CHAPTER
117
Role of Halo Traction and
Halo-Femoral Traction in Paralytic/
Neuromuscular Scoliosis
INTRODUCTION
Axial traction to correct spinal deformity is not a new concept;
in fact, the first applications were reported in ancient Hindu
mythological epics (3500 to 1800 BC).11 Traction for spinal
deformity correction fell into disfavor due to the production of
spinal cord injury and paraplegia created by the application of
excessive distraction to the spine. Over the last few decades,
with refinement in the knowledge of spinal anatomy and bio-
mechanics, the concept of controlled axial traction has regained
attention with the use of the Harrington outrigger, Cotrel trac-
tion, and halo traction. This chapter will outline the three most
commonly applied techniques of spinal traction currently in
use: preoperative halo-gravity traction, intraoperative halo-
femoral traction (IHFT), and the internal distraction tech-
nique (Table 117.1).
PREOPERATIVE HALO-GRAVITY
TRACTION
Spinal traction takes advantage of the viscoelastic properties of
the spinal column. After traction application, an immediate ini-
tial correction occurs and is likely due to the elasticity (or stiff-
ness) of tissues and is then secondarily followed by a creep
phase, in which most of the correction is achieved. In the 1960s,
Cotrel reintroduced the use of preoperative traction, utilizing
a pelvic sling with a head halter, to improve the overall spinal
correction at the time of surgery and to minimize neurologic
deficits. The approach was routinely used in many centers in
the 1960s and 1970s but lost favor after several centers demon-
strated no benefit for this type of preoperative traction when
used prior to surgery with Harrington instrumentation. Since
that time four other general techniques of preoperative axial
spinal traction have been reported: halo-femoral, halo-pelvic,
halo-tibial, and halo-gravity.3,9,10,15,16,20
The addition of a distal femoral or tibial traction pin into
one or both legs permits a high level of distraction to be
applied. Correction of coronal spine deformities has been
reported to be 41% to 57% with 53% correction of pelvic obliq-
LWBK836_Ch117_p1265-1278.indd 1265
Scott J. Luhmann
David L. Skaggs
uity.3,10 In addition to the expected halo-related complications
and traction-related complications, this form of traction, due to
the need for extended bed rest and the presence of a distal
traction pin in the appendicular skeleton, has had complica-
tions in up to 81% of patients, consisting of dislocations of the
hip, deep vein thrombosis, extremity fractures after traction
removal, peripheral nerve traction injuries, paraplegia, and
pressure sores.3,10,14 Because of the high rate of complications,
these two types of traction have fallen out of common use; how-
ever, this method has been advocated for use intraoperatively.
A second method of distal fixation was the use of pelvic fixa-
tion via half pins or small wires. With pelvic fixation, the most
common complication is pelvic pin site infections/loosening,
but unique to this method of fixation are the complications of
peritoneal penetration and/or perforation of the intestine,20
ischemic necrosis of odontoid process, cranial neuropraxias,
hip contractures, and superior mesenteric artery syndrome.
Lastly, long-term pathologic changes of the cervical spine have
been reported in more than 50% of patients.21 The main rea-
son for these unique complications in the cervical spine is the
ability to exert high, long-term traction when the pelvis is used
as an anchor point.
With evolution in spine instrumentation, from Harrington
rods to third-generation Cotrel--Dubousset instrumentation,
the need for routine preoperative traction has declined. Despite
the overall decline in the use of preoperative traction, halo-
gravity traction has become more popular and has been shown
to be effective in the treatment of complicated spinal deformi-
ties.8,15 As opposed to the other methods mentioned, this alter-
native technique uses the patients body weight as a counter-
force to the halo traction. The patient can not only use the
traction in bed but also can ambulate with the use of a modi-
fied walker or wheelchair. In addition, the individual can par-
ticipate in a physiotherapy program (Fig. 117.1) to improve
pulmonary function and overall fitness. This traction can be
used before a single-stage anterior or posterior fusion and also
between stages of circumferential spine fusions.23
The strengths/weakness and indications and contraindica-
tions for this method of traction are listed in Tables 117.2 and
117.3. The impact of traction on pulmonary function deserves
1265
8/25/11 10:06:21 PM
 1266 Section X Paralytic Deformity

TABLE 117.1 Strengths and Weaknesses of Traction

Preoperative halo gravity
Intraoperative halo femoral
Internal distraction
Strengths
1. Permits gradual application of traction
2. Correction while patient is awake
3. Low risk of neurologic problems
1. Preoperative hospitalization unnecessary
2. Can easily adjust traction force to achieve
desired correction
3. Improves pelvic obliquity
4. Decreases operative time
1. No external force application
Weaknesses
1. Requires weeks or months of continuous, daily
treatment
2. Pin site issues
3. Contraindicated for cervical and occipitocervical
instability
1. Additional operative time for halo application and
traction pin insertion with scarring
2. Contraindicated for cervical or occipitocervical
instability
3. Relative contraindication with kyphotic deformity
1. Shorter-term application of traction; less stress
relaxation and creep

