Neurologic Deficit During Halo-Gravity Traction in the Treatment of Severe Thoracic Kyphoscoliotic Spinal Deformity

Pediatric Halo Use: Indications, Application, and Potential Complications

A halo has many applications for the treatment of pediatric spine pathology. It is most commonly used with gravity traction for the correction of severe thoracolumbar deformity over the course of several weeks before a staged fusion or growing implant placement. It is also used for preoperative optimization, secure positioning of small skulls for prone spine approach, cervical deformities such as basilar invagination, trauma treatment, or postoperative immobilization with a halo vest. Application of a halo is generally straightforward, but surgeons must be vigilant about complications and risks.

Key Concepts

(1)Halo placement must be done with an understanding of safe corridors for pin placement and pin torque specific to a patient's bony anatomy, quality, and age.(2)In severe thoracolumbar spinal deformity, halo-gravity traction (HGT) allows for elongation of the spine, correction of deformity, and chest elongation before the second-stage placement of implants.(3)In the cervical spine; HGT can be used to reduce basilar invagination before occipitocervical fusion, C1-2 rotatory subluxation before C1-2 fusion. A halo vest orthosis can be a definitive treatment for atlanto-occipital dislocation without neurologic injury.(4)Complications such as pin site infections and nerve palsies are frequent but most resolve quickly with appropriate management and vigilant monitoring.

Surgical management of omega deformity in a patient with neurofibromatosis type 1: a case report

PURPOSE

To describe the surgical treatment in a patient with a partial omega deformity in the thoracic spine with neurofibromatosis type 1.

METHODS

The patient was a 55-year-old man with an omega deformity, which is defined as a curvature in which the end vertebra is positioned at the level of, above, or below the apical vertebra (i.e., a horizontal line bisecting it). We performed halo gravity traction (HGT) for 7 weeks, followed by posterior spinal instrumented nearly equal in situ fusion from T2-L5 with three femoral head allografts and a local bone autograft. We avoided reconstruction of the thoracic anterior spine because of his severe pulmonary dysfunction.

RESULTS

HGT improved the % vital capacity from 32.5 to 43.5%, and improved the Cobb angle of the kyphosis from > 180° before traction to 144° after traction. The Cobb angle of kyphosis and scoliosis changed from > 180° preoperatively to 155° and 146°, respectively, postoperatively, and 167° and 156°, respectively, at final follow-up. His postoperative respiratory function deteriorated transiently due to bilateral pleural effusions and compressive atelectasis, which was successfully treated with a frequent change of position and nasal high flow for 1 week. At final follow-up, his pulmonary function improved from 0.86 to 1.04 L in VC, and from 32.5 to 37.9% in %VC. However, there was no overall improvement in preoperative distress following surgery, although his modified Borg scale improved from 3 preoperatively to 0.5 postoperatively. One month after discharge, he felt worsening respiratory distress (SpO2:75%) and was readmitted for pulmonary hypertension for 2 months. He was improved by non-invasive positive pressure ventilation (biphasic positive airway pressure) for 1 week, medication and daily lung physiotherapy. Thereafter, he has been receiving permanent daytime (0.5 L/min) and nighttime (2 L/min) oxygen therapy at home. A solid arthrodesis through the fusion area was confirmed on computed tomography. However, the kyphosis correction loss was 12° (i.e., 155°-167°), while the scoliosis correction loss was 10° (i.e., 146°-156°) at 2 years of recovery.

CONCLUSIONS

We suggest that nearly equal in situ fusion is a valid option for preventing further deformity deterioration and avoiding fatal complications.

Halo Gravity Traction for the Correction of Spinal Deformities in the Pediatric Population: A Systematic Review and Meta-Analysis

OBJECTIVE

Halo gravity traction (HGT) is an effective way of managing pediatric spinal deformities in the preoperative period. This study comprehensively reviews the existing literature and evaluates the effect of HGT on various radiographic parameters regarding spinal correction and, secondarily, evaluates the improvement in pulmonary function as well as nutritional status.

METHODS

In accordance with PRISMA guidelines, a comprehensive search was conducted for articles on HGT in the treatment of spinal deformity. Spinal deformity after traction and surgery, change of pulmonary function, nutritional status, and prevalence of complications were the main outcome measurements. All meta-analyses were conducted using random models according to the between-study heterogeneity, estimated with I².

