Halo-Femoral Traction

External traction is applied by affixing to the patient’s head a halo and effecting countertraction through a device extending from the halo and affixed to the femur, tibia, or pelvis, or by using the patient’s body weight to provide the countertractive force (halo-gravity traction). The literature contains reports of the use of these methods in series of patients without untreated controls. In general, more significant corrective forces are generated by halo-femoral and halo-tibial traction than by halo-gravity traction.

Originally described by Kan and colleagues,3 halo-femoral traction is one form of gaining control of severe curves in neuromuscular and idiopathic scoliosis. In their 1967 study, Kan and colleagues described achieving correction through halo-femoral traction over a period of 2 to 6 weeks and then maintaining the correction with casting, bracing, fusion, or instrumented fusion. The average correction they achieved was 48% (preoperative average curve of 112 degrees corrected to an average of 58 degrees). A;; complications were transient, but included paresthesias, hypertension, and an abducent nerve palsy.3 There have been a few more modern studies of the efficacy of halo-femoral traction. Mehlman et al studied 24 patients who had halo-femoral traction with a pretraction spinal release and post-traction posterior fusion.4 Eleven of these patients had idiopathic scoliosis with an average preprocedure curve of 85 degrees; these 11 patients had a 55% curve correction after release and traction and a 67% curve correction after fusion. Only one of Mehlman and colleagues’ 24 patients experienced an adverse event in the form of a transient, bilateral lower-extremity sensory deficit, which resolved with reduction of the traction weight. Qiu and colleagues described a series of 30 patients with idiopathic scoliosis who underwent halo-femoral traction before posterior instrumented fusion. In a group in which the average coronal deformity was 91 degrees, Qiu et al noted an average 58% correction after fusion, as well as an average 33% correction of thoracic kyphosis. Transient brachial plexus palsy was seen in 10% of the patients.5 Other complications associated with halo-femoral traction are pin-site infections, triceps palsy, deep vein thromboses, and hip dislocation.1,6

Halo-Pelvic Traction

Halo-pelvic traction has the benefit of allowing more direct tension to be applied to the spine without crossing the hip joint; however, the constant, high level of traction in this technique is associated with several complications. In the initial description by O’Brien and coworkers in 1971, halo-pelvic traction was used primarily for patients with severe spinal deformities of neuromuscular or tuberculous pathology.7 Ransford and Manning described a series of 114 patients treated with halo-pelvic traction that included 72 patients with infantile, juvenile, and adolescent idiopathic scoliosis (AIS). An average correction of 55% was achieved; however, the treatment course was long, with 4 to 6 weeks in traction and 3 months of bed rest following fusion, and was fraught with complications including pin-site problems, cranial-nerve palsies, and spinal-cord paraplegia.8 Despite the powerful correction effected by this method, the prevalence of complications has driven halo-pelvic traction out of favor. Wilkins and MacEwen noted cranial nerve palsy in 6 of 70 patients treated with halo-femoral or halo-pelvic traction.9 The abducent nerve was the most commonly affected, with involvement of the glossopharyngeal, hypoglossal, and vagus nerves being less common. Other complications of halo-pelvic traction are avascular necrosis of the tip of the dens, peritoneal penetration or intestinal perforation by traction pins, and hip dislocation.10,11

Halo-Gravity Traction

In contrast to halo-femoral and halo-pelvic traction, halo-gravity traction appears to be a simpler and safer method to correct severe scoliotic curves. This method, which was popularized by Stagnara, uses the weight of the patient’s body as the counterforce.12 Correction occurs in the frontal and sagittal planes, and truncal decompensation improves. In addition, in contrast to the case with halo-femoral traction, which requires prolonged bed rest, the forces in halo-gravity traction can be applied while a patient is in bed, a wheelchair, or a walking frame. Contraindications to halo traction include cervical kyphosis or stenosis, significant instability, or ligamentous laxity. A few case series have investigated the success of halo-gravity traction in correcting severe scoliotic curves. Rinella and coworkers conducted a retrospective analysis of 33 patients with severe scoliosis, kyphoscoliosis, or kyphosis.1 Four of the 33 patients had idiopathic scoliosis, and in these patients the main coronal curve ranged from 84 to 131 degrees with a mean of 101 degrees. In the patients with idiopathic scoliosis, traction resulted in an average 54% decrease in the main coronal curve. The only complication associated with the four cases of idiopathic scoliosis was rod migration.

