Preoperative management through modified halo-pelvic distraction assembly in a case of severe thoracic spine kyphosis
- Department of Orthopedics and Spine Surgery, Ghurki Trust Teaching Hospital, Lahore, Punjab, Pakistan
- Department of Anatomy, University of Health Sciences, Lahore, Punjab, Pakistan
DOI:10.25259/SNI_254_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Muhammad Saad Ilyas1, Abdullah Shah1, Aftab Rahim Afridi1, Uruj Zehra2, Ijaz Ahmad1, Amer Aziz1. Preoperative management through modified halo-pelvic distraction assembly in a case of severe thoracic spine kyphosis. 14-Jun-2021;12:290
How to cite this URL: Muhammad Saad Ilyas1, Abdullah Shah1, Aftab Rahim Afridi1, Uruj Zehra2, Ijaz Ahmad1, Amer Aziz1. Preoperative management through modified halo-pelvic distraction assembly in a case of severe thoracic spine kyphosis. 14-Jun-2021;12:290. Available from: https://surgicalneurologyint.com/surgicalint-articles/10877/
Background: Halo-traction device has been seen with favorable outcome in managing the patients with severe kyphotic deformities preoperatively, however, associated complications are inevitable. Slight modifications can improve the outcome and clinical efficacy.
Case Description: A 14-year-old boy was presented with severe kyphotic deformity of 141° from T1 to T10 thoracic vertebrae with diffuse paraspinal calcification in thoracic spine and complete loss of power of both lower limbs. A modified halo-pelvic distraction device was applied before the definitive surgery. The device comprised halo and pelvic assembly, the halo ring was connected to the head with 06 pins, while pelvic assembly had Ilizarov half pins connected to the arches. The assembly construct had four threaded rods, two of them were placed anterolateral and the other two were posterolateral. Distraction at the rate of 3 mm/day was started from 1st postoperative day for 35 days. The neurology improved in both lower limbs and kyphotic angle reduced to 56° from 141°. Surgery at this stage was done and a standalone solid titanium cage was placed from T1 to T10 vertebral body after debridement. No peri- or post-operative complications were observed.
Conclusion: The application of halo-pelvic distraction before corrective surgeries can not only reduce the severity of the kyphotic deformity making the definitive surgery easy but neurology can also be improved. The high-risk complications associated with acute correction of deformities can be minimized using our modified halo-pelvic distraction device.
Keywords: Halo-pelvic distraction, Kyphosis, Spine
The management of severe form of kyphosis is always a challenge for spine surgeons considering the associated risk of pulmonary complications, high potential for bleeding, and related neurological complications.[
Later on, the technique was improved and a pelvic ring was used that secured the two halves of the pelvis by two threaded pins traversing the whole length of the pelvis. The extension bars fitted to the halo and pelvic rings were gradually elongated to provide fixation and distraction. The powerful corrective forces could be applied through this technique while the patient remained mobile during treatment.[
Recently, a few studies have published the outcome of self-designed halo-pelvic ring on patients with severe kyphotic deformities and showed satisfactory results, but few complications still persist.[
A 14-year-old boy was presented in outpatient department with severe kyphotic deformity of the thoracic spine and complete loss of power of both lower limbs. The patient had a history of a progressively increasing kyphotic deformity since the age of 4 years, almost 4–5 months back, he started developing weakness of both legs.
On physical examination, bossing of the thoracic cage was observed with short abdomen and both iliac crest almost touching the ribs [
Radiographic picture of spine showed severe kyphosis of 141° from T1 to T10 thoracic vertebrae on lateral view with diffuse paraspinal calcifications, most likely representing a granulomatous lesion [Figure1b]. MRI revealed acute angle kyphotic deformity appreciated at the upper-mid dorsal spine due to multiple deshaped dorsal vertebrae (starting from T1 down till T10), resulting in significant canal narrowing posteriorly with cord compression and compressive myelopathic changes. Abnormal marrow signals were appreciated in vertebrae with pathological reduction in their heights, with indistinct/eroded adjacent end plates and involved intervening discs, suggesting squeal of chronic disco vertebral osteomyelitis (caries spine).
Pathological necrotic tissue was also appreciated in pre- and paravertebral spaces at the affected levels. Similarly, variable sized paraspinal collections were identified with areas of low-intensity signals/signal void suggested chronic calcified component [
Distraction using a modified halo-pelvic distraction assembly was planned to stretch out the soft tissues aiming to decrease the severity of the deformity and compression on the spinal cord and to improve the neurology.
Modified halo-pelvic distraction assembly and its application
An assembly was prepared with the following modifications:
Pelvic ring was substituted with two lateral arches which allowed the patient to lie supine in bed. Supra-acetabular region was chosen for half pin placement which provided a sturdy anchorage and gave a strong construct. Muscles were not pierced for the placement of wires or pins that minimized the risk of infection and pain. The assembly construct had four rods, two of them were placed anterolateral and the other two were posterolateral. The aim was to provide balanced distraction forces so that the sagittal or coronal balance should not be affected.
Pelvic ring was substituted with two lateral arches which allowed the patient to lie supine in bed.
Supra-acetabular region was chosen for half pin placement which provided a sturdy anchorage and gave a strong construct.
Muscles were not pierced for the placement of wires or pins that minimized the risk of infection and pain.
The assembly construct had four rods, two of them were placed anterolateral and the other two were posterolateral. The aim was to provide balanced distraction forces so that the sagittal or coronal balance should not be affected.
A halo ring according to the head size was chosen and connected to the head with 06 threaded pins.
