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The impact of halo-gravity traction on curve rigidity and pulmonary function in the treatment of severe and rigid scoliosis and kyphoscoliosis: a clinical study and narrative review of the literature

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Abstract

Introduction

The treatment of rigid and severe scoliosis and kyphoscoliosis is a surgical challenge. Presurgical halo-gravity traction (HGT) achieves an increase in curve flexibility, a reduction in neurologic risks through gradual traction on a chronically tethered cord and an improvement in preoperative pulmonary function. However, little is known with respect to the ideal indications for HGT, its appropriate duration, or its efficacy in the treatment of rigid deformities.

Materials and methods

To investigate the use of HGT in severe deformities, we performed a retrospective review of 45 patients who had severe and rigid scoliosis or kyphoscoliosis. The analysis focused on the impact of HGT on curve flexibility, pulmonary function tests (PFTs), complications and surgical outcomes in a single spine centre.

Results

PFTs were used to assess the predicted forced vital capacity (FVC%). The mean age of the sample was 24 ± 14 years. 39 patients had rigid kyphoscoliosis, and 6 had scoliosis. The mean apical rotation was 3.6° ± 1.4°, according to the Nash and Moe grading system. The curve apices were mainly in the thoracic spine. HGT was used preoperatively in all the patients. The mean preoperative scoliosis was 106.1° ± 34.5°, and the mean kyphosis was 90.7° ± 29.7°. The instrumentation used included hybrids and pedicle screw-based constructs. In 18 patients (40%), a posterior concave thoracoplasty was performed. Preoperative PFT data were obtained for all the patients, and 24 patients had ≥3 assessments during the HGT. The difference between the first and the final PFTs during the HGT averaged 7.0 ± 8.2% (p < .001). Concerning the evolution of pulmonary function, 30 patients had complete data sets, with the final PFT performed, on average, 24 months after the index surgery. The mean preoperative FVC% in these patients was 47.2 ± 18%, and the FVC% at follow-up was 44.5 ± 17% (a difference that did not reach statistical significance). The preoperative FVC% was highly predictive of the follow-up FVC% and the response during HGT. The mean flexibility of the scoliosis curve during HGT was only 14.8 ± 11.4%, which was not significantly different from the flexibility measures achieved on bending radiographs or Cotrel traction radiographs. In rigid curves, the Cobb angle difference between the first and final radiographs during HGT was only 8° ± 9° for scoliosis and 7° ± 12° for kyphosis. Concerning surgical outcomes, 13 patients (28.9%) experienced minor and 15 (33.3%) experienced major complications. No permanent neurologic deficits or deaths occurred. Additional surgery was indicated in 12 patients (26.7%), including 7 rib-hump resections. At the final evaluation, 69% of the patients had improved coronal balance, and at a mean follow-up of 33 ± 23.3 months, 39 patients (86.7%) were either satisfied or very satisfied with the overall outcome.

Conclusion

The improvement of pulmonary function and the restoration of sagittal and coronal balance are the main goals in the treatment of severe and rigid scoliosis and kyphoscoliosis. A review of the literature showed that HGT is a useful tool for selected patients. Preoperative HGT is indicated in severe curves with moderate to severe pulmonary compromise. HGT should not be expected to significantly improve severe curves without a prior anterior and/or posterior release. The data presented in this study can be used in future studies to compare the surgical and pulmonary outcomes of severe and rigid deformities.

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References

  1. Zhang JG, Wang W, Qiu GX, Wang YP, Weng XS, Xu HG (2005) The role of preoperative pulmonary function tests in the surgical treatment of scoliosis. Spine 30:218–221

    Article  PubMed  CAS  Google Scholar 

  2. Weinstein SL (1999) Natural history. Spine 24:2592–2600

    Article  PubMed  CAS  Google Scholar 

  3. Pehrsson K, Danielsson A, Nachemson A (2001) Pulmonary function in adolescent idiopathic scoliosis: a 25 year follow-up after surgery or start of brace treatment. Thorax 56:388–393

    Article  PubMed  CAS  Google Scholar 

  4. Vitale MG, Matsumoto H, Bye MR, Gomez JA, Booker WA, Hyman JE, Roye DP (2008) A retrospective cohort study of pulmonary function, radiographic measures, and quality of life in children with congenital scoliosis. Spine 33:1242–1249

