EXPERIENCE OF HALOPELVIC TRACTION IN THE TREATMENT OF SEVERE SPINE DEFORMITY: A CASE SERIES

Background: Severe and rigid scoliosis and kyphosis are difficult to treat but with the advent of new spinal operative techniques and implants, it has become manageable in expert hands. However these implants are too expensive for developing countries like us. The Halo-pelvic traction is a relatively cheaper device system used to treat such deformities. Moreover, rapid curve correction and one stage surgery may lead to permanent neurological deficit. Ali S.A. Associate Professor of Orthopaedic Surgery, Gujranwala Medical College, University Teaching Hospital Gujranwala Ch. A.A. Assistant Professor / Visiting Faculty Amna Inayat Medical College, Lahore Humayun A.S. Senior Registrar, Department of Orthopaedic Surgery Unit–I KEMU / Mayo Hospital, Lahore Dar U.Z. Assistant Professor of Orthopaedic Surgery Gujranwala Medical College, Gujranwala Awais S.M. Chairman Department of Orthopaedic Surgery KEMU / Mayo Hospital, Lahore Objective: To evaluate treatment outcome of Halopelvic Traction in the treatment of severe scoliosis and kyphosis. Methodology: This descriptive study was conducted in the department of Orthopedics surgery and traumatology unit – I, King Edward Medical University, Mayo Hospital Lahore from September 2010 to August 2012. The patients with severe spinal deformity which could not be corrected at a single stage were included. A Performa was made for each patient and results were statistically analyzed by using SPSS version 20. Results: Total no. of 07 patients were treated, out of them 04 scoliosis patients having mean Cobb’s angle of 77.25 ± 5.31o before treatment, improved significantly to 45 ± 5.35o after surgery (p 0˂.0001), 03 kyphosis patients with mean Kyphus angle of 96.67 ± 24.66o improved to 58.33 ± 17.56o (p˂0.0001). Two major complications i.e. one paraplegia which recovered incompletely and one had CSF discharge from cranial pin that was also revived thoroughly after changing the position of the pin. Conclusion: Halopelvic traction device can help in treating the patients of severe scoliosis and kyphosis.


Introduction
Scoliosis is a spinal deformity that is three dimensional because it involves both angular and rotational Original Article asymmetry of vertebrae and ribs. Kyphosis is an excessive dorsal curvature of spine i.e. in sagittal plane. Scoliosis may be idiopathic, congenital or secondary to some disease. Numerous potential etiologies of kyphosis have been recognized like TB spine, Scheuermann's disease, ankylosing spondylitis etc. These disorders influences roughly 1 in 1000 individuals, while around 1 in 10,000 affected people has a severe spinal deformity. [1][2][3] Conservative treatment is helpful in relief of painful scoliosis but it will not correct the deformity. When symptoms are not controlled by conservative management more truculent treatment may be obligatory. 4 The technique of surgical treatment depends on the age of the patient, the type and size of the deformity, and the presence or absence of spinal cord compression causing a neurologic deficit. 5 Halo-pelvic is a powerful and effective device. It is a type of external fixator used to distract and correct deformities of spine. It consists of Halo and pelvic components connected by 04 rods. 6,7 Halo skeletal traction was first introduced by Perry and Nickel, 1959. 8 De-Wald and Ray reported the pelvic halo in 1970. 9 A controlled distraction and correction can be carried out for final procedure of spinal fusion. It has several advantages over other techniques like it can hold the neck or trunk better than meticulously molded plaster casts, jackets or spinal orthosis securely after correction of spinal deformities. Skeletal traction by skull calipers has been utilized for the cervical spine but this is only efficacious in one plane. 8,9 It can be used in patients with severe pulmonary restriction, pressure sores from a cast, soft tissue contractures, or inability to control pelvic tilt and rotation. It provides gradual and controlled forces. It has excellent results in treating severe, rigid spinal deformities. 10 We made the device through our local resources to assess the outcome of surgery in the severe deformities of spine.

Materials and Methods
This descriptive study was conducted in seven patients having severe spinal deformities seeking for the correction of Scoliosis and Kyphosis and carried out during September 2010 to August 2012 within two years. Data was collected, surgery was performed and follow ups were made at department of orthopedic surgery and traumatology unit -I (DOST-I) / King Edward Medical University / Mayo Hospital Lahore.
The diagnosis was made by history, hospital treatment record, clinical features and X-ray appearance of the lesion.

