed before and after HGT. Coronal Cobb (CC) and Sagittal Cobb (SC) angles were measured on the Pre-HGT, Post-HGT and 6 week postop x-rays.

RESULTS

Thirty patients were included. Average age at GR/GG implantation was 9 years. Most cases (n = 24, 80%) were idiopathic. Most pts had kyphoscoliosis (n = 16, 53.3%). Pre-HGT CC averaged 112 ± 22° and SC averaged 106 ± 26°. CC and SC improved 29% after HGT. There was a significant improvement in body mass index following HGT. CC improved further to 70 ± 14° (36% vs. pre-HGT) and SC to 63 ± 21° (41%) with GR/GG placement. HGT-related complications occurred in nine patients (30%); eight pin site infections, one cranial abscess. Most HGT complications were managed with local pin care and oral antibiotics. Halo revision was required in two pts (6.7%). There was no change in PFTs with HGT (P > 0.05). Averagely, 14 levels were spanned during GR/GG implantation; two patients required vertebral column resection. Surgical complications occurred in nine (30%) patients. At average 16 month follow-up, seven patients (23.3%) required reoperation.

CONCLUSION

Preoperative HGT can make severe EOSD curves amenable to GR/GG implantation. HGT results in ∼30% correction with improvement to ∼35-40% following GR/GG. HGT has a 30% complication rate but most are pin-site infections managed with pin-site care and oral antibiotics; 6.7% of patients require revision.

LEVEL OF EVIDENCE

4.

PREOPERATIVE HALO-GRAVITY TRACTION WITH AND WITHOUT ANTERIOR RELEASE FOR SEVERE SCOLIOSIS

ABSTRACT Objective: This study aims to compare the use of halo-gravity traction (HGT) with and without previous anterior release, in terms of curve reduction, for the treatment of pediatric severe spinal deformity. Methods: From 2010 to 2016, all patients treated with HGT prior to instrumentation for scoliosis and kyphoscoliosis were reviewed. They were assessed by deformity etiology, previous anterior release, instrumentation procedure used, traction protocol, major Cobb angle before traction, after the protocol, and after the instrumentation procedure. Twelve patients met these criteria and constituted the sample groups: Group I (n=7) with anterior release and Group II (n=5) without anterior release. Results: The average pre-traction major curve Cobb angles were 114.9o and 108.4º for Group I and II, respectively (P>0.05). After HGT, both groups achieved a significant reduction in curve angle (P<0.05). Group I presented an average Cobb angle of 95.0o after HGT, representing a 17.3% (19.8o) curve reduction. Group II presented a Cobb angle of 80.1o, representing a 25.2% (28.4o) curve reduction. The difference between the two groups in relation to the reduction of major curve after HGT was not statistically significant (P=0.073). After the surgical procedure, the correction achieved was significantly improved (P<0.05), without statistically significant difference between the two groups (P>0.05). No major HGT related complications were reported. Conclusions: Anterior release prior to HGT did not increase major curve correction after posterior surgery for severe pediatric idiopathic and syndromic scoliosis. HGT is an effective and safe technique, though it frequently presents minor and transitory complications. Level of Evidence III; Retrospective Comparative Study.

Halo Gravity Traction Can Mitigate Preoperative Risk Factors and Early Surgical Complications in Complex Spine Deformity

STUDY DESIGN

Retrospective review of prospective cohort.

OBJECTIVE

We sought to examine the role of halo gravity traction (HGT) in reducing preoperative surgical risk.

SUMMARY OF BACKGROUND DATA

The impact of HGT on procedure choice, preoperative risk factors, and surgical complications has not been previously described.

METHODS

Patients treated with HGT before primary surgery were included. The FOCOS Score (FS) was used to quantify operative risk. FS was calculated using patient-factors (ASIA, body mass index, etiology), procedure-factors (PcF; osteotomy planned, number of levels fused, etc.), and curve magnitude (CM). Scores ranged from 0 to 100 with higher scores indicating increased risk. FS was calculated before and after HGT to see how changes in FS affected complication rates.