further comment. In severe scoliosis and kyphoscoliosis, poor
pulmonary function is, in part, due to the restrictive spinal
deformity. With the application of halo-gravity traction, pulmo-
nary function has been demonstrated to improve signifi-
cantly.15--17 Pulmonary function tests (PFTs) obtained during
preoperative traction can be helpful in documenting improve-
ments in pulmonary function and should be considered in the
timing of surgical intervention. The other less obvious issue is
the positive impact on the patients overall medical cardiopul-
monary fitness, above the obvious quantitative improvement in
PFTs and nutritional status.18
COMPLICATIONS AND MANAGEMENT
Complications with the use of halo-gravity traction can be bro-
ken down into halo-related complications and traction-related
problems.15 The technique of halo application and its care
appear deceptively simple; however, there are many pitfalls one
can encounter. The most common complication is pin loosen-
ing, occurring up to 87% of the time.6,10,15,16 Anterior pins
loosen most commonly and, in the absence of infection, can be
retightened by advancing one to two revolutions. If this does not
tighten then the pin should be removed and shifted to another
location. If the pin advances too far, intracranial penetration
can occur in up to 4% of patients.6,7 Secondary brain abscesses
have been reported after intracranial pin penetration.
Another common pin site--related complications reported
are superficial and deep infections, which occur in 39% to 59%
of children.6,10,15,16 Superficial infections are much more com-
mon than deep infections and are not typically associated with
pin loosening. Treatment typically consists of a short course of
oral antibiotics (7 days of cephalexin) with or without pin
removal. However, deep infections or persistent superficial
infections require pin removal, irrigation and debridement of
the pin site, placement of a new pin site, and intravenous anti-
biotics. Other less common pin site complications are superior
migration of the halo due to inappropriate position above the
equator of the cranium, skin necrosis, anterior pin site scar-
ring, pin site pain, and injury to the supraorbital nerve.6,7
Traction-related complications appear to be related to the
duration of traction and the amount of traction applied to the
spine. Excessively fast correction of scoliosis and kyphoscoliosis
increases the risk of neurologic injury. This risk is increased
with the presence of intraspinal anomalies or previous spinal
surgery. MacEwen et al reported six cases of preoperative para-
plegia related halo-femoral or halo-pelvic traction.12 One of the
more common problems are cranial nerve palsies, which have
been reported for the trochlear (IV), abducens (VI), glossopha-
ryngeal (IX), vagus (X), and hypoglossal (XII) nerves both as
isolated and combined deficits.12,24 Of the cranial nerve inju-
ries, the most common palsy is the loss of lateral gaze secondary
to traction on cranial nerve VI.2,10,12,24 The usual course of cra-
nial nerve palsy is resolution within 6 to 10 weeks of
onset.2,12,24

Figure 117.1. Patient on treadmill in traction setup.
CLINICAL EVIDENCE
Several clinical reports have demonstrated the safety and effi-
cacy of halo-gravity traction. Rinella et al reported a retrospec-
tive analysis of 33 patients who had preoperative halo-gravity
traction prior to posterior spinal fusion for severe coronal and

LWBK836_Ch117_p1265-1278.indd 1266 8/25/11 10:06:21 PM

 Chapter 117 Role of Halo Traction and Halo-Femoral Traction in Paralytic/Neuromuscular Scoliosis
TABLE 117.2 Strengths and Weakness of Halo-Gravity Traction
Strengths
Noninvasive technique
Traction performed on awake, alert patient permits early detection of
neurological symptoms (i.e., cranial nerve weakness or deficits)
Most effective on more cephalad deformities (i.e., cervical,
cervicothoracic, proximal thoracic)
Effective for gradual correction of sagittal and coronal plane deformities
Improves truncal alignment by centering the head over the pelvis
Low rate of complications
Overall patient tolerance
Permits improvement of pulmonary function
Eventual instrumentation and fusion easier due to lesser degree of spinal
deformity
sagittal plane deformities.15 Mean preoperative coronal curve
magnitude was 84, which improved 46% down to 46, and
mean thoracic kyphosis decreased 33. The mean increase in
spinal length, as measured by the distance from C7 to S1
increased 6.3 cm. There were no permanent neurologic com-
plications. There were seven halo-related problems: four cases
of halo pin loosening requiring replacement, one infected pin
site, one case of nystagmus, and one case of nausea and vomit-
ing. Sink et al reported a review of 19 patients with severe sco-
liosis whose pretreatment coronal Cobb was 83.16 Traction was
utilized for a mean 13 weeks (6 to 28 weeks) with an improve-
ment of the coronal Cobb to 55 (35% improvement). Trunk
decompensation improved in all patients, and the average
increase in trunk height was 5.3 cm. Janus et al reported on 20
osteogenesis imperfecta patients treated with preoperative
halo-gravity traction. Mean prehalo Cobb of 78 decreased to
53 prior to surgery (32% improvement).9 These three reports
did not document any permanent neurologic complications
and concluded that preoperative halo-gravity traction improves
trunk balance and coronal and sagittal alignment in children
with severe spinal deformity.
DESCRIPTION OF TECHNIQUE
Prior to the initiation of halo-gravity traction a thorough neu-
rological assessment is essential, not only to identify any find-
ings suggestive of an intraspinal anomaly but also to establish a
baseline to which neurological examination during the trac-
tion treatment can be compared. Strong consideration should
Indications and
TABLE 117.3 Contraindications of
Halo-Gravity Traction
Indications Contraindications
Severe scoliosis or kyphoscoliosis Occipitocervical or cervical
Previously failed spinal fusion instability
surgery
Significant truncal
decompensation
Poor pulmonary function due to
restrictive spinal deformity
LWBK836_Ch117_p1265-1278.indd 1267
1267
Weaknesses
Pin site problems
Requires traction be applied through occipitocervical junction
and cervical spine
Less effective on thoracolumbar and lumbar deformities
Less effective for patients with increased tone or spasticity
Requires intellectually and behaviorally competent individual
Typically requires inpatient hospital treatment; challenges of
coverage of treatment by third-party payers.
be given to obtaining magnetic resonance imaging (MRI) of
entire neuraxis prior to traction for severe spinal deformity.
The placement of the halo is done in the operating room
under deep sedation or general anesthesia, which minimizes
patient movement and pain/distress (Fig. 117.2). In patients
with small or misshapen craniums placement of the halo can be
challenging, hence a full complement of sizes and pin configu-
rations must be available. Placement of the halo must be just
above the eyebrows and earlobes, which in most patients will
put the halo caudal to equator of cranium, which will prevent
cranial migration of halo. The ring should be no greater than
1 cm away from the skin to minimize cantilevering of the pins
on the ring, and there should be no contact of the ring with the
ear as skin necrosis is a possible complication. The anterior
pins are positioned over the lateral one third of eyebrows to
avoid the supraorbital and supratrochlear nerves and frontal
sinus. More lateral pin placement risks injury to the temporal
artery and thin temporal bone. If patient has undergone previ-
ous hydrocephalus surgery, one should look for the subcutane-
ous ventricular shunt tubing prior to halo application. The pos-
terior pins should be placed across halo on opposite side of
Figure 117.2. Application of halo under anesthesia in the operat-
ing room.
8/25/11 10:06:22 PM
 1268 Section X Paralytic Deformity