    Article  PubMed  Google Scholar 

  5. Rizzi PE, Winter RB, Lonstein JE, Denis F, Perra JH (1996) Adult spinal deformity and respiratory failure: surgical results in 35 patients. Spine 22:2517–2530

    Article  Google Scholar 

  6. Jackson RP, Simmons EH, Striptinis D (1989) Coronal and sagittal plane spinal deformities correlating with back pain and pulmonary function adult idiopathic scoliosis. Spine 14:1391–1397

    Article  PubMed  CAS  Google Scholar 

  7. Buchowski JM, Skaggs DL, Sponseller PD (2007) Temporary internal distraction as an aid to correction of severe scoliosis. J Bone Joint Surg A 89:297–309

    Article  Google Scholar 

  8. Suk Se-II, Kim J-H, Kim W-J, Lee S-M, Chung E-R, Nah K-H (2002) Posterior vertebral column resection for severe spinal deformities. Spine 27:2374–2382

    Article  PubMed  Google Scholar 

  9. Di Silvestre M, Bakaloudis G, Lolli F, Vommaro F, Martikos K, Parisini P (2008) Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80°: pedicle screws versus hybrid instrumentation. Eur spine J 17:1336–1349

    Article  PubMed  Google Scholar 

  10. Rinella A, Lenke L, Whitaker C, Kim Y, Park S-S, Peelle M, Edwards C, Bridwell K (2005) Perioperative halo-gravity traction in the treatment of severe scoliosis and kyphosis. Spine 30:475–482

    Article  PubMed  Google Scholar 

  11. Sponseller PD, Takenaga RK, Newton P, Boachie O, Flynn J, Letko L, Betz R, Bridwell K, Gupta M, Marks M, Bastrom T (2008) The use of traction in the treatment of severe spinal deformity. Spine 33:2305–2309

    Article  PubMed  Google Scholar 

  12. Letts RM, Palakar G, Bobechko WP (1975) Preoperative skeletal traction in scoliosis. J Bone Joint Surg A 57:616–619

    CAS  Google Scholar 

  13. Winter RB, Lonstein JE (2010) The Moe maximal correction test to determine true curve flexibility. A historical note with current application. Spine 35:1733–1735

    Article  PubMed  Google Scholar 

  14. Lenke LG, Sides BA, Koester LA, Hensley M, Blanke KM (2010) Vertebral column resection for the treatment of severe spinal deformity. Clin Orthop Relat Res 468:687–699

    Article  PubMed  Google Scholar 

  15. Yamin S, Li L, Tianjun G, Yupeng Z (2008) Staged surgical treatment for severe and rigid scoliosis. J Orthop Surg Res 3:1–9

    Article  Google Scholar 

  16. Qiu Y, Liu Z, Zhu F, Wang B, Yu Y, Zhu Z, Qian B, Ma W (2007) Comparison of effectiveness of Halo-femoral traction after anterior spinal release in severe idiopathic and congenital scoliosis: a retrospective study. J Orthop Surg Res 2:1–7

    Article  Google Scholar 

  17. Kuklo TR, Lenke LG, OBrien MF, Lehman RA Jr, Polly DW Jr, Schroeder TM (2005) Accuracy and efficacy of thoracic pedicle screws in curves more than 90 degrees. Spine 30:222–226

    Article  PubMed  Google Scholar 

  18. Watanabe K, Lenke LG, Bridwell KH, Kim YJ, Kim Y-W, Kim YB, Hensley M, Stobbs G (2008) Comparison of radiographic outcomes for the treatment of scoliotic curves greater than 100 degrees. Wires versus hooks versus screws. Spine 33:1084–1092

    Article  PubMed  Google Scholar 

  19. Suh SW, Modi HN, Yang J, Song H-R, Jang K-M (2009) Posterior multilevel vertebral osteotomy for correction of severe and rigid neuromuscular scoliosis. A preliminary study. Spine 34:1315–1320

    Article  PubMed  Google Scholar 

  20. Wazeka AN, DiMaio MF, Boachie-Adjei O (2004) Outcome of pediatric patients with severe restrictive lung disease following reconstructive spine surgery. Spine 29:528–533

    Article  PubMed  Google Scholar 

  21. Wang Y, Zheng G, Zhang X, Zhang Y, Xiao S, Wang Z (2010) Comparative analysis between shape memory alloy-based correction and traditional correction technique in pedicle screws constructs for treating severe scoliosis. Eur Spine J 19:394–399

