Halo-gravity traction for the treatment of pediatric cervical spine disorders

View More View Less
  • 1 Department of Orthopaedic Surgery, Boston Children’s Hospital;
  • 2 Harvard Medical School, Boston, Massachusetts;
  • 3 Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center; and
  • 4 Department of Orthopaedic Surgery, Rainbow Babies and Children’s Hospital, Cleveland, Ohio
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities.

METHODS

Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2–24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications.

RESULTS

The mean duration of HGT was 25 days (IQR 13–29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%–40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°–122°) to 56° ± 17.6° (range 32°–96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%–57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17–43 days).

Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24–48 hours.

CONCLUSIONS

HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.

ABBREVIATIONS AE = adverse event; ARS = atlantoaxial rotatory subluxation; BW = body weight; HGT = halo-gravity traction; HVGT = halo-vest-gravity traction; IONM = intraoperative neuromonitoring; LOS = length of stay; NF1 = neurofibromatosis type 1; SAC = space available for the spinal cord; SCC = spinal cord compression.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Daniel J. Hedequist: Boston Children’s Hospital, Boston, MA. daniel.hedequist@childrens.harvard.edu.

INCLUDE WHEN CITING Published online December 27, 2019; DOI: 10.3171/2019.10.PEDS19513.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Abd-El-Barr MM, Snyder BD, Emans JB, Proctor MR, Hedequist D: Combined preoperative traction with instrumented posterior occipitocervical fusion for severe ventral brainstem compression secondary to displaced os odontoideum: technical report of 2 cases. J Neurosurg Pediatr 25:724729, 2016

    • Search Google Scholar
    • Export Citation
  • 2

    Beier AD, Vachhrajani S, Bayerl SH, Aguilar CY, Lamberti-Pasculli M, Drake JM: Rotatory subluxation: experience from the Hospital for Sick Children. J Neurosurg Pediatr 9:144148, 2012

    • Search Google Scholar
    • Export Citation
  • 3

    Bogunovic L, Lenke LG, Bridwell KH, Luhmann SJ: Preoperative halo-gravity traction for severe pediatric spinal deformity: complications, radiographic correction and changes in pulmonary function. Spine Deform 1:3339, 2013

    • Search Google Scholar
    • Export Citation
  • 4

    Bouchoucha S, Khelifi A, Saied W, Ammar C, Nessib MN, Ben Ghachem M: Progressive correction of severe spinal deformities with halo-gravity traction. Acta Orthop Belg 77:529534, 2011

    • Search Google Scholar
    • Export Citation
  • 5

    Crawford AH, Herrera-Soto J: Scoliosis associated with neurofibromatosis. Orthop Clin North Am 38:553562, vii, 2007

  • 6

    Cronin CG, Lohan DG, Mhuircheartigh JN, Meehan CP, Murphy J, Roche C: CT evaluation of Chamberlain’s, McGregor’s, and McRae’s skull-base lines. Clin Radiol 64:6469, 2009

    • Search Google Scholar
    • Export Citation
  • 7

    Dodwell ER, Pathy R, Widmann RF, Green DW, Scher DM, Blanco JS, : Reliability of the modified Clavien-Dindo-Sink complication classification system in pediatric orthopaedic surgery. JBJS Open Access 3:e0020, 2018

    • Search Google Scholar
    • Export Citation
  • 8

    Donnally CJ III, Munakomi S, Varacallo M (eds): Basilar Invagination. Treasure Island, FL: StatPearls Publishing, 2019

  • 9

    Emans J: Preliminary halo-gravity traction facilitates insertion of growing rods or VEPTR devices in severe early onset spinal deformity, presented at the 42nd Annual Meeting of the Scoliosis Research Society, September 5–8, 2007, Edinburgh, United Kingdom

    • Export Citation
  • 10

    Ginsburg GM, Bassett GS: Hypoglossal nerve injury caused by halo-suspension traction. A case report. Spine (Phila Pa 1976) 23:14901493, 1998

    • Search Google Scholar
    • Export Citation
  • 11

    Goel A: Torticollis and rotatory atlantoaxial dislocation: a clinical review. J Craniovertebr Junction Spine 10:7787, 2019

  • 12

    Goel A, Bhatjiwale M, Desai K: Basilar invagination: a study based on 190 surgically treated patients. J Neurosurg 88:962968, 1998

  • 13

    Iwasaki M, Yamamoto T, Miyauchi A, Amano K, Yonenobu K: Cervical kyphosis: predictive factors for progression of kyphosis and myelopathy. Spine (Phila Pa 1976) 27:14191425, 2002

    • Search Google Scholar
    • Export Citation
  • 14

    Kawabata S, Watanabe K, Hosogane N, Ishii K, Nakamura M, Toyama Y, : Surgical correction of severe cervical kyphosis in patients with neurofibromatosis Type 1. J Neurosurg Spine 18:274279, 2013