anterior pins, typically behind the upper, outer region of the

earlobe.
Typically four or six pins (two anteriorly, and two or four
pins posteriorly) are sufficient for most patients. In patients
with a lower traction weight goal (20% total body weight),
shorter planned traction length (i.e., 4 weeks), normal bone
mass and quality, and older age (>11 years) four pins are usu-
ally sufficient. However, the age at which it is safer to shift
between four pins and multiple pins (six to eight) has not been
established.6,13 After identification of the appropriate number
and placement of the pins, the pins are advanced sequentially
from finger- tightness to the final tension in 2 inch/lbs incre-
ments. Usually pin insertion torque of 6 to 8 inch/lbs is ade-
quate in older patients, less in younger children (i.e., 4 inch/
lbs), and only to finger tightness or 2 inch/lbs in infants/tod-
dlers.13 Extreme care must be exercised with loose pins, and in
general retightening pins after 24 to 48 hours is not recom-
mended due to the risk of cranial penetration. If there is a
symptomatic loose pin, removing the symptomatic pin and
placing a pin in a new site nearby should be considered.
Once the halo is applied, the traction is applied through
either a rope/pulley/weight apparatus or a scale device (Figs.
117.3 and 117.4). Approximately 3 to 5 lbs of traction is initially
applied immediately after the halo is applied. The traction
weight is then increased in a scheduled fashion (1 to 3 lbs/d)
until the desired weight goal is achieved. For most patients, the
goal should be between 30% and 45% of body weight (Figs.
117.5A to D). If the patient is at high risk for development of a Figure 117.4. Traction setup utilizing scale as used by Texas
neurological deficit due to existing myelopathy, severe spinal Scottish Rite Hospital. (Courtesy of Dan Sucato, MD).
deformity (i.e., kyphoscoliosis), or multiple previous spine sur-
geries, then a slower rate of weight increase is recommended.
Typically, the goal is for the younger, smaller patients to be almost levitating off their chairs with minimal contact of their
buttocks with the chair.15,16 By doing so, the maximal amount of
force can be applied to the spinal deformity. Traction is applied
for a minimum of 12 hours a day, and the weight is decreased
to 50% to 75% at bedtime, mainly to decrease the proximal
migration of the patient in bed. The pin sites are treated by
shower cleansing without any direct cleaning of the pin sites
with hydrogen peroxide, Betadine, or other topical solution or
ointment.
Neurological assessment is performed every 8 hours. Cranial
nerve assessment (especially abducens) and neurologic exami-
nation of the upper and lower extremities (motor and sensory
examinations) should be performed by the nursing staff and
any changes should be immediately reported. Physiotherapists
should work with these patients on a daily basis to assist in
mobilization with the use of walkers and adapted treadmills,
which provide continuous traction (Fig. 117.1). The traction
apparatus on treadmill permits the patient to exercise, improv-
ing pulmonary function and increasing patients aerobic fitness
while limiting the effect of osteoporosis, which has plagued
other forms of preoperative traction methods. The duration of
preoperative traction is 2 to 12 weeks depending on overall
patient health, medical comorbidities, and the response of the
curves to traction. Extended courses of traction (8 to 12 weeks)
are often performed to optimize pulmonary function and nutri-
tion (and not only to improve curve correction).

PEARLS AND PITFALLS

1. The anterior halo pins should be placed over the lateral one
Figure 117.3. Traction setup with weights on walker. third of the eyebrows to avoid the supraorbital nerve. The

LWBK836_Ch117_p1265-1278.indd 1268 8/25/11 10:06:23 PM

 Chapter 117 Role of Halo Traction and Halo-Femoral Traction in Paralytic/Neuromuscular Scoliosis 1269

A B C

D E F

Figure 117.5. A 9-year-old boy status post multiple previous anterior and posterior thoracic fusions with
postoperative progression to severe kyphoscoliosis with 263 of combined coronal and sagittal deformity.
(A and B) Pretraction erect anteroposterior and lateral radiographs. (C and D) After 25 lbs traction demon-
strating a 20% overall improvement of deformity (263 pretraction to 211 in traction). (E, and F) 2 years
after posterior spinal fusion.