    Article  PubMed  Google Scholar 

  22. Burrows B, Cline MG, Knudson RJ, Taussig LM, Lebowitz MD (1983) A descriptive analysis of the growth and decline of the FVC and FEV1. Chest 83:717–724

    Article  PubMed  CAS  Google Scholar 

  23. Pehrsson K, Larsson S, Oden A, Nachemson A (1992) Long-term follow-up of patients with untreated scoliosis. A study of mortality, causes of death, and symptoms. Spine 17:1091–1096

    Article  PubMed  CAS  Google Scholar 

  24. Glassmann SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG (2007) The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine 32:2764–2770

    Article  Google Scholar 

  25. Hempfing A, Ferraris L, Koller H, Rump J, Metz-Stavenhagen P (2007) Is anterior release effective to increase flexibility in idiopathic thoracic scoliosis? Assessment by traction films. Eur Spine J 16:515–520

    Article  PubMed  CAS  Google Scholar 

  26. Vora V, Crawford A, Babekhir N, Boachie-Adjei O, Lenke L, Peskin M, Charles G, Kim Y (2007) A pedicle screw construct gives an enhanced posterior correction of adolescent idiopathic scoliosis when compared with other constructs: myth or reality. Spine 32:1869–1874

    Article  PubMed  Google Scholar 

  27. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC (1993) Lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Respir J 6:5–40

    Google Scholar 

  28. Murray RJ (2007) Respiratory manifestations of extrapulmonary disorders. Elsevier Saunders, Philadelphia

    Google Scholar 

  29. Hempfing A, Koller H, Ferraris L, Meier O (2008) The effect of concave rib osteotomies on spinal flexibility in AIS: a biomechanical intra-operative assessment of spinal rigidity using a strain gauge distraction device. In: IMAST 2008, Hong Kong, China

  30. Rawlins BA, Winter RB, Lonstein JE, Denis FM, Kubic PT, Wheeler WB, Ozolins AL (1996) Reconstructive spine surgery in pediatric patients with major loss in vital capacity. J Pediatr Orthop 16:284–292

    Article  PubMed  CAS  Google Scholar 

  31. Payo J, Perez-Grueso FS, Fernandez-Baillo N, Garcia A (2009) Severe restrictive lung disease and vertebral surgery in a pediatric population. Eur Spine J 18:1905–1910

    Article  PubMed  Google Scholar 

  32. Gonzalez C, Ferris G, Diaz J, Inmaculada F, Nunez J, Marin J (2003) Kyphoscoliotic ventilatory insufficiency: effects of long-term intermittent positive-pressure ventilation. Chest 124:857–862

    Article  PubMed  Google Scholar 

  33. Koumbourlis AC (2006) Scoliosis and the respiratory system. Pediatr Respir Rev 7:152–160

    Article  Google Scholar 

  34. Swank SM, Winter RB, Moe JH (1982) Scoliosis and cor pulmonale. Spine 7:343–354

    Article  PubMed  CAS  Google Scholar 

  35. Smiljanic I, Kovac V, Cimic M (2010) Changes in pulmonary function parameters after surgical treatment of idiopathic scoliosis. Coll Antropol 33:145–152

    Google Scholar 

  36. Savini R, Parisini P, Vicenzi G (1976) Respiratory function in severe scoliosis before and after treatment (a review of 76 cases). Ital J Orthop Traumatol 2:247–259

    PubMed  CAS  Google Scholar 

  37. Sucato DJ (2010) Management of severe spinal deformity. Scoliosis and kyphosis. Spine 35:2186–2192

    Article  PubMed  Google Scholar 

  38. Kearon C, Viviani GR, Kirkley A, Killian KJ (1993) Factors determining pulmonary function in adolescent idiopathic thoracic scoliosis. Am Rev Respir Dis 148:288–294

    PubMed  CAS  Google Scholar 

  39. Newton PO, Perry A, Bastrom TP, Lenke LG, Betz RR, Clements D, D’Andrea L (2007) Predictors of change in postoperative pulmonary function in adolescent idiopathic scoliosis. Spine 32:1875–1882

    Article  PubMed  Google Scholar 

  40. Adam CJ, Cargill SC, Askin GN (2007) Computed tomographic-based volumetric reconstruction of the pulmonary system in scoliosis. Trends in lung volume and lung volume asymmetry with spinal curve severity. J Pediatr Orthop 27:677–681

