Skip to main content

Predicting the impact of intraoperative halo-femoral traction from preoperative imaging in neuromuscular scoliosis

Spine Deformity volume 10, pages 679–687 (2022)Cite this article

Abstract

Purpose

Intraoperative traction (ITx) has been demonstrated to be a useful adjunct intervention at the time of posterior spinal fusion (PSF) for the treatment of severe neuromuscular scoliosis (NMS) to improve the coronal spinal deformity and pelvic obliquity. The purpose of this study is to determine if preoperative flexibility radiographs can predict the amount of spinal deformity and pelvic obliquity correction at final follow-up.

Methods

This was a retrospective analysis of a single-surgeon series who underwent PSF to the pelvis with adjunct ITx for NMS. Database query identified 76 NMS patients, of which 41 met inclusion criteria. Demographic, radiographic and operative data were analyzed.

Results

Of the 41 study patients, 56% (n = 23) were male and mean age at surgery was 13.6 years. Mean follow-up of 4.1 years (minimum follow-up 2 years). 35 patients had cerebral palsy, 5 patients were syndromic, and 1 patient had myelomeningocele. The average preoperative weight was 35 kg and all were wheelchair ambulators. Total traction applied on average was 49% of the preoperative body weight. Mean preoperative coronal deformity was 91° which improved to 43° at final follow-up (53% correction). Push-supine imaging had the strongest correlation to major coronal deformity outcome at final follow-up (r2 = 0.87, p ≤ 0.0001). Compared to push-supine imaging, there was a mean greater coronal deformity correction of 18 ± 10° (p ≤ 0.0001) at final follow-up. To predict the final coronal deformity, the regression equation was final Cobb angle = 1.13085 + preop push-supine Cobb angle × 0.68830. Mean preoperative pelvic obliquity was 34° which improved to 12° at final follow-up (65% correction). Push-supine imaging had the strongest correlation to pelvic obliquity outcome at final follow-up (r2 = 0.59, p = 0.0001). Compared to push-supine imaging, there was a mean greater pelvic obliquity correction of 3 ± 10° (p = 0.0857) at final follow-up. The regression equation was final POB = 6.42096 + preop push-supine POB × 0.36675. Mean preoperative kyphosis was 70° and 52° at final follow-up (26% correction).

Conclusion

The results of this study demonstrated for preoperative planning that the push-supine flexibility radiograph is most predictive of the coronal deformity and of the pelvic obliquity correction. At final follow-up in this NMS population, there was a mean greater improvement of 18° for coronal deformity versus preoperative push-supine imaging and 3° for pelvic obliquity versus preoperative push-supine imaging. At the time of PSF, ITx is an effective adjunct technique to improve coronal deformity and POB for NMS producing 53% coronal correction, 65% POB correction, and 26% kyphosis correction.

Level of evidence

IV.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. Benson ER, Thomson JD, Smith BG, Banta JV (1998) Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis. Spine (Phila Pa 1976) 23:2308–2317 (discussion 18)

    CAS  Article  Google Scholar 

  2. Drummond D, Breed AL, Narechania R (1985) Relationship of spine deformity and pelvic obliquity on sitting pressure distributions and decubitus ulceration. J Pediatr Orthop 5:396–402

    CAS  Article  PubMed  Google Scholar 

  3. Majd ME, Muldowny DS, Holt RT (1997) Natural history of scoliosis in the institutionalized adult cerebral palsy population. Spine (Phila Pa 1976) 22:1461–1466

    CAS  Article  Google Scholar 

  4. Comstock CP, Leach J, Wenger DR (1998) Scoliosis in total-body-involvement cerebral palsy. Analysis of surgical treatment and patient and caregiver satisfaction. Spine (Phila Pa 1976) 23:1412–1424 (discussion 24–5)

    CAS  Article  Google Scholar 

  5. Thometz JG, Simon SR (1988) Progression of scoliosis after skeletal maturity in institutionalized adults who have cerebral palsy. J Bone Jt Surg Am 70:1290–1296