LWBK836_Ch117_p1265-1278.indd 1269 8/25/11 10:06:24 PM

 1270 Section X Paralytic Deformity

posterior pins should be placed directly opposite to the ante-

Strengths and Weaknesses of
rior pins. All pins should be placed below the equator of skull
TABLE 117.4 Intraoperative Halo-Femoral
to prevent superior migration of halo during traction.
2. Initial traction weight should be between 3 and 5 lbs and Traction
then increased sequentially.
Strengths Weaknesses
3. Frequent nursing neurological assessments (every 8 hours)
are necessary. Effective on all types of Necessity of supraorbital and
4. Pin site problems occur; the most common pin site compli- neuromuscular patients distal femoral pins with
cations are superficial infections, which can be treated with regardless of diagnosis secondary scarring
oral antibiotics. Improves truncal alignment by Requires traction be applied
5. One should exercise caution when retightening pins to pre- centering the head over the through occipitocervical
pelvis junction and cervical spine
vent intracranial pin placement.
Effective on all deformities Requires 15 min of additional
6. Neurological problems most commonly are cranial nerve
regardless of location time preincision to place
and temporary. halo- and distal femoral
7. Preoperative halo-gravity traction can be a useful tool in the traction pin
treatment of severe scoliosis and kyphoscoliosis with a low Corrects pelvic obliquity Risk of intracranial placement
rate of temporary complications. of halo pins due to
osteopenic cranium
Eventual instrumentation and
INTRAOPERATIVE HALO-FEMORAL fusion easier due to lesser
TRACTION degree of spinal deformity
Low rate of complications
No need for preoperative
As mentioned in the previous section, the use of preoperative
traction
halo-femoral/pelvic/tibial traction has been shown to have an
Patients head can hang free in
unacceptably high complication.3,10,14 Despite this, the tech- traction eliminating any
nique has shown to be effective in preoperatively correcting pressure over the eyes
coronal deformities (41% to 57%) and pelvic obliquity (up to
53%).3,10 By using this method intraoperatively, one can avoid
the problems associated with long-term traction yet gain the
benefits of direct axial traction during the surgical procedure. COMPLICATIONS AND MANAGEMENT
In nonambulatory neuromuscular scoliosis (i.e., cerebral
palsy, spinal muscle atrophy, myelomeningocele, muscular dys- Little information exists on complications of IHFT. Since the
trophy), progressive scoliosis with long, sweeping thoracolum- traction is applied for only one surgical procedure, complica-
bar curves can cause significant pelvic obliquity, which can cre- tions related to extended traction are not experienced (i.e., pin
ate sitting imbalance and, more problematically, recalcitrant site or traction pin infection, pin loosening, etc.). Theoreti-
pressure sores and pain. This problem is potentiated by abnor- cally, it is possible with the distal femoral traction pin to injure
mal protective skin sensation and the typically low muscle mass. the distal femoral physis, posterior neurovascular structures,
The goal of surgical treatment of this population is different and to create an iatrogenic femur fracture; however, these com-
than for the idiopathic scoliosis patients, specifically to correct plications have not been reported in published reports of
the pelvic obliquity and to obtain, and maintain, a painless, IHFT.
well-balanced spine above the pelvis. Hence, the aim is to estab-
lish a good sitting balance. Most reports on the surgical treat- CLINICAL EVIDENCE
ment of neuromuscular scoliosis (myelomeningocele, cerebral
palsy, Duchennes muscular dystrophy) recommend correction Takeshita et al reported a retrospective case-control study com-
of the pelvic obliquity and fusion to the sacrum when sitting paring outcomes of neuromuscular patients undergoing spine
imbalance is severe.1,23 fusion with and without IHFT.19 In the control group (n = 20),
The strengths/weakness and indications/contraindications the mean preoperative pelvic obliquity was 17, which improved
for this method of traction are listed in Tables 117.4 and 117.5. to 7 postoperatively (52%). The mean preoperative pelvic
The major challenge in the surgical correction of neuromuscu- obliquity in the halo-femoral traction group (n = 20) was 26,
lar scoliosis is how to obtain spinal correction and, secondarily, which improved to 6 postoperatively (78% improvement); a
how to maintain this alignment during the postoperative
period. Osteopenia is a common problem, which, when pres-
ent, poses challenges in how to obtain spinal correction. In Indications and
those patients with large, stiff curves, the addition of an ante- Contraindications of
rior release increased curve flexibility and permitted better cor- TABLE 117.5 Intraoperative Halo-Femoral
rection. The use of IHFT allows direct skeletal traction and cor- Traction
rection of the spinal deformity and pelvic obliquity (Fig. 117.6).
During the surgical procedure, most, if not all, of the correc- Indications Contraindications
tion is obtained by the IHFT obviating the need for significant
spinal implant manipulation for correction. By offloading the Nonambulatory Occipitocervical or cervical instability
neuromuscular Significant kyphosis or kyphoscoliosis
implants, the chance of loosening and losing fixation at the
scoliosis
bone--implant interface is lessened.

LWBK836_Ch117_p1265-1278.indd 1270 8/25/11 10:06:26 PM

 Chapter 117 Role of Halo Traction and Halo-Femoral Traction in Paralytic/Neuromuscular Scoliosis 1271

A B C

Figure 117.6. A 14-year-old boy with spastic quadriplegic cerebral palsy with pain and sit-
ting problems due to scoliosis and pelvic obliquity. (A and B) Preoperative upright anteroposte-
rior and lateral radiographs with 97 lumbar curve and severe pelvic obliquity. (C and D) 1 year
postoperative upright radiographs after posterior spinal fusion with intraoperative halo-femoral
D
traction but no anterior release. Note level pelvis and good sagittal and coronal spinal balance.

statistically significant difference (p = .001). There were no
reported intraoperative or postoperative halo-femoral traction-
related complications (i.e., femoral fractures, pin site infec-
tions, pin cutout, etc.) (Figs. 117.6A to D). Vialle et al reported
on 110 patients with cerebral palsy who underwent posterior
spinal fusion.22 The initial 59 control patients underwent
routine posterior spinal fusion with the next 51 consecutive
patients having IHFT with lower extremity skin traction. The
traction group had shorter operative times (282 minutes vs. 335
minutes), less intraoperative maneuvers necessary for leveling
the pelvis, better coronal Cobb correction (63% vs. 44%), and
better correction of pelvic obliquity (81% vs. 56%). Direct

LWBK836_Ch117_p1265-1278.indd 1271 8/25/11 10:06:26 PM

 1272 Section X Paralytic Deformity

skeletal fixation appears to be optimal (i.e., halo and skeletal

pin fixation) to exert enough axial force to the spine and min-
imizing skin complications.