    Article  PubMed  Google Scholar 

  41. Gill I, Eagle M, Mehta JS, Gibson MJ, Bushby YK, Bullock R (2006) Correction of neuromuscular scoliosis in patients with preexisting respiratory failure. Spine 31:2478–2483

    Article  PubMed  Google Scholar 

  42. Sink EL, Karol LA, Sanders J, Birch JG, Jonston CE, Herring JA (2001) Efficacy of perioperative halo-gravity traction in the treatment of severe scoliosis in children. J Pediatr Orthop 21:519–524

    Article  PubMed  CAS  Google Scholar 

  43. Kim YJ, Lenke LG, Bridwell KH, Cheh G, Whorton J, Sides B (2007) Prospective pulmonary function comparison following posterior segmental spinal instrumentation and fusion of adolescent idiopathic scoliosis. Spine 32:2685–2693

    Article  PubMed  Google Scholar 

  44. Yaszay B, Jazayeri R, Lonner B (2009) The effect of surgical approaches on pulmonary function in adolescent idiopathic scoliosis. J Spinal Disord 22:278–283

    Article  Google Scholar 

  45. Izatt MT, Harvey JR, Adam CJ, Fender D, Labrom RD, Askin GN (2006) Recovery of pulmonary function following endoscopic anterior scoliosis correction: evaluation at 3, 6, 12, and 24 months after surgery. Spine 31:2469–2477

    Article  PubMed  Google Scholar 

  46. Vedantam R, Lenke LG, Bridwell KH, Haas J, Linville DA (2000) A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to the surgical approach used for spinal arthrodesis. Spine 25:82–90

    Article  PubMed  CAS  Google Scholar 

  47. Koller H, Zenner J, Hitzl W, Meier O, Ferraris L, Acosta F, Hempfing A (2010) The morbidity of open transthoracic approach for anterior scoliosis correction. Spine 35:1586–1592

    Article  Google Scholar 

  48. Kadoury S, Cheriet F, Beasuejour M, Stokes IA, Parent S, Labelle H (2009) A three-dimensional retrospective analysis of the evolution of spinal instrumentation for the correction of adolescent idiopathic scoliosis. Eur Spine J 18:23–37

    Article  PubMed  Google Scholar 

  49. Nepple JJ, Lenke LG (2009) Severe idiopathic scoliosis with respiratory insufficiency treated with preoperative traction and staged anteroposterior spinal fusion with a 2-level apical vertebrectomy. Spine J 9:E9–E13

    Article  PubMed  Google Scholar 

  50. Lonner BS, Murthy SK, Boachie-Adjei O (2005) Single-staged double anterior and posterior spinal reconstruction for rigid adult spinal deformity: a report of four cases. Spine J 5:104–108

    Article  PubMed  Google Scholar 

  51. Hamed AM (2010) Effect of multi rib osteootmy on pulmonary functions after correction of adolescent scoliosis. In: 45th annual meeting of the SRS, Kyoto, Japan

  52. Olgun ZD, Demirkiran HG, Ayvaz M, Alanay A, Yazici M (2009) Is vertebral column resection the only effective treatment option for correction in adolescent patients with complex congenital thoracic kyphoscoliosis: the safety and efficacy of posterior all pedicle screw instrumentation combined with multiple chevron and concave rib osteotomies. In: 17th IMAST, Toronto, Canada

  53. Park DK, Braaksma B, Hammerberg K, Sturm P (2009) The effect of long-term halo traction in pediatric deformity. In: 16th IMAST, Vienna, Austria

  54. Seller K, Haas S, Raab P, Krauspe R, Wild A (2005) Preoperative halo-traction in severe paralytic scoliosis. Z Orthop Ihre Grenzgeb 143:539–543

    Article  PubMed  CAS  Google Scholar 

  55. Flierl S, Carstens C (1997) The effect of halo-gravity traction in the preoperative treatment of neuromuscular scoliosis. Z Orthop Ihre Grenzgeb 135:162–170

    Article  PubMed  CAS  Google Scholar 

  56. Tokunaga M, Minami S, Kitahara H, Isobe K, Nakata Y, Moriya H (2000) Vertebral decancellation for severe scoliosis. Spine 25:469–474

    Article  PubMed  CAS  Google Scholar 

  57. Wang Y, Zhang Y, Zhang X, Huang P, Xiao S, Wang Z, Liu Z, Liu B, Lu N, Mao K (2008) A single posterior approach for multilevel modified vertebral column resection in adults with severe rigid congenital kyphoscoliosis: a retrospective study of 13 cases. Eur Spine J 17:361–372