RESULTS

A total of 96 patients were included. Halo-related complications occurred in 34% of patients but revision was required in only 8.3%. Average FS improved by 18 points after HGT. CM, PcF, and patient-factors all improved (P < 0.05). The greatest changes were in CM and PcF. The planned rate of three-column osteotomies dropped from 91% to 38% after HGT. FS (area under the curve [AUC]: 0.68, P = 0.023) and change in FS (AUC: 0.781, P < 0.001) was successfully able to predict the rate of surgical complications. A preoperative FS of 74 was identified as a cut-off for a higher rate of surgical complications (sensitivity 58.8%, specificity 74.7%). Patients with a reduction in FS <  = 10pts were five times more likely to have a complication (relative risk 5.2, 95% confidence interval: 1.9-14.6, P < 0.001). A multivariate regression showed that change in FS was an independent predictor of complication rates (P < 0.05).

CONCLUSION

FS can successfully predict surgical risk in pediatric patients with complex spinal deformity. Preoperative HGT can reduce FS and surgical risk by improving CM, lowering three-column osteotomies use, and improving body mass index. A reduction in FS after HGT predicts a lower rate of surgical complications.

LEVEL OF EVIDENCE

3.

Halo Gravity Traction for Severe Pediatric Spinal Deformity: A Clinical Concepts Review

For the past 35 years, we have used halo gravity traction (HGT) to treat patients with a wide variety of underlying spinal deformities. This clinical concepts review will cover the indications, contraindications, HGT technique details, and our preferred method of dynamic HGT. Emphasis will be placed on our protocol, and recommendations that help to avoid complications. HGT is best applied by a standardized team approach intending to medically and nutritionally optimize the patient in preparation for an operative or medical/interventional treatment that will maintain and improve on the deformity correction achieved while avoiding peri- and postoperative complications.

The Ecuador Pediatric Spine Deformity Surgery Program: An SRS-GOP Site, 2008-2016

STUDY DESIGN

Retrospective case series.

OBJECTIVES

The purpose of this study is to (1) describe the development of our Spinal Deformity Program; (2) assess the surgical outcomes, including health-related quality of life (HRQOL), radiographic measures, and complications; and (3) explore predictors for HRQOL outcomes.

SUMMARY OF BACKGROUND DATA

The Scoliosis Research Society (SRS) is very interested in international program site development to provide safe surgical care for children in low- and middle-income countries (LMICs). There is a need for reporting program development and outcomes from these sites. After several years of building local relations and infrastructure, our program started performing spine surgery in 2008.

METHODS

All operations were performed at Roberto Gilbert Elizalde Children's Hospital in Guayaquil, Ecuador. At a minimum of two years and average of four years postoperatively, patients received a clinical evaluation, radiographs, and the Spanish SRS-22r questionnaire.

RESULTS

Twenty-eight (74%) of the 38 children who received spine surgery between May 2008 and 2015 are included in this study. Twenty-three (82%) were female with an average age of 14 years at the time of surgery and 18 years at follow-up. The mean total SRS-22r score was 4.3 and mean percentage major curve correction was 57%. Curve location was found to be a significant predictor of postoperative SRS-22r scores with double curves having poorer scores (p = .004). Two complications were pseudarthrosis and postoperative delayed paraplegia, both of which resolved after revision surgery. No infections or other long-term complications have occurred.

CONCLUSIONS

The development of equitable surgical care for all children is a primary goal of the SRS. Undertaking the task to perform surgery in LMIC comes with the responsibility to monitor and maintain the highest quality. Our program was safely developed to address the surgical needs of children with good midterm HRQOL outcomes, adequate radiographic curve correction, and no permanent complications.

LEVEL OF EVIDENCE

Level IV.

Radiographic, Pulmonary, and Clinical Outcomes With Halo Gravity Traction

STUDY DESIGN

Single-center retrospective chart review.

OBJECTIVES AND SUMMARY

Halo gravity traction (HGT) is a safe and effective intervention to improve spinal deformity prior to corrective instrumentation. Our study aimed to report on a large series of patients undergoing HGT, demonstrate the correlation between thoracic height achieved and pulmonary function, and evaluate the efficacy of nutritional assessment and intervention while in HGT for these often malnourished or nutritionally compromised patients.