Sink et al conducted a retrospective review of 19 children with severe scoliosis who underwent spinal fusion surgery after 6 to 21 weeks of preoperative halo-gravity traction.2 Only 4 of the 19 patients had idiopathic scoliosis. Preoperative traction lasted from 14 to 18 weeks and postoperative traction ranged from 0 to 4 weeks. One patient had posterior spinal fusion complemented by traction, which yielded a 22% decrease (from 97 to 76 degrees) in the main coronal curve immediately after traction and a 26% decrease (from 97 to 72 degrees) after fusion. Three patients had anterior and posterior spinal fusion complemented by traction. This resulted in an average decrease in the main coronal curve of 43% immediately after traction and of 51% after fusion. Although halo-gravity traction is primarily used for neuromuscular scoliosis, Sink and colleagues’ study described it as an effective method of correcting rigid idiopathic scoliosis. Seller et al conducted one of the few studies done of the safety and efficacy of halo traction with a comparison control group; however, the patients in this study had neuromuscular spinal deformities.13 In the group not treated with halo traction the main Cobb angle decreased by an average of 57% (from 77 to 33 degrees). In the halo-traction group the average decrease in the main Cobb angle was 61% (from 85 to 33 degrees). The difference was not significant (P = 0.19), and Seiler and colleagues herefore concluded that unless there are specific indications for halo traction, it is not needed as a standard procedure in treating neuromuscular deformities.

Although halo-gravity traction is not without complications, it has a lower incidence of neurological complications. Sink et al2 reported a 30% complication rate, which came mainly from pin loosening and pin-site infections, but also a case of cervical paresthesia in a child with Klippel-Feil syndrome. Rinella and colleagues1 reported pin loosening, pin-site infection, nausea, nystagmus, cervical discomfort, and trapezial soreness as complications and symptoms associated with halo-gravity treatment. In a study of 300 cases of halo-gravity and halo-femoral traction combined with posterior fusion of severe scoliosis, Qian and coworkers described three cases of treatment with halo-gravity traction in which brachial-plexus palsy lasting up to 3 months was discovered.14 A temporary hypoglossal nerve injury with halo-gravity traction, manifested as difficulty in swallowing, difficulty in speaking, or protrusion of the tongue has been reported.15 Although halo-gravity traction is a powerful tool in the treatment of rigid scoliosis, its associated risks and discomforts should be discussed thoroughly with the patient and patient’s family before treatment is begun.

Technique of Halo-Gravity Traction

In the authors’ experience, patients with unusually stiff curves (bony apical fusions or flexibility of <20% on radiographs made during traction), pretraction release can be a useful adjunct in allowing traction to correct extraspinal tissue contractures. Most patients, however, begin traction without a release, which probably results in the lowest risk of eventual infection. Usually, the halo is applied with sedation and local anesthesia. Six to eight pins are used in children under the age of 6 years, to minimize the risk of loosening of the halo. The pins are tightened to 4 inch-pounds of torque in children under 6 years of age, or to 6 to 8 inch-pounds for older children or adults (assuming normal cranial bone density). The halo is placed just below the equator of the skull, above the eyebrows and the pinnae of the ears. The anterior pins are placed laterally to the mid-portion of the eyebrows to avoid the supra-orbital nerves. Every effort is made to place the posterior pins diametrically opposite the anterior pins. After 24 to 48 hours the pins may be retightened. If there is clinical indication of loosening after this, the pin should be relocated. Traction is started immediately with 5 lbs of weight for young children and 10 lbs for those closer to maturity. The traction weight is gradually increased by 2 to 3 lbs/day as tolerated, with the goal being a weight of 33 to 50% of the patient’s body weight. The bed is inclined downward caudally. The patient’s skin should be inspected regularly, because bony prominences are common in this patient population and pressure sores are a risk. This is especially true of patients who have significant kyphosis or who have difficulty in turning over. The traction is applied continuously throughout the day. Patients should be in an upright position in a halo wheelchair or walker during part of the day. For a patient sitting in a wheelchair, the goal is to suspend the patient’s trunk as much as possible ( Fig. 15.1 ). Traction may also be applied while the patient is standing in a specially constructed walker. The traction weight may be decreased when the patient is sleeping, especially when the weight nears its maximum.

Given the various forces involved, traction has different implications according to the body’s position. Neurological assessments of the patient’s upper and lower extremities are done three times per day and cranial nerve function is checked daily. The duration of preoperative halo-gravity traction may vary from 2 to 12 weeks depending on the magnitude of the patient’s curve, its response to traction, and the patient’s overall medical condition. Radiographs should be obtained approximately every week for assessing the improvement in the patient’s spinal curve. Patients with borderline pulmonary or nutritional reserve may benefit from long periods of traction to optimize their nutrition and minimize their pulmonary restrictive defect.

Related posts:

7 The Case for Bracing 6 The Importance of the Sagittal Plane: Spinopelvic Considerations 28 The Impact of Genetics Research on Adolescent Idiopathic Scoliosis 23 Spinopelvic Fixation in Idiopathic Scoliosis 17 Surgical Treatment of the Right Thoracic Curve Pattern 10 Biomechanics and Reduction of Scoliosis

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