    • Search Google Scholar
    • Export Citation
  • 15

    Koller H, Zenner J, Gajic V, Meier O, Ferraris L, Hitzl W: 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 21:514529, 2012

    • Search Google Scholar
    • Export Citation
  • 16

    Laohacharoensombat W, Wajanavisit W, Woratanarat P: Cervical neurofibromatosis with quadriparesis: management by fibular strut graft. Indian J Orthop 44:9597, 2010

    • Search Google Scholar
    • Export Citation
  • 17

    Li P, Bao D, Cheng H, Meng F, Li J: Progressive halo-vest traction preceding posterior occipitocervical instrumented fusion for irreducible atlantoaxial dislocation and basilar invagination. Clin Neurol Neurosurg 162:4146, 2017

    • Search Google Scholar
    • Export Citation
  • 18

    Mubarak SJ, Camp JF, Vuletich W, Wenger DR, Garfin SR: Halo application in the infant. J Pediatr Orthop 9:612614, 1989

  • 19

    Nemani VM, Kim HJ, Bjerke-Kroll BT, Yagi M, Sacramento-Dominguez C, Akoto H, : Preoperative halo-gravity traction for severe spinal deformities at an SRS-GOP site in West Africa: protocols, complications, and results. Spine (Phila Pa 1976) 40:153161, 2015

    • Search Google Scholar
    • Export Citation
  • 20

    Peng X, Chen L, Wan Y, Zou X: Treatment of primary basilar invagination by cervical traction and posterior instrumented reduction together with occipitocervical fusion. Spine (Phila Pa 1976) 36:15281531, 2011

    • Search Google Scholar
    • Export Citation
  • 21

    Powell EC, Leonard JR, Olsen CS, Jaffe DM, Anders J, Leonard JC: Atlantoaxial rotatory subluxation in children. Pediatr Emerg Care 33:8691, 2017

    • Search Google Scholar
    • Export Citation
  • 22

    Rinella A, Lenke L, Whitaker C, Kim Y, Park SS, Peelle M, : Perioperative halo-gravity traction in the treatment of severe scoliosis and kyphosis. Spine (Phila Pa 1976) 30:475482, 2005

    • Search Google Scholar
    • Export Citation
  • 23

    Roye BD, Campbell ML, Matsumoto H, Pahys JM, Welborn MC, Sawyer J, : Establishing consensus on the best practice guidelines for use of halo gravity traction for pediatric spinal deformity. J Pediatr Orthop 40:e42e48, 2020

    • Search Google Scholar
    • Export Citation
  • 24

    Shen X, Wu H, Shi C, Liu Y, Tian Y, Wu X, : Preoperative and intraoperative skull traction combined with anterior-only cervical operation in the treatment of severe cervical kyphosis (>50 degrees). World Neurosurg 130:e915e925, 2019

    • Search Google Scholar
    • Export Citation
  • 25

    Simsek S, Yigitkanli K, Belen D, Bavbek M: Halo traction in basilar invagination: technical case report. Surg Neurol 66:311314, 2006

  • 26

    Sponseller PD, Takenaga RK, Newton P, Boachie O, Flynn J, Letko L, : The use of traction in the treatment of severe spinal deformity. Spine (Phila Pa 1976) 33:23052309, 2008

    • Search Google Scholar
    • Export Citation
  • 27

    Stagnara P: [Cranial traction using the “Halo” of Rancho Los Amigos.] Rev Chir Orthop Reparatrice Appar Mot 57:287300, 1971 (French)

    • Search Google Scholar
    • Export Citation
  • 28

    Sucato DJ: Management of severe spinal deformity: scoliosis and kyphosis. Spine (Phila Pa 1976) 35:21862192, 2010

  • 29

    Taddonio RF Jr, King AG: Atlantoaxial rotatory fixation after decompressive laminectomy. A case report. Spine (Phila Pa 1976) 7:540544, 1982

    • Search Google Scholar
    • Export Citation
  • 30

    Yamamuro Y, Demura S, Murakami H, Kato S, Yonezawa N, Yokogawa N, : Acute progressive adolescent idiopathic cervical kyphosis: case report. J Neurosurg Spine 30:783787, 2019

    • Search Google Scholar
    • Export Citation
  • 31

    Yang C, Wang H, Zheng Z, Zhang Z, Wang J, Liu H, : Halo-gravity traction in the treatment of severe spinal deformity: a systematic review and meta-analysis. Eur Spine J 26:18101816, 2017

    • Search Google Scholar
    • Export Citation
  • 32

    Zeng H, Liang Y, Wang X, Shen X, Luo C, Xu Z, : Halo traction, single-segment circumferential fixation treating cervical tubercular spondylitis with kyphosis. Clin Neurol Neurosurg 138:5965, 2015

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 243 243 76
Full Text Views 52 52 12
PDF Downloads 59 59 11
EPUB Downloads 0 0 0