METHODS

107 patients underwent HGT for severe spinal deformity. Major coronal and sagittal Cobb angles, T1-T12 ht, and T1-S1 ht were collected pre-HGT, during HGT, postoperation, and 2 years postoperation. Pulmonary function tests (PFTs) recorded forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Nutritional interventions such as formal nutrition consult, resulting nutritional supplementation, or interventions were recorded.

RESULTS

Patients were in HGT for mean of 82.1 days and mean maximum percentage body weight in traction was 49.5%. Mean major coronal Cobb angle prior to HGT was 92.6°, improving to 65.8° in maximal traction and to 47° after surgical intervention. Traction accounted for 78% of T1-T12 height and 79% of T1-S1 length gains from pre- to postoperation. We showed a positive correlation between gain in T1-T12 height and percentage predicted changes in FVC and FEV1. Weight Z score for the entire cohort of patients improved from -2.8 pretraction to -2.4 in traction and then to -2.3 postoperative.

CONCLUSIONS

Our study again demonstrated that HGT achieves radiographic improvement safely and effectively in severe spinal deformity. We demonstrated a positive correlation between improvement in PFTs and increase in thoracic height seen with HGT. Additionally, improvement in weight Z score was seen in the entire population and the most at risk patients for malnutrition, results that have not been shown before.

LEVEL OF EVIDENCE

Level IV.

Use of Halo-Gravity Traction and a Magnetically Controlled Growing Rod for Untreated Severe Kyphoscoliosis in an Adolescent: A Case Report

CASE

We utilized a novel staged approach for an adolescent with severe kyphoscoliosis; it involved 8 weeks of initial halo-gravity traction as well as implantation and expansion (every 2 weeks) of a magnetically controlled growing rod over 6 months, followed by spinal fusion. The patient was a 13-year-old girl with an untreated idiopathic deformity (thoracic scoliosis with a curve of 145° and kyphosis with a curve of 120°). No osteotomies other than inferior facetectomies were required at the final fusion, and the final scoliosis curve was 57°, a correction of 60.7%.

CONCLUSION

The staged approach resulted in a straightforward, safe, gradual correction of severe kyphoscoliosis. We consider this an option for patients with scoliosis with a curve of ≥130° on initial presentation.

Approaching Spine Research in an Outreach Setting: What Type of Infrastructure is Conducive for Conducting Research?

Organizing medical research in an outreach setting can be a challenging task, especially when it involves complex spine procedures in patients whom it is difficult to follow-up for long term. Disease severity at presentation is often advanced in outreach settings due to limited local resources, surgeon expertise, and hospital infrastructure. Case complexity can present a challenge to local and outreach surgeons alike. This article will describe what encompasses an ideal outreach program as it relates to spine, how to manage cost in an outreach setting, collection of outcome data, and maintaining long-term follow-up. As one of the criticisms of medical outreach is the relative paucity of outcome data, this article discusses methods to collect and report outcomes abroad. We also discuss the value of translating outcome questionnaires to different languages and cross-cultural comparisons. In addition, relatively rare pathologies are often seen with greater frequency abroad. These patients are ideally suited for a focused case series than can guide treatment decisions.

Surgical correction of severe spinal deformities using a staged protocol of external and internal techniques

INTRODUCTION

There is high risk of neurologic complications in one-stage management of severe rigid spinal deformities in adolescents. Therefore, gradual spine stretching variants are applied. One of them is the use of external transpedicular fixation.

PURPOSE

Our aim was to retrospectively study the outcomes of gradual correction with an apparatus for external transpedicular fixation followed by internal fixation used for high-grade kyphoscoliosis in adolescents.

METHODS

Twenty five patients were reviewed (mean age, 15.1 ± 0.4 years). Correction was performed in two stages: 1) gradual controlled correction with the apparatus for external transpedicular fixation; and 2) internal posterior transpedicular fixation. Rigid deformities in eight patients required discapophysectomy. Clinical and radiographic study of the outcomes was conducted immediately after treatment and at a mean long-term period of 3.8 ± 0.4 years. Pain was evaluated using the visual analogue scale (VAS, 10 points). The Oswestry questionnaire (ODI scale) was used for functional assessment.

