Halo-gravity traction device

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Halo-gravity traction device
Halo Brace.png
Illustration of a halo brace
Specialty Orthopedics

Halo-gravity traction (HGT) is a type of traction device utilized to treat spinal deformities such as scoliosis, [1] [2] congenital spine deformities, cervical instability, basilar invagination, and kyphosis. [3] It is used prior to surgical treatment to reduce the difficulty of the following surgery and the need for a more dangerous surgery. [4] [5] [6] The device works by applying weight to the spine in order to stretch and straighten it. Patients are capable of remaining somewhat active using a wheelchair or a walker whilst undergoing treatment. Most of the research suggests that HGT is a safe treatment, and it can even improve patients' nutrition or respiratory functioning. However, some patients may experience side effects such as headaches or neurological complications. The halo device itself was invented in the 1960s by doctors working at the Riancho Los Amigos hospital. [7] [8] [9] Their work was published in a paper entitled "The Halo: A Spinal Skeletal Traction Fixation Device." [10] The clinician Pierre Stagnara utilized the device to develop Halo-Gravity traction. [11] [12] [13]

Contents

Technique

Halo-gravity traction works by straightening and stretching the compressed spine. [14] [15] It relies on the viscoelastic properties of vertebrae. This means vertebrae can stretch over time. Doctors will apply weight to the spine, and gradually increase it over time, slowly straightening and stretching it. [16] Patients undergoing the procedure will typically spend the entire course of the treatment, which is usually three to eight weeks, in a hospital. Usually, halo-gravity traction is the first step in the treatment plan for a child with severe spinal deformity. Following the procedure, it is common for a surgical operation such as spinal fusion surgery to be performed afterward to permanently mend the issue. [14] [17] It is utilized before the operation to reduce the need for a more dangerous operation and to reduce the risk of damage to the soft tissues or nerves that surround the spine during the surgery. [15] [18] [19] In addition, HGT has also been found to reduce the risk of complications during the following surgery. [20] [21] [22]

To perform halo-traction therapy a surgeon will use six to ten small pins to attach a "halo" made of a metal ring to the patient's skull. [23] [24] [25] Doctors will typically leave one to two centimeters of distance between the halo and the patient's head. It is common for older patients to be given eight pins while younger patients are given 10. Prior to pin placement, some patients may undergo hair removal. It is not required for successful treatment, but it can help to reduce the risk of pin infection from hair getting caught in a pin or scalp necrosis. [7] The pins will be placed into the forehead bones to prevent the head from moving. Pin placement is determined using a CT scan. The chosen area will be cleaned with betadine swabs. Usually, two to three pins are placed in the frontal and occipital areas. Pins placed on the occipital area will have to be placed one centimeter above and behind the auricle of the ear. Pins placed on the anterior of the head will likely be placed one centimeter to above the sides of the eyebrow to avert potential damage to the supraorbital and the supratrochlear nerves, and potential muscle damage. Parietal placements are generally avoided as the skull around this area is generally softer, which risks the pins puncturing the temporal artery. Typically, the pins will tightened to a torque equivalent to the age of the child using a torque wrench. Adults can withstand tighter torques than children can. [26] Whilst this operation is being performed the child will be given general anesthesia. [7] In infant children, significantly less torque is required to tighten the pins. This allows for the pins to be placed in more areas than they could be placed in older patients. [27]

Afterward, the halo will be attached to a pulley system which is attached to the patient's bed, walker, or wheelchair. [28] Spring-type pulleys are typically used as they allow for the patient to self-regulate the weight applied to the pulley, which improves the safety of the device. [29] : 390  Spring-based HGT devices are also cheaper and easier to build than other methods of construction. [30] It is common for patients to begin the procedure with 5-10 pounds of weight on the pulley system. [29] : 387  Over the next few weeks, clinicians will add weight to the pulley, which will slowly straighten the patient's spine over time. Eventually, a weight greater than 50% of the patient's body weight may be achieved. [23] [31] Doctors will monitor the movements and strength and will take x-rays of the patient to track their progress. They will adjust the amount of weight on the pulley system based on the results. All patients will undergo cranial nerve testing during the procedure. [23] After the spine has reached its optimal position, spinal fusion surgery will be performed on the patient. [15]