Surgical Technique Anterior Spine Release
In kyphosis apex was exposed by thoracotomy and osteotomy of body of apical vertebra performed.
In scoliosis apex and adjacent vertebrae were exposed by thoracotomy from convex side and minimum three to maximum five discs excised. Rib was used as bone graft in the disc space.

Application of Halopelvic Traction
Skull radiographs were used to assess the cortical thickness of the skull. 04 cranial pins were inserted in frontal and two in temporoccipital bone. Two locally manufactured pins threaded from the middle (like Denhem pin) were inserted in the iliac crest and two pins in posterior superior iliac spine. Halo and pelvic components were connected to the pins. 04 connector rods were linked with halo and pelvic component. 1 mm twice daily (slow) distraction started the next day of surgery which was increased to 2 -5 mm (gradually) by daily assessing the neurology. Distraction was stopped or reversed in case of pain or numbness in the limbs.

Arthrodesis of Spine:
After achieving a good correction a second stage surgery by the same thoracotomy approach was performed by placing a fibular graft in the bodies of vertebrae. In third stage traction was removed and plaster of Paris jacket was applied after 4 -6 months which was replaced by an orthosis after about 1 -2 months which was worn till the union (arthrodesis) was achieved.

Statistical Analysis
All data was recorded and analyzed using SPSS version 20. Qualitative data was presented in form of frequency (%). The quantitative data (age and curvature) is presented in the form of mean ± S.D. The significance of procedure was compared in terms of curvature using Wilcoxon Rank test (due to small sample size). P-value ≤ 0.05 was considered as significant.
One female patient developed paraplegia which recovered completely after decreasing traction. One had CSF discharge from a cranial pin which recovered after pin removal. There was no serious pin tract infection in this series.

Discussion
The correction of severe spinal deformities is difficult. Severe rigid spinal curve can be corrected with staged surgeries. Halo-pelvic traction can be helpful in the correction of these severe spinal deformities. It provides better outcomes in problematic fixed spinal deformities. Pins insertion and infection required expertise and good care. 9,10 The majority of problems are related to the pin sites and pin should be cleaned with antibacterial solution daily or as per needed on observation. In present study there was no major pin tract infection.
The age of the patients at the time of treatment ranged from 8 to 17 years (Mean 15.14 ± 3.23 SD). One female patient developed paraplegia who recovered incompletely after decreasing traction leaving six patients who completed their treatment. The average time in halo-pelvic apparatus was 26 weeks with   In present study 6 patients had the deformity in the thoracolumbar spine and 01 had in cervicodorsal spine. The average number of diseased / destroyed vertebrae was 2. The D10 vertebra was most commonly involved and the most common site of kyphosis was dorsal spine. The severity of deformity was measured by Cobb method. Mean scoliosis was 77.25 ± 5.31 which improved to mean 41.75%. The mean kyphosis Cobb angle was 96.67 ± 24.66 (Range 60º -125º) which corrected to mean 39.66%.
O'Brien et al reported a case of paralytic scoliosis with 120 degree thoracolumbar curve corrected to 61 degrees (50.88%) with Halo-pelvic traction. 10 In present study Cobb angle was corrected with mean of 39.66% for kyphosis and 41.74% for scoliosis. Kalamchi et al reported 36 patients with paralytic scoliosis secondary to poliomyelitis with average age of 14.6 years treated by halopelvic traction achieving 46% correction. 11 Yamin et al, treated 21 patients with average Cobb angle of 62º (range 40° to 89°) after first-stage release and traction surgical procedures, the average correction achieved was 44.2% (range 23.9 to 63.9%) which improved to 65.2% (range 39.8% to 79.5%) in second stage instrumentation. 12 Treatment outcome is influenced by the severity of deformity, flexibility of spine, age of the patient and type of deformity. Spinal cord has less tolerance to traction that's why paraplegia is not uncommon with other complications like pin loosening, pin infection, cranial nerve involvement etc. But with slow distraction a good correction may be achieved. The experience in this study with halo-pelvic traction method can be used in the treatment of severe and rigid deformities with magnitude of curve more than 70° and flexibility less than 10° that require staged surgery. The application of posterior instrumentation after correction of spine deformities with halopelvic traction is superior to our method but these gadgets are expensive, long learning curve for surgeons and have their own complications. The halo-pelvic distraction followed by arthrodesis of spine without instrumentation can be used in low socio-economic group due to low cost and good results.

Conclusion
Slow distraction by Halopelvic device is good and relatively cheaper procedure which can be used for correction of severe spinal deformities especially in our set up having poor socioeconomic status.