RESULTS

Deformity correction with the external apparatus was 64.2 ± 4.6% in the main curve and 60.7 ± 3.7% in the compensatory one. It was 72.8 ± 4.1% and 66.2 ± 5.3% immediately after treatment and 70.8 ± 4.6% and 64.3 ± 4.2% at long term, respectively. Pain relieved by 33.2 ± 4.2% (p < 0.05) immediately after treatment and by 55.6 ± 2.8% (p < 0.05) at long term. ODI reduced by 30.2 ± 1.7% (p < 0.05) immediately after treatment and by 37.2 ± 1.6% (p < 0.05) at long term.

CONCLUSION

The apparatus for external transpedicular fixation provides gradual controlled correction for high-grade kyphoscoliosis in adolescents. Transition to internal fixation preserves the correction achieved, and correction is maintained at long term.

Strategies for Surgical Management of Large, Stiff Spinal Deformities in Children

Management of large, severe, stiff spinal deformities in children can be challenging. Adjunctive treatments used in conjunction with spinal osteotomy, instrumentation, and fusion can improve the ultimate degree of deformity correction. These adjunctive treatments include preoperative halo-gravity traction, intraoperative halo-femoral traction, temporary internal spinal distraction, and anterior spinal release. Each of these techniques has unique indications and individual risks. When the appropriate protocols are followed, these techniques can be safe and efficacious.

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

PURPOSE

The surgical treatment of severe adolescent spinal deformities is challenging and carries substantial risks of mortality and morbidity. To mitigate this risk, surgeons have employed various methods as this study designed to evaluate the safety and effectiveness of preoperative halo-femoral or halo gravity traction (HGT) followed by posterior-only surgery in the management of severe scoliosis.

METHOD

A total number of 23 patients with severe scoliosis treated by preoperative skeletal traction (halo gravity or halo femoral) followed by posterior fusion and instrumentation in one stage. All patients were followed for a minimum of 2 years after surgery.

RESULTS

The average age of the patients was 12.7 years at the time of surgery. Mean of the Cobb angle improved from 99.9° ± 8.2° preoperatively to 75.3° ± 8° post-traction and 49.5° ± 7.7° postoperatively. Kyphosis angle corrected from 56.4° ± 9.5° to 38.6° ± 5.8°. The preop-FVC% was 41 ± 6.1% and after 1 year follow-up FVC% was 45.7 ± 7.7%. No patients required an anterior release due to amount of their deformity.

DISCUSSION

Despite the benefits of modern instrumentation procedures, the treatment of severe scoliosis can be very competing. We think that by applying preoperative halo femoral traction and halo-gravity traction, managing severe scoliosis will be in safe and easy manner and can lead to better deformity correction and less neurological complications and facilitate to avoid anterior operation for severe scoliosis and its related complications.

Pediatric orthopedic surgery in humanitarian aid

Pediatric orthopedic surgery in humanitarian aid is conducted mainly in cooperation with emerging countries. Each mission is different, and depends on numerous parameters such as the country, the frequency of such missions, the pathologies encountered, the local structure and team, and the non-governmental organization (NGO) involved. Pathologies vary in etiology (tuberculosis, poliomyelitis) and severity. Each mission requires the presence of an experienced surgeon. Working conditions are often rudimentary. Surgical indications should be restricted to procedures that are going to be effective, with minimal postoperative complications, without any surgical "acrobatics". Teaching should be in association with the local university, and adapted to local needs. Mission objectives need to be realistic. Surgical indications should be adapted to local conditions, and the surgeon needs to be able to say "no" to procedures involving undue risk. The surgeon on mission should cooperate with local teams and be able to adapt to unusual situations. Assessment of results is essential to improving efficacy and evaluating the success of the mission.

Distal Adding-on and Risk Factors in Severe and Rigid Scoliosis

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to identify associated risk factors of distal adding-on in severe and rigid scoliosis.

SUMMARY OF BACKGROUND DATA

Previous work has evaluated the challenges in the treatment of patients with severe and rigid scoliosis and the risks of complications. Furthermore, although several studies have investigated postoperative distal adding-on and attendant risk factors in Lenke type 1A scoliosis, very few have focused on distal adding-on in severe and rigid scoliosis.