DESCRIPTION OF TECHNIQUE
The application of the halo frame was described earlier in this
chapter. Similar to the halo, the distal femoral traction pin is
placed during, or immediately after induction of anesthesia to
minimize delay in the start of surgery. The traction pin is inserted
into the femur on the side of the elevated hemipelvis. Typically,
a threaded pin approximately 2 mm or larger is utilized. Smooth
pins may slide medially or laterally during the surgical procedure
and permit the traction bow to apply direct pressure to the skin
and cause skin breakdown. Similarly, larger traction bows are rec-
ommended to minimize the pressure, and the bow may be placed
over the tibial tubercle during the application of traction.
While the patient is in the supine position, prior to turning
the patient prone, the pin entry sites are localized just proximal
to the femoral epicondyle. This minimizes the likelihood of iat-
rogenically injuring the distal femoral physis. Medial to lateral
placement also minimizes likelihood of an injury to posterior
neurovascular bundle. The pin can be placed with either a
manual hand drill or a power drill and should be placed per-
pendicular to the long axis of the femur. After securing the
traction pin to the bow, the ends of the pins should be heavily
padded to prevent skin injury to the contralateral limb
(Fig. 117.7). The patient is then placed in the prone position
on the four- or six-posterior Jackson frame. The traction is then
applied, with 15 lbs on the halo and 15 to 20 lbs on the femoral
traction pin (Fig. 117.8). Weight is increased, up to 30 lbs on
the femoral side, until the pelvic obliquity is corrected to a clin-
ically level position (Fig. 117.9). This correction of pelvic obliq-
uity can be confirmed clinically by palpating the upper margin
of the iliac wings or alternatively can be confirmed radiograph-
ically. It is important to recheck around the traction pin and
bow to ensure that no excessive pressure is present against the
skin medially, laterally, or more importantly over the tibial
tubercle. Unacceptable pressure over the tibial tubercle can be
rectified by placing gel pads or egg crate foam between the
traction bow and the skin and by flexing the knee and placing
more pillows under the legs and feet.
Figure 117.8. Intraoperative head-halo positioning permits the
face to be without any pressure as the halo rests on the clear plastic
face board.
In general, the weights should be fairly equal on both sides
to prevent the patient from migrating cephalad or caudad dur-
ing surgery. This can be partially countered by placing the
patient into a slight reverse-Trendelenburg position. The halo
and femoral traction pins are removed after the patient has
been placed supine after being moved from operative table.
PEARLS AND PITFALLS
1. Avoid placement of traction pin in the proximal tibia to pre-
vent iatrogenic damage to the proximal tibial physis.
2. Careful padding of the tip of the traction pins and the trac-
tion bow prevents lower extremity skin problems during sur-
gery.
3. Although pin cutout in osteoporotic bone is a concern, this
has not been demonstrated to occur. The use of lower trac-
tion weights applied through a centrally placed pin lowers
the likelihood of this from occurring.
4. Extreme care should be exercised in individuals without
neurological diagnoses (e.g., cerebral palsy, spinal muscle
atrophy, etc.) and in those with severe kyphosis and kyphosco-
liosis deformities. Neurologic deficits are a concern, and the
use of descending tract spinal cord monitoring is essential.

Figure 117.9. Intraoperative positioning of patients with 20 lbs of

Figure 117.7. Intraoperative demonstration of lower extremity traction weight applied to halo and 20 lbs to the distal femoral trac-
positioning with right distal femoral traction pin in place. tion bow.

LWBK836_Ch117_p1265-1278.indd 1272 8/25/11 10:06:28 PM

 Chapter 117 Role of Halo Traction and Halo-Femoral Traction in Paralytic/Neuromuscular Scoliosis 1273

TABLE 117.6 Strengths and Weaknesses of Internal Distraction Technique

Strengths Weaknesses
Effective on all types of patients regardless of diagnosis Does not automatically center the head over the pelvis
Applicable regardless of cervical spine instability (traction is not Distraction is acutely applied . . . does not permit secondary
applied through occipitocervical junction or cervical spine) viscoelastic improvement in deformity
Effective on thoracolumbar deformities Requires additional time and dissection to place TIDR anchors
Corrects pelvic obliquity Dorsally placed kyphosis-producing distractive technique. Need
accurate neuromonitoring
Eventual instrumentation and fusion easier due to lesser degree of Increased risk of deep infection for two-stage approach
spinal deformity
Low rate of complications
No need for preoperative traction
Avoids scarring and complications associated with halos and distal
traction pin
Gradual correction applied during surgery in many obviate need for
anterior release
Direct axial traction force applied to spine