Whilst undergoing the procedure, patients are encouraged to remain as active as possible. Activities such as low-impact play, walking, or standing can all increase the benefits of halo-traction therapy. However, patients are limited to leaving the traction for only a short time span. They can leave for activities such as repositioning, changing clothes, daily medical care, showering, or using the toilet. Baby shampoo is required to be used for bathing purposes as other shampoos could contain chemicals that react negatively with the metal halo. Patients will be required to utilize a special bed for sleeping whilst in the traction. After ending treatment the patient is required to avoid strenuous activities for a few months as their spine and muscles will still need to recover. Some patients may wear an orthopedic vest or a halo vest. [15]

Side effects

Halo-gravity traction has been found to be almost completely safe. [29] : 385  [32] Patients who have undergone the procedure report that they have a greater ability to stand upright, an increased appetite, and an improved body image. [33] It can improve respiratory functioning by relieving pressure on the lungs caused by a deformed spine. [13] [34] [35] Patients often gain weight and have improved nutrition following HGT. [36] This may occur since HGT can correct issues associated with spinal deformities, such as exercise, comorbid metabolic disorders, and gastrointestinal malformations. These issues are associated with malnutrition and low weight, and HGT can lead to weight gain by correcting them. [37] When in combination with surgical release, HGT may improve the flexibility of the spine and lead to more spinal correction. [38] [39]

Patients may experience pain from the pins, which is usually caused by the loosening of the pins. This can be remedied by tightening them. Up to 20% of patients may experience infections at the site where the pins were applied. These infections are typically treated with antibiotics. One rare, but serious complication of the procedure can be the development of intra-cranial abscesses due to septic contamination of the pin site. [13] Some patients experience headaches around the area where the pins were applied for a short while after the halo is attached. It is common for patients to recover from this pain in less than 24 hours. [29] : 384  Halo therapy will leave small lesions in the skin when the pins are first removed. Typically, they will turn into scabs after a few days. Patients who have undergone the procedure will also have small scars on their foreheads. These scars will typically fade over time. [15]

If the traction that is applied is greater than the tolerable amount, the patient may feel cervical pain, cranial nerve lesions, nausea, vertigo, [40] or dizziness. These side effects are treated by lowering the level of weight applied. [41] Some patients may suffer from motor paresis after the application of the device. Typically it is present in patients with preexisting spinal cord abnormalities. [29] : 389  Generally, HGT does not cause neurological side effects due to the slow progression of traction. The spine adjusts slowly over time, and as a result, consequences are generally limited. Children are less likely than adolescents or adults to experience neurological side effects, due to the softness and flexibility of their spine, as well as their low weight. [42]

Erb's palsy has been identified as a rare neurological side effect of HGT. [43] One 2006 study published in the journal "Studies in Health Technology and Informatics" found that in extremely rare cases HGT could induce Erb's palsy, ulnar nerve paralysis, and median nerve palsy in cases. In the seven cases identified by the study, all patients had fully recovered within a few months of treatment. The likelihood of developing Erb's palsy due to HGT is associated with the weight of the traction. [44] Another study published in the Journal of Spinal Disorders & Techniques found that patients may experience Erb's palsy or sensory loss during or after treatment. However, none of the patients who had experienced these side effects reported in this study had permanent neurological loss. [45]

One 2016 clinical study published in BioMed Research International found that HGT resulted in reduced bone density among patients with kyphoscoliosis. [46] However, little other research has investigated this potential side effect or found any evidence to support this claim. [37]

Patients with bone conditions such as fibrous dysplasia or osteogenesis imperfecta may be unsuitable for treatment if the pins are not capable of safely being applied to the bone. [29] : 385  Osteoporosis is considered a contraindication that sometimes may prevent treatment, however, doctors may avert complications by utilizing more pins with a lower torque. [40] Absolute contraindications for halo-gravity traction include the presence of a stenotic segment, an intradural or extradural lesion, lesions in the skull by the sites of pin application, [12] any lesion or tumor by the spine cord, [23] severe skull deformity, and spine instability. [12]

Effectiveness

Most of the research conducted on HGT found that it is mostly a safe, [47] reliable, [47] and effective treatment. [48] [49] [50] The average correction rate of HGT has been shown to be 19.4% for sagittal curves and 24.1% coronal curvature. [12] One 2013 study on 33 patients published in the journal Spine Deformity found an average correction rate of 33% for coronal curves and 35% for sagittal. [51] According to a cohort study conducted on 75 subjects investigating the efficacy of Halo traction therapy found an improvement rate of 31% to 66% for the spine. They found a coronal curvature improvement of 19.6% for adolescents, and 12% for adults. Kyphosis had improved at a rate of 23.9% for adolescents. Afterward, spinal surgery performed on people who had undergone the procedure had a greater