Perioperative Halo-Gravity Traction in the Treatment of Severe Scoliosis and Kyphosis
Background: Few reports review the use of perioperative and intraoperative halo-gravity traction as an adjunct to modern instrumentation methods in the treatment of severe scoliosis and kyphosis. Rapid curve correction can increase the risk of neurologic compromise, especially if there is significant kyphosis. Other methods of traction (halo-femoral, halo-tibial) require extended courses of bedrest, while halo-pelvic traction is associated with several long-term complications. Halo-gravity traction is a safe alternative that has the benefit of allowing patients to be out of bed to socialize and participate in exercise programs. We performed an analysis of patients with severe scoliosis and/or kyphosis to evaluate curve correction rates and complications associated with perioperative halo-gravity traction.
Materials and Methods: 40 patients with severe operative scoliosis, kyphoscoliosis, or kyphosis were analyzed based on standing pretreatment, traction (prior to anterior or posterior fusion), postoperative, and final radiographs. Patients were categorized by age at date of surgery (2-20 yrs, mean 13+8 yrs.), gender (21M, 19F), major coronal curve magnitude (range: 22-150 deg., ave.: 90 deg.), major compensatory coronal curve magnitude (range: 8-123 deg, ave.: 54 deg.), major sagittal curve magnitude (range: 13-143 deg., ave.: 65 deg.), traction protocol (traction-ASF-traction-PSF, ASF-traction-PSF, traction-PSF, ASF/PSF-traction-ASF/PSF), and procedure type [ASF/ PSF, PSF]. Halo-traction-related and long-term complications were noted in each case.
Results: When comparing patients who underwent preoperative traction, the major curve decreased by 15.9±11.9 deg. (p=0.0001) prior to the initial procedure. In traction after ASF, the major curve decreased by an average of 17.6±19.7 deg. (p=0.02) relative to preoperative in-traction measurements, and 28.7±17.9 deg. (p<0 .0001) over initial measurements. After the final procedure, major curve reduced an average of 19.4±17.7 deg. (p<0.0001) when compared to post-ASF traction values. In comparison pretreatment measurements, 42.4±25.5 degrees or 46.1% after PSF relative assessments. Similarly, thoracic kyphosis (T5-T12) decreased 17.5±21.2 (p="0.007)" during while lumbar lordosis 13.5±25.0 Thoracic 11.3±19.5 ASF and 21.6±19.7 At a minimum 2-years follow-up, loss correction averaged 6.8±9.6 for coronal curves, 2.7±22.3 kyphosis. Surgical complications included: temporary respiratory distress (2 - one required multiple intubations), malignant hyperthermia (1), coagulopathy supraventricular tachycardia rod migration superficial wound infections (6), pseudarthroses (2), instrumentation loosening with progression (1). terms halo-related symptoms, there were 2 cases halo pin requiring replacement, infected site, case nystagymus, nausea dizziness, brachial plexus palsy. The dizziness resolved immediately lowering amount traction.
Discussion: The treatment of severe scoliosis can be very challenging despite the benefits of modern instrumentation methods, especially if there is significant kyphosis. Halo-gravity traction is a safe, well-tolerated method of applying gradual, sustained traction to maximize postoperative correction in this difficult population. There were no permanent neurologic deficits in this series.