TEMPORARY INTERNAL DISTRACTION the use of TIDR in a staged fashion (1 or 2 weeks later from the
primary surgery). However, Buchowski et al reported no neuro-
The use of temporary intraoperative distraction rods (TIDRs) logic complications or wound infections with this technique.4
for the correction of severe scoliosis was initially utilized during Another concern is compromising spine fixation points, such
the development of Harrington instrumentation by the use of as pedicle screws, when used for TIDR end points. To minimize
an outrigger, which could be applied intraoperatively. This con- this problem, avoid using pedicle screws as the cephalad fixa-
cept has recently regained interest as an alternative to preop- tion points for the TIDR construct and use ribs instead. The
erative halo-gravity or IHFT.4 The indication for TIDR is severe caudal fixation points are typically pedicle screws or the iliac
spinal deformity of the thoracic and lumbar spine, including wing. If pedicle screws are used then using two or three linked
severe pelvic obliquity. In general, in most instances in which pedicle screw that are not at the end of the construct will not
halo traction is considered for a thoracic or lumbar spinal compromise fixation at the lowest instrumented level.
deformity, a temporary rod may be also be considered. The
only absolute requirement is the presence of sufficient tempo-
CLINICAL EVIDENCE
rary bony fixation points in which to anchor the rods near the
top and bottom of the deformity. Anchor points may include Buchowski et al reviewed 10 patients, from 2 institutions, whose
the spine, pelvis, or ribs. This technique can be utilized in situ- surgical treatment utilized TIDR to improve the surgical out-
ation with cervical problems (i.e., deformity or instability) or comes of posterior spinal fusion for severe, complex rigid sco-
distal deformity (i.e., hip flexion deformity). The strengths/ liosis.4 All patients in this series had contraindications to
weakness and indications/contraindications for this method of traditional halo-gravity traction due to cervical instability,
traction are listed in Tables 117.6 and 117.7. kyphosis, or stenosis. All patients underwent primary posterior
release with six undergoing concomitant anterior release. Four
COMPLICATIONS AND MANAGEMENT of the patients had one surgical procedure (one distraction)
with six patients having staged treatment (two distractions).
At present, there is little information on complications with this Mean preoperative curve size was 104, mean distractive correc-
technique. The risk of wound infection is likely increased with tion was 53% (mean 49), and mean postoperative curve size
was 20 (80% improvement).
Indications and
TABLE 117.7 Contraindications of
DESCRIPTION OF TECHNIQUE
Internal Distraction
As opposed to the other two methods of traction, TIDR may be
Indications Contraindications performed in a two-stage fashion with the first stage consisting
of spinal releases (posterior or combined anterior/posterior)
Severe spinal deformity Lack of adequate fixation points for
(thoracolumbar) TIDR
and TIDR placement.4,5 Because of the recovery time between
Pelvic obliquity Inability to tolerate two-stage TIDR the two stages, it is imperative to maximize the chances of
due to medical comorbidities or returning to the operating room for completion of the surgical
poor nutritional status. plan. Preoperative medical evaluation (such as pulmonary, car-
Inability to neuromonitor the spinal diac, neurological) can be helpful depending on the patients
cord function during TIDR underlying medical condition. In addition to the routine pre-
Rigid kyphosis or kyphoscoliosis operative plain radiographic imaging (upright anteroposterior
Spinal cord abnormalities (syrinx, and lateral views and right and left supine side bending), trac-
diastematomyelia, tethered cord) tion films are particularly helpful in predicting the amount of

LWBK836_Ch117_p1265-1278.indd 1273 8/25/11 10:06:32 PM

 1274 Section X Paralytic Deformity

correction possible with TIDR. A general rule of thumb is that

the TIDR usually leads to greater correction of the deformity
than that demonstrated on traction radiograph, and if the cor-
onal curve improves more than 50%, then TIDR (or external
traction) is likely unnecessary. Because of the application of a
distraction force across the deformity, we recommend an MRI
of entire spine to evaluate for intraspinal abnormalities. Spinal
cord monitoring of the upper and lower extremities with soma-
tosensory-evoked potentials and neurogenic mixed--evoked or
transcranial motor--evoked potentials are absolutely necessary.
Preoperative planning should include evaluation of the
bony anchor points for the temporary rod. A basic principle in
choosing anchor points for the temporary rod is to expect that
these anchors will plow through bone a bit, compromising the Figure 117.10. The up-going hooks can be placed suprape-
riosteal as the neurovascular bundle present caudal to the ribs will
holding power of the final anchor. Thus, one should not plan
typically slide anterior to the rib during distraction.
to use the temporary anchors as permanent anchors at either
end vertebrae of the final construct. For example, pedicle
screws will plow upwards in the upper thoracic spine during
their use in securing a temporary rod, so these compromised
general, the apex of the iliac crest appears to be the best place
pedicles should not be used as end vertebrae anchor points in
(Fig. 117.12). If the anchor is lateral to the apex, then the
the final implant. Selection of the cephalad and caudal TIDR
anchor point may slip further laterally. In small children, the
sites is recommended to be one to two level above and below
lateral-cephalad iliac anchor location may be too small to accept
the most inclined vertebra (end Cobb vertebra), respectively.
an iliac screw, so an S hook is likely the best option for these
The upper portion of the rod is generally attached to the
patients.
ribs or the spine. When attaching to ribs, standard large spinal
One of the real advantages of the temporary rod technique
laminar hooks are used on two ribs to disperse the loads (Figs.
is that an anterior release is generally not needed, because cor-
117.7 and 117.8). An advantage of applying the temporary rod
rection through posterior surgery is generally sufficient.
to the ribs rather than the spine is that the spine is then left
However, if a surgeon chooses to perform an apical anterior
unobstructed to placement of the permanent rod while actively
release, this would be done before placement of the temporary
applying distraction to the ribs. A disadvantage of ribs as an
rod. Buchowski et al recommend a one-stage TIDR surgical
anchor point is that one cannot push quite as hard on ribs com-
procedure for most spinal deformities, reserving the two-stage
pared with the spine. If one chooses to use the spine as an
surgery for the most severe deformities. If two stages are
upper anchor point, hooks are generally preferable to pedicle
planned, the interval between the first and second surgical
screws for two reasons: most importantly, when pushing upwards
stage is typically a 1-week period, which appears adequate to
on thoracic pedicle screws, plowing through the bone occurs
more easily than when pushing downwards, thus it is easy to
ruin the pedicle screw site as a permanent fixation point; in
addition, up-going infralaminar or transverse process hooks
permit easier seating of the rod into the hook.
The caudal anchor points are generally in the lumbar spine
or pelvis. As the pedicles are generally stronger in the lumbar
spine and the direction of force is downwards, the use of two
pedicle screws as a distal anchor point works well. The caudal
TIDR fixation points are commonly pedicle screws in the lum-
bar spine at two or three adjacent levels, so the surgeon should
use the levels a minimum of two above the final caudal level of
the fusion, planning that these screws will likely be suboptimal
for end-construct fixation. In addition, increasing the diameter
of the pedicle screws at the caudal end of the distraction con-
struct improves the fixation in the final fusion construct.
If the caudal TIDR fixation point is to be the pelvis to cor-
rect pelvic obliquity, fixation can be to the sacrum or iliac wing
utilizing an S-shaped hook or to the pelvis with an iliac screw
(Figs. 117.9 and 117.10). If iliac screw fixation is chosen, it is
preferred to place the TIDR iliac screw lateral and proximal to
the site of the definitive iliac screw, as the screw placed for TIDR
is likely to loosen during the distraction. Inserting a longer and
larger diameter screw can additionally improve iliac fixation.
Alternatively an S hook may be placed over the top of the iliac
crest or sacral ala (Fig. 117.11). Regardless of which type of
anchor is chosen, there is a mechanical advantage in correcting
pelvic obliquity if the anchor is placed lateral to the spine. In Figure 117.11. S hook anchor on iliac crest.

