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.

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.

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.