    Article  PubMed  Google Scholar 

  58. Li M, Ni J, Li Y, Fang X, Gu S, Zhang Z, Zhu X (2009) Single-staged anterior and posterior spinal fusion: a safe and effective alternative for severe and rigid adolescent idiopathic scoliosis in China. J Paediatr Child Health 45:246–253

    Article  PubMed  Google Scholar 

  59. Ayvaz M, Akalan N, Yazici M, Alanay A, Acaroglu E (2009) Is it necessary to operate all split cord malformations before corrective surgery for patients with congenital spinal deformities. Spine 34:2413–2418

    Article  PubMed  Google Scholar 

  60. Suken A, Shah MD, Sucato D, Newton PO, Shufflebarger HL, Emans JB, Sponseller PD, Neiss G, Yorgova P, Lenke LG (2010) Perioperative neurologic events from a multicenter consecutive series of pediatric vertebral column resection: nature, frequency and outcomes. In: 17th IMAST, Toronto, Canada

  61. Takaso M, Nakazawa T, Imura T, Takahira N, Itoman M, Takahashi K, Yamazaki M, Otori S, Akazawa T, Minami S, Kotani T (2010) Surgical management of severe scoliosis with high-risk pulmonary dysfunction in Duchenne muscular dystrophy. Int Orthop 34:401–406

    Article  PubMed  Google Scholar 

  62. Hamzaoglu A, Ozturk C, Aydogan M, Tezer M, Aksu N, Bruno MB (2008) Posterior only pedicle screw instrumentation with intraoperative halo-femoral traction in the surgical treatment of severe scoliosis (>100°). Spine 33:979–983

    Article  PubMed  Google Scholar 

  63. Pizones J, Izquierdo E, Sanchez-Marscal F, Alvarez P, Zuniga L, Gomez A (2010) Does wide posterior multiple level release improve the correction of adolescent idiopathic scoliosis curves? J Spinal Disord Tech 23(7):e24–e30

    Article  PubMed  Google Scholar 

  64. Lenke LG, O’Leary PT, Bridwell KH, Sides BA, Koester LA, Blanke KM (2009) Posterior vertebral column resection for severe pediatric deformity. Spine 34:2213–2221

    Article  PubMed  Google Scholar 

  65. Bullmann V, Halm H, Schulte T, Lerner T, Weber TP, Liljenqvist UR (2006) Combined anterior and posterior instrumentation in severe and rigid idiopathic scoliosis. Eur Spine J 15:440–448

    Article  PubMed  Google Scholar 

  66. Saeed MU, Dacuycuy MAC, Kennedy DJ (2007) Halo pin insertion-associated brain abscess. Case report and review of literature. Spine 32:E271–E274

    Article  PubMed  Google Scholar 

  67. Limpaphayom N, Skaggs DL, McComb G, Krieger M, Tolo VT (2007) Complications of halo use in children. In: 42nd annual meeting of the SRS, Edinburgh, Scotland

  68. Liang J, Qiu G, Shen J, Zhang J, Wang Y, Li S, Zhao H (2010) Predictive factors of postoperative pulmonary complications in scoliotic patients with moderate or severe pulmonary dysfunction. J Spinal Disord 23:388–392

    Article  Google Scholar 

  69. Udink ten Cate FEA, van Royen BJ, Heerde M, Roerdink D, Plötz FB (2008) Incidence and risk factors of prolonged mechanical ventilation in neuromuscular scoliosis surgery. J Pediatr Orthop B 17:203–206

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. German Scoliosis Center Bad Wildungen, Werner-Wicker-Klinik, Im Kreuzfeld 4, 34537, Bad Wildungen, Germany

    Heiko Koller, Juliane Zenner, Vera Gajic, Oliver Meier & Luis Ferraris

  2. Research Office, Biostatistics, Paracelsus Medical University, Salzburg, Austria

    Wolfgang Hitzl

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  1. Heiko Koller
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  2. Juliane Zenner
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  3. Vera Gajic
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Correspondence to Heiko Koller.

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Koller, H., Zenner, J., Gajic, V. et al. The impact of halo-gravity traction on curve rigidity and pulmonary function in the treatment of severe and rigid scoliosis and kyphoscoliosis: a clinical study and narrative review of the literature. Eur Spine J 21, 514–529 (2012). https://doi.org/10.1007/s00586-011-2046-5

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