LWBK836_Ch117_p1265-1278.indd 1274 8/25/11 10:06:32 PM

 Chapter 117 Role of Halo Traction and Halo-Femoral Traction in Paralytic/Neuromuscular Scoliosis 1275

Figure 117.12. The temporary rod (black arrows) is attached to

two ribs at the top, and an iliac screw in the pelvis. Following distrac-
tion and osteotomies, the pelvis is now level, the scoliosis is signifi-
cantly corrected, and the permanent right rod (white arrows) can be
placed while the temporary rod is still in place holding correction. In
this particular case, the entire surgery was done at one stage, as the
temporary rod led to sufficient correction.

achieve the maximal correction from the TIDR construct. At

the second stage the temporary rods are removed, the final
implants are placed, and fusion is performed.
At the time of surgery, the goal is to place the temporary
rod in the spine and begin distraction as early as possible in Figure 117.13. Large lumbar hooks fits well on ribs of moderate
the procedure to take advantage of the viscoelastic nature of to large size children. Hooks are placed just lateral to transverse pro-
the spine (Fig. 117.13). Retensioning of the TIDR constructs cesses, with an upward distraction force.
several times during the surgery permits gradual deformity
correction and lessens acute loading of the distraction con-
amounts of distraction throughout the surgery. For two-stage
struct, which lowers the stresses on the bone--implant inter-
procedures, no bone graft is used at the initial procedure as
face and permits neuromonitoring assessments. After estab-
fusion is not the goal. Closure is challenging at times when sig-
lishing the cephalad and caudal TIDR sites, two rods are
nificant distraction and lengthening has been placed across the
placed (one at each end) and maximally overlapped and con-
spine. Furthermore, the temporary rod usually remains lateral to
nected by a side-to-side connector. Distraction is applied across
these rods via the side-to-side connector. In large curves, it
may be a challenge to get to the anchor points in rods lined
up straight enough for this to occur, but a combination of dis-
traction and rod manipulation is usually sufficient to get the
rods parallel. In cases of extreme deformity, one may need to
apply a very small rod to the upper anchor points and another
very small rod to the lower anchor points with these two rods
connected to a third rod with multiaxial transverse connectors
(Fig. 117.14).
Once the temporary rod has been placed and the distraction
has been applied, one should proceed with subperiosteal dissec-
tion of the remainder of the spine and release of the spine (Figs.
117.15A to I). In most cases, apical osteotomies are indicated for
correction of these severe curves. Placement of the remainder of
the planned spine fixation points is then completed (i.e., pedicle
screws, wires, hooks). One shortcoming of using a temporary rod
is that it is technically difficult to place pedicle screws at the apex
of the deformity on the concave side of the curve. This is because
the temporary rod physically limits how far down one can put his
or her hands to place the pedicle screw in the rotated vertebral
Figure 117.14. Small temporary rods were placed in the upper
and lower anchor points and connected to a temporary rod by two
bodies. This positioning improves over time with further distrac- multiaxial transverse connectors. This type of temporary rod configu-
tion, and pedicle screws that could not be placed initially may be ration is generally too prominent to close soft tissue over but provides
able to be placed later in the surgery following osteotomies and a good start at distraction and aligning the upper and lower anchors
further distraction, or at the second-stage surgery. An essential and should and, which then allows lower-profile rods and connectors
part of this procedure is to apply multiple episodes of small to be placed later in the case.

LWBK836_Ch117_p1265-1278.indd 1275 8/25/11 10:06:34 PM

 1276 Section X Paralytic Deformity

A B

Figure 117.15. A 12-year-old

girl with adolescent idiopathic sco-
liosis. (A and B) Preoperative clini-
cal photographs. (C and D)
Preoperative upright radiographs
with main thoracic Cobb measure-
ment of 112. On side bending, the
Cobb measurement was 73 and on
C D
traction view was 67. (continued)

the transverse processes. Raising thick local flaps with the paraspi-
nal muscles (including the trapezius, latissimus, and rhomboids
in one thick layer) is often necessary. These large potential dead
spaces should be drained with closed suction drains to lower the
likelihood of hematoma formation, which could become sec-
ondarily infected.
In the postoperative management of a two-stage surgery,
nutrition is a primary concern. The use of total parenteral nutri-
tion in these patients immediately following the initial procedure
is recommended as it optimizes patients nutritional status. Total
parenteral nutrition should be continued until adequate regular
oral intake is demonstrated. Mobilization such as sitting, stand-
ing, and walking to help avoid pulmonary and other problems is
encouraged. To allow mobilization following surgery, one should
make sure that sufficient implant stability is obtained at the time
of the temporary rod application.
PEARLS AND PITFALLS
1. Avoid using the most proximal and distal fusion levels as
fixation points for the temporary rod as some plowing of
temporary anchors can be expected.
2. Pedicle screws in the upper thoracic vertebrae tend to plow
in a cephalad direction rather easily; for this reason, we gen-
erally use up-going hooks for cephalad fixation of the tem-
porary rod.

LWBK836_Ch117_p1265-1278.indd 1276 8/25/11 10:06:44 PM

 Chapter 117 Role of Halo Traction and Halo-Femoral Traction in Paralytic/Neuromuscular Scoliosis 1277

E F G

H I

Figure 117.15. (Continued) (E) Intraoperative anteroposterior radiograph demonstrating temporary rod
anchored to two ribs on the top left. Distraction caused some derotation of the vertebral bodies, making
placement of the concave apical pedicle screws easier. (F and G) Postoperative radiographs demonstrating
improvement from preoperative Cobb of 112 down to 26. (H and I) Postoperative clinical photographs.

