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

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>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).</jats:p><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>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.</jats:p></jats:sec>

Atlantoaxial rotatory fixation in childhood: a staged management strategy incorporating manipulation under anaesthesia

“…Early diagnosis and effective initial reduction are key to successful management of AARF in childhood [10,12,[14][15][16][17]. In many instances, this can be achieved through simple conservative measures, comprising analgesia, muscle relaxants and collars without MUA [21,22]. However, where torticollis does not resolve promptly, escalation of treatment is essential as delay is a significant factor in poor long-term outcome [15,19].…”

“…The two main options for achieving closed reduction are traction (Halter or skull traction) and MUA with radiographic screening [12,[21][22][23][24]. Whilst there are reports of successful outcomes using traction, patient compliance particularly in the very young will not infrequently preclude its use in the awake patient.…”

Systematic review of the nonsurgical management of atlantoaxial rotatory fixation in childhood

“…In many instances, AARF is managed with simple nonsurgical measures such as analgesia, muscle relaxants, and collars without manipulation under anesthesia (MUA). 24,53 However, where torticollis does not resolve promptly, escalation of treatment to include either nonsurgical reduction or surgical intervention is generally considered essential to avoid a poor long-term outcome. There was no consensus on the method of reduction among the different studies.…”

Os odontoideum

“…[ 4 , 8 , 35 , 87 ] Immobilization consisting of collar fixation or cervical traction can also be utilized. [ 6 , 88 ] Numerous reports have documented successful cases of long-term conservative management for patients with stable OO. [ 1 , 7 , 89 , 90 ] Conversely, cases of neurological deterioration and sudden death have also been documented.…”