    CAS  Article  Google Scholar 

  6. Stevens DB, Beard C (1989) Segmental spinal instrumentation for neuromuscular spinal deformity. Clin Orthop Relat Res 242:164–168

    Article  Google Scholar 

  7. Sarwark J, Sarwahi V (2007) New strategies and decision making in the management of neuromuscular scoliosis. Orthop Clin N Am 38:485–496 (v)

    Article  Google Scholar 

  8. Swank SM, Cohen DS, Brown JC (1989) Spine fusion in cerebral palsy with L-rod segmental spinal instrumentation. A comparison of single and two-stage combined approach with Zielke instrumentation. Spine (Phila Pa 1976) 14:750–759

    CAS  Article  Google Scholar 

  9. Lonstein JE, Akbarnia A (1983) Operative treatment of spinal deformities in patients with cerebral palsy or mental retardation. An analysis of one hundred and seven cases. J Bone Jt Surg Am 65:43–55

    CAS  Article  Google Scholar 

  10. Keeler KA, Lenke LG, Good CR et al (2010) Spinal fusion for spastic neuromuscular scoliosis: is anterior releasing necessary when intraoperative halo-femoral traction is used? Spine (Phila Pa 1976) 35:E427–E433

    Article  Google Scholar 

  11. Boachie-Adjei O, Lonstein JE, Winter RB et al (1989) Management of neuromuscular spinal deformities with Luque segmental instrumentation. J Bone Jt Surg Am 71:548–562

    CAS  Article  Google Scholar 

  12. Gau YL, Lonstein JE, Winter RB, Koop S, Denis F (1991) Luque-Galveston procedure for correction and stabilization of neuromuscular scoliosis and pelvic obliquity: a review of 68 patients. J Spinal Disord 4:399–410

    CAS  Article  PubMed  Google Scholar 

  13. Mohamad F, Parent S, Pawelek J et al (2007) Perioperative complications after surgical correction in neuromuscular scoliosis. J Pediatr Orthop 27:392–397

    Article  PubMed  Google Scholar 

  14. Rinella A, Lenke L, Whitaker C et al (2005) Perioperative halo-gravity traction in the treatment of severe scoliosis and kyphosis. Spine (Phila Pa 1976) 30:475–482

    Article  Google Scholar 

  15. Takeshita K, Lenke LG, Bridwell KH et al (2006) Analysis of patients with nonambulatory neuromuscular scoliosis surgically treated to the pelvis with intraoperative halo-femoral traction. Spine (Phila Pa 1976) 31:2381–2385

    Article  Google Scholar 

  16. Fuhrhop SK, Keeler KA, Oto M et al (2013) Surgical treatment of scoliosis in non-ambulatory spastic quadriplegic cerebral palsy patients: a matched cohort comparison of unit rod technique and all-pedicle screw constructs. Spine Deform 1:389–394

    Article  PubMed  Google Scholar 

  17. O’Brien M, Kuklo T, Blanke K, Lenke L (2005) Radiographic measurement manual. Spinal deformity study group. Medtronic Sofamor Danek

  18. Bogunovic L, Lenke LG, Bridwell KH, Luhmann SJ (2013) Preoperative halo-gravity traction for severe pediatric spinal deformity: complications, radiographic correction and changes in pulmonary function. Spine Deform 1:33–39

    Article  PubMed  Google Scholar 

  19. Watanabe K, Lenke LG, Bridwell KH et al (2010) Efficacy of perioperative halo-gravity traction for treatment of severe scoliosis (>/=100 degrees). J Orthop Sci 15:720–730

    Article  PubMed  Google Scholar 

  20. Vialle R, Delecourt C, Morin C (2006) Surgical treatment of scoliosis with pelvic obliquity in cerebral palsy: the influence of intraoperative traction. Spine (Phila Pa 1976) 31:1461–1466