LWBK836_Ch117_p1265-1278.indd 1277 8/25/11 10:06:46 PM

 1278 Section X Paralytic Deformity
3. The temporary rod should be placed as early as possible dur-
ing the first surgery, so multiple distractions can be applied
to the rods during the procedure as releases and osteoto-
mies are performed.
4. One should be aware of the risk of elevating the left shoul-
der with aggressive distraction.
5. Neuromonitoring is essential during the procedure as the
spine will be lengthened.
CONCLUSION
The goal of surgical management of severe spinal deformities
is to optimally correct the sagittal and coronal spinal deformity
in as safe a manner as possible (Fig. 117.15). The three traction
techniques presented in this chapter have been demonstrated
to be safe and efficacious tools in the overall surgical treatment.
Each technique has its strengths and weaknesses and the sur-
geon needs to assess the necessity and applicability of adjunc-
tive traction for each spinal deformity. Continued research is
necessary on all three techniques to better delineate the opti-
mal indications and technique of traction. Despite the recent
advances spinal instrumentation, the time-tested method of
axial spinal traction continues to have an important role in the
treatment of severe spinal deformities.
REFERENCES
1. Alman BA, Kim HK. Pelvic obliquity after fusion of the spine in Duchenne muscular dys-
trophy. J Bone Joint Surg Br 1999;81:821--824.
2. Barsoum WK, Mayerson J, Bell R. Cranial nerve palsy as a complication of operative trac-
tion. Spine 1999;24:585--586.
3. Bonnett C, Perry J, Brown JC, et al. Halo-femoral distraction and posterior spine fusion for
paralytic scoliosis. J Bone Joint Surg Am 1972;54:202.
LWBK836_Ch117_p1265-1278.indd 1278
4. Buchowski JM, Bhatnagar R, Skaggs DL, et al. Temporary internal distraction as an aid to
correction of severe scoliosis. J Bone Joint Surg Am 2006;88:2035--2041.
5. Buchowski JM, Skaggs DL, Sponseller PD. Temporary internal distraction as an aid to cor-
rection of severe scoliosis. Surgical technique. J Bone Joint Surg Am 2007;89(Suppl 2):
297--309.
6. Dormans JP, Criscitiello AA, Drummond DS, et al. Complications in children managed
with immobilization in a halo vest. J Bone Joint Surg Am 1995;77:1370--1373.
7. Garfin SR, Botte MJ, Waters RL, et al. Complications in the use of the halo fixation device.
J Bone Joint Surg Am 1986;68:320--325.
8. Huang MJ, Lenke LG. Scoliosis and severe pelvic obliquity in a patient with cerebral palsy:
surgical treatment utilizing halo-femoral traction. Spine 2001;26:2168--2170.
9. Janus GJ, Finidori G, Englebert RH, et al. Operative treatment of severe scoliosis in osteo-
genesis imperfecta: results of 20 patients after halo traction and posterior spondylodesis
with instrumentation. Eur Spine J 2000;9:486--491.
10. Kane WJ, Moe JH, Lai CC. Halo-femoral pin distraction in the treatment of scoliosis. J Bone
Joint Surgery [Am] 1967;49:1018--1019.
11. Kumar K. Spinal deformity and axial traction. Spine 1996;21:653--656.
12. MacEwen GD, Bunnell WP, Sriram K. Acute neurological complications in the treatment
of scoliosis. A report of the Scoliosis Research Society. J Bone Joint Surg Am 1975;57:
404--408.
13. Mubarak SJ, Camp JF, Vuletich W, et al. Halo application in the infant. J Pediatr Orthop
1989;9:612--614.
14. Ransford AO, Manning CW. Complications of halo-pelvic distraction for scoliosis. J Bone
Joint Surg [Br] 1975;57:131--138.
15. Rinella A, Lenke LG, Whitaker C, et al. Perioperative halo-gravity traction in the treatment
of severe scoliosis and kyphosis. Spine 2005;30:475--482.
16. Sink EL, Karol LA, Sanders J, et al. Efficacy of perioperative halo-gravity traction on the
treatment of severe scoliosis in children. J Pediatr Orthop 2001;21:519--524.
17. Swank SM, Lonstein JE, Moe JH, et al. Surgical treatment of adult scoliosis. A review of two
hundred and twenty-two cases. J Bone Joint Surg Am 1981;63:268--287.
18. Swank SM, Winter RB, Moe JH. Scoliosis and cor pulmonale. Spine 1982;7:343--348.
19. Takeshita K, Lenke LG, Bridwell KH, et al. Analysis of patients with nonambulatory neuro-
muscular scoliosis surgically treated to the pelvis with intraoperative halo-femoral traction.
Spine 2006;31:2381--2385.
20. Toledo LC, Toledo CH, MacEwen GD. Halo traction with the circolectric bed in the treat-
ment of severe spinal deformities: a preliminary report. J Pediatr Orthop 1982;2:554--559.
21. Tredwell SJ, OBrien JP. Apophyseal joint degeneration in the cervical spine following halo-
pelvic distraction. Spine 1980;5:497--501.
22. Vialle R, Delecourt C, Morin C. Surgical treatment of scoliosis with pelvic obliquity in
cerebral palsy: the influence of intraoperative traction. Spine 2006;31:1461--1466.
23. Wild A, Haak H, Kumar M, et al. Is sacral instrumentation mandatory to address pelvic
obliquity in neuromuscular thoracolumbar scoliosis due to myelomeningocele? Spine
2001;26:E325--329.
24. Wilkins C, MacEwen GD. Cranial nerve injury from halo traction. Clin Orthop 1977;126:
106--110.
8/25/11 10:06:49 PM