METHODS

In this study, 48 consecutive patients with severe and rigid scoliosis underwent posterior spinal fusion surgery. The parameters of preoperative, immediately postoperative, and minimum 2-year follow-up radiographs were evaluated. The patients were classified as positive or negative for distal adding-on at follow-up, and risk factors were comparatively analyzed in the two groups.

RESULTS

The average Cobb angle and flexibility of the main thoracic curve (MTC) were 107.4° ± 15.9° and 16.4% ± 10.2%, respectively, before surgery. Distal adding-on was observed in 12 patients (25.0%) at follow-up. Univariate analysis identified several factors significantly associated with distal adding-on. Furthermore, significant independent risk factors identified by stepwise logistic regression analysis included the correction rate of the MTC immediately after surgery (odds ratio: 1.107, 95% confidence interval: 1.024-1.197, P = 0.011) and the difference between the lower instrumented vertebra (LIV) and last touching vertebra (LTV) levels (odds ratio: 0.121, 95% confidence interval: 0.028-0.518, P = 0.004).

CONCLUSION

In severe and rigid scoliosis, a high correction rate of the MTC immediately after surgery and the LIV level above the LTV were significantly associated with distal adding-on.

LEVEL OF EVIDENCE

3.

Halo-gravity traction in the treatment of severe spinal deformity: a systematic review and meta-analysis

PURPOSE

Halo-gravity traction has been reported to successfully assist in managing severe spinal deformity. This is a systematic review of all studies on halo-gravity traction in the treatment of spinal deformity to provide information for clinical practice.

METHODS

A comprehensive search was conducted for articles on halo-gravity traction in the treatment of spinal deformity according to the PRISMA guidelines. Appropriate studies would be included and analyzed. Preoperative correction rate of spinal deformity, change of pulmonary function and prevalence of complications were the main measurements.

RESULTS

Sixteen studies, a total of 351 patients, were included in this review. Generally, the initial Cobb angle was 101.1° in the coronal plane and 80.5° in the sagittal plane, and it was corrected to 49.4° and 56.0° after final spinal fusion. The preoperative correction due to traction alone was 24.1 and 19.3%, respectively. With traction, the flexibility improved 6.1% but postoperatively the patients did not have better correction. Less aggressive procedures and improved pulmonary function were observed in patients with traction. The prevalence of traction-related complications was 22% and three cases of neurologic complication related to traction were noted. The prevalence of total complications related to surgery was 32% and that of neurologic complications was 1%.

CONCLUSION

Partial correction could be achieved preoperatively with halo-gravity traction, and it may help decrease aggressive procedures, improve preoperative pulmonary function, and reduce neurologic complications. However, traction could not increase preoperative flexibility or final correction. Traction-related complications, although usually not severe, were not rare.

Halo Gravity Traction Is Associated with Reduced Bone Mineral Density of Patients with Severe Kyphoscoliosis

Background. Halo gravity traction (HGT) is one of the most commonly used perioperative techniques for the treatment of severe kyphoscoliosis. This study was to explore the influence of HGT on the BMD of these patients. Methods. Patients with severe kyphoscoliosis treated by preoperative HGT for at least 2 months were included. Patients' BMD were assessed by dual-energy X-ray absorptiometry at lumbar spine (LS, L2–L4) and femur neck (FN) of the nondominant side. The weight and duration of traction, as well as baseline characteristics, were recorded. Results. Twenty patients were recruited. The average traction duration was 77.9 ± 13.0 days while the mean traction weight was 39.9% ± 11.1% of total body weight. Remarkable decrease of BMD was observed at LS of 17 (85%) patients and at FN of 18 (90%) patients. After HGT, 75% of patients were found to have osteoporosis, the incidence of which was significantly higher than that before HGT (35%). The correlation analysis revealed BMD reduction was only significantly correlated with the traction duration. Conclusions. The current study showed that preoperative HGT can have obvious impact on the BMD. The BMD reduction is associated with traction duration, suggesting that long traction duration may bring more bone mineral loss.