    Article  Google Scholar 

  21. Hamzaoglu A, Ozturk C, Aydogan M et al (2008) Posterior only pedicle screw instrumentation with intraoperative halo-femoral traction in the surgical treatment of severe scoliosis (>100 degrees). Spine (Phila Pa 1976) 33:979–983

    Article  Google Scholar 

  22. Erdem MN, Oltulu I, Karaca S, Sari S, Aydogan M (2018) Intraoperative halo-femoral traction in surgical treatment of adolescent idiopathic scoliosis curves between 70 degrees and 90 degrees: is it effective? Asian Spine J 12:678–685

    Article  PubMed  PubMed Central  Google Scholar 

  23. Auerbach JD, Spiegel DA, Zgonis MH et al (2009) The correction of pelvic obliquity in patients with cerebral palsy and neuromuscular scoliosis: is there a benefit of anterior release prior to posterior spinal arthrodesis? Spine (Phila Pa 1976) 34:E766–E774

    Article  Google Scholar 

  24. MacEwen GD, Bunnell WP, Sriram K (1975) Acute neurological complications in the treatment of scoliosis. A report of the Scoliosis Research Society. J Bone Jt Surg Am 57:404–408

    CAS  Article  Google Scholar 

  25. Lenke LG, Sugrue PA, Bridwell KH et al (2015) Paper #14 the radiographic and clinical impact of preoperative halo-gravity traction in the treatment of early-onset spinal deformity. Spine Deformity 3:617–618

    Article  Google Scholar 

  26. Barsoum WK, Mayerson J, Bell GR (1999) Cranial nerve palsy as a complication of operative traction. Spine (Phila Pa 1976) 24:585–586

    CAS  Article  Google Scholar 

  27. Wilkins C, MacEwen GD (1977) Cranial nerve injury from halo traction. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-197707000-00015

    Article  PubMed  Google Scholar 

  28. Saleh H, Yohe N, Razi A, Saleh A (2018) Efficacy and complications of the use of Gardner-Wells Tongs: a systematic review. J Spine Surg 4:123–129

    Article  PubMed  PubMed Central  Google Scholar 

  29. Grundy DJ (1983) Skull traction and its complications. Injury 15:173–177

    CAS  Article  PubMed  Google Scholar 

  30. Choo JH, Liu WY, Kumar VP (1996) Complications from the Gardner-Wells tongs. Injury 27:512–513

    CAS  Article  PubMed  Google Scholar 

Download references

Acknowledgements

The author would like to acknowledge his research mentor, Dr. Scott Luhmann, the NIH for providing stipend funding, and the Washington University Office of Medical Student Research for helping to make this possible.

Funding

NIH Grant T35HL007815-25, Washington University Summer Research Program.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA

    Thomas Bane

  2. Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Children’s Place, Suite 4S60, St. Louis, MO, 63110, USA

    Scott J. Luhmann

Authors
  1. Thomas Bane
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Scott J. Luhmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: TB and SJL. Drafting the work or revising it critically for important intellectual content: TB and SJL. Final approval of the version to be published: TB and SJL. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: TB and SJL.

Corresponding author

Correspondence to Scott J. Luhmann.

Ethics declarations

Conflict of interest

No conflicts exist for any of the authors pertaining to the submitted work.

Ethical approval

No human subjects or animals participated therefore no informed consent was obtained. IRB approval was obtained from Washington University Institutional Review Board.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bane, T., Luhmann, S.J. Predicting the impact of intraoperative halo-femoral traction from preoperative imaging in neuromuscular scoliosis. Spine Deform 10, 679–687 (2022). https://doi.org/10.1007/s43390-021-00461-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s43390-021-00461-w

Keywords

  • Neuromuscular scoliosis
  • Scoliosis
  • Intraoperative traction
  • Posterior spinal fusion
  • Preoperative imaging