RESULTS

A total of 694 patients from 24 studies were included in this review. Compared with pretraction values, the average coronal Cobb angle reduction after traction was 27.66° (95% confidence interval [CI], 23.41-31.90; P < 0.001) and 47.43° (95% CI, 39.32-55.54; P < 0.001) after surgery. The sagittal Cobb angle reduction after HGT and surgery was 27.23° (95% CI, 22.83-31.62; P <0.001) and 36.77° (95% CI, 16.90-56.65; P < 0.001), respectively. There was a statistically significant improvement in the overall pulmonary function, as evident by an increase in a forced vital capacity of 8.44% (95% CI, -5.68 to -11.20; P < 0.001), and an increase in nutritional status, with a percentage correction of body mass index by 1.58 kg/m² (95% CI, -2.14 to -1.02; P < 0.001) after HGT application.

CONCLUSIONS

HGT has been shown to significantly improve coronal deformities, sagittal deformities, nutritional status, and pulmonary function in the preoperative period.

Pediatric Spine Trauma

Pediatric spine has growth potential with incomplete ossification, and also unique biomechanics which have important implications for trauma patients. This article intends to review various aspects of pediatric spine trauma including epidemiology, anatomy and biomechanics, and clinically relevant details of each type of injury based on the location and mechanism of injury. With the appropriate but not superfluous treatment, pediatric spine trauma patients can have better chance of recovery. Therefore, as a spine surgeon, understanding the general concept for each injury subtype together with the debate and progress in the field is inevitable.

Selection of Fusion Level for Adolescent Idiopathic Scoliosis Surgery : Selective Fusion versus Postoperative Decompensation

Adolescent idiopathic scoliosis (AIS), which is associated with an extensive range of clinical and radiological presentations, is the one of the most challenging spinal disorders. The goals of surgery are to correct the deformity in 3 dimensions and to preserve motion segments while avoiding complications. Despite the ongoing evolution of classification systems and algorithms for the surgical treatment of AIS, there has been considerable debate regarding the selection of an appropriate fusion level in AIS. In addition, there is no consensus regarding the exact description, relationship, and risk factors of coronal decompensation following selective fusion. In this review, we summarize the current concepts of selection of the fusion level for AIS and review the available information about postoperative coronal decompensation.

Posterior-only versus combined anterior-posterior fusion in Scheuermann disease: a systematic review and meta-analysis

OBJECTIVE

Combined anterior-posterior (AP) surgery is considered the gold standard for surgical treatment of Scheuermann kyphosis. There are trends toward posterior-only (PO) surgery for correcting this deformity because of the availability of multisegmental compression instruments and posterior shortening osteotomy. To date, surgical strategies for Scheuermann kyphosis remain controversial. The purpose of this study was to compare various surgical approaches for the treatment of Scheuermann kyphosis, including radiological correction and intraoperative outcomes, using a systematic review and meta-analysis.

METHODS

A comprehensive database search of PubMed, EMBASE, Web of Science, and Cochrane Library was performed to identify studies concerning Scheuermann kyphosis. The inclusion criteria were direct comparisons between AP and PO surgeries for Scheuermann kyphosis and assessment of the angle of thoracic kyphosis preoperatively and postoperatively. The authors used the principles of a cumulative meta-analysis by updating the pooled estimate of the treatment effect.

RESULTS

Data from 13 studies involving 1147 participants (542 patients in the AP group and 605 patients in the PO group) were included. The average age was 18.2 years for the AP and 17.9 years for the PO group. The overall mean difference of changes in thoracic kyphosis angles between the AP and PO surgeries was 0.23° (95% CI -2.24° to 2.71°). In studies in which posterior shortening osteotomies were not performed, PO surgery resulted in a significantly low degree of correction of thoracic kyphosis, with a mean difference of 5.59° (95% CI 0.34°-10.83°). Studies in which osteotomies were performed revealed that the angle of correction for PO surgery was comparable to that of AP surgery. Regardless of fixation methods, PO surgical approaches achieved comparable angles.

CONCLUSIONS

PO surgery using posterior osteotomies can achieve correction of Scheuermann kyphosis as successfully as AP surgery does. Reflecting the advancement of surgical technology, large prospective studies are necessary to identify the proper treatments for Scheuermann kyphosis.