title: 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.
abstract: BACKGROUND
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors: German Scoliosis Center Bad Wildungen, Werner-Wicker-Klinik, Im Kreuzfeld 4, 34537, Bad Wildungen, Germany. heiko.koller@t-online.de
authors: Heiko
authors: H
authors: Koller
authors: Juliane
authors: J
authors: Zenner
authors: Vera
authors: V
authors: Gajic
authors: Oliver
authors: O
authors: Meier
authors: Luis
authors: L
authors: Ferraris
authors: Wolfgang
authors: W
authors: Hitzl
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D016267:External Fixators / Q000592:standards*; D005260:Female; D006801:Humans; D007738:Kyphosis / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000295:instrumentation / Q000379:methods*; D012129:Respiratory Function Tests; D012131:Respiratory Insufficiency / Q000503:physiopathology / Q000517:prevention & control / Q000628:therapy*; D012189:Retrospective Studies; D012600:Scoliosis / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D012720:Severity of Illness Index; D014143:Traction / Q000295:instrumentation / Q000379:methods*; D055815:Young Adult