A total of four Ilizarov half pins were used in the pelvic assembly. Two Ilizarov half pins of 6 mm each were passed in the supra acetabular area one on both sides. Anterior inferior iliac spine was approached through blunt dissection after giving a 2 cm incision, almost 2 cm below and medial to the anterior superior iliac spine (ASIS) on both sides. The outer cortex at anterior inferior iliac spine was drilled with a 4 mm drill bit and a 6 mm half pin was passed using a T handle.
The 2nd site for half pin placement was about 10 cm posterior to the ASIS. After making a small incision, the outer cortex was drilled and a 6 mm half pin was passed in between the inner and outer tables of the iliac bone on both sides using a T handle. Both half pins on either side were connected to an Ilizarov arch using male posts and rancho cubes. Both arches were connected with each other through two threaded rods to strengthen the construct [
Distraction device consisted of four threaded rods, two anterolateral and two posterolateral connecting pelvic assembly to the halo assembly.
Distraction was started on the 1st postoperative day at the rate of 3 mm per day divided in three intervals of 1 mm each. On the 5th postoperative day, the patient started to move his right foot and started to feel touch sensations in his right leg. Distraction was continued at this constant pace of 3 mm per day for 35 days. The patient was closely monitored for his progress by getting weekly X-rays of the spine and measuring the trunk height and kyphotic angle.
After 35 days of distraction, rib hump and thoracic knuckle markedly improved and Cobb angle reduced from 141° to 56° [
At this time, resection of vertebral bodies, thorough debridement and stabilization using a vertebral standalone cage through anterior approach, was planned and surgery was performed by the senior author (AA). A cage was placed from T1 to T10 vertebral body after debridement [
GeneXpert analysis of the tissue revealed multidrug-resistant tuberculosis. Postoperatively, the patient is doing well and put on 2nd line antituberculous therapy.
The standard surgical technique for severe kyphotic deformity is associated with serious complications. Preoperative correction through halo-pelvic distraction can reduce the risk of perioperative and postoperative complications and can significantly reduce the kyphotic deformity.[
Two out of four Ilizarov half pins were placed in the supraacetabular area instead of only placing them in ilium or iliac crest[
To the best of our knowledge, this is the 1st time modified halo-pelvic distraction device has used the antero- and postero-lateral rods for the provision of balanced distraction force and for maintaining sagittal and coronal balance. A recently published report on modified halo-pelvic assembly reported cervical discomfort and negative sagittal balance in patients managed with their modified assembly. Their distraction assembly used only anterolateral rods which might have hyperextended the cervical region and caused these symptoms,[
Most neurologic complications, such as cranial nerve injuries and paraplegia, are known to occur as a result of high distraction forces,[
The halo-pelvic distraction can make intraoperative instrumentation easy for surgeons, during correction surgery, due to adjusted paraspinal musculature and lengthened spinal canal hence reducing surgery time.[
Considering the excellent outcome in the current case, it is hoped that this modified assembly may help surgeons who are involved in the treatment of rigid scoliosis.
The preoperative management of severe kyphotic deformity through our modified halo-pelvic distraction device can significantly decrease the perioperative and postoperative complications associated with corrective surgeries. The application of halo-pelvic distraction before corrective surgeries can not only reduce the severity of the kyphotic deformity making the definitive surgery easy but also improve the patient’s subsequent neurological examination. The high-risk complications associated with acute correction of deformities can be minimized using our modified halo-pelvic distraction device.
1. Dove J, Hsu LC, Yau AC. The cervical spine after halo-pelvic traction. An analysis of the complications of 83 patients. J Bone Joint Surg Br. 1980. 62-b: 158-61
2. Erdem MN, Oltulu I, Karaca S, Sari S, Aydogan M. Intraoperative halo-femoral traction in surgical treatment of adolescent idiopathic scoliosis curves between 70° and 90°: Is it effective?. Asian Spine J. 2018. 12: 678-85
3. Hsu LC. Halo-pelvic traction: A means of correcting severe spinal deformities. Hong Kong Med J. 2014. 20: 358-9
4. Hwang CJ, Kim DG, Lee CS, Lee DH, Cho JH, Park JW. Preoperative halo traction for severe scoliosis. Spine (Phila Pa 1976). 2020. 45: E1158-65
5. 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. 2012. 21: 514-29
6. Muheremu A, Ma Y, Ma Y, Ma J, Cheng J, Xie J. Halo-pelvic traction for severe kyphotic deformity secondary to spinal tuberculosis. Medicine (Baltimore). 2017. 96: e7491
7. Neal KM, Siegall E. Strategies for surgical management of large, stiff spinal deformities in children. J Am Acad Orthop Surg. 2017. 25: e70-8
8. O’Brien JP, Yau AC, Smith TK, Hodgson AR. Halo pelvic traction. A preliminary report on a method of external skeletal fixation for correcting deformities and maintaining fixation of the spine. J Bone Joint Surg Br. 1971. 53: 217-29
9. Qi L, Xu B, Li C, Wang Y. Clinical efficacy of short-term pre-operative halo-pelvic traction in the treatment of severe spinal deformities complicated with respiratory dysfunction. BMC Musculoskelet Disord. 2020. 21: 665
10. Qin Y, Sun R, Wu C, Wang L, Zhang C. Exosome: A novel approach to stimulate bone regeneration through regulation of osteogenesis and angiogenesis. Int J Mol Sci. 2016. 17: 712
11. Wang Y, Li C, Liu L, Qi L. Halo-pelvic traction for extreme lumbar kyphosis: 3 rare cases with a completely folded lumbar spine. Acta Orthop. 2020. 92: 9-14
12. 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. 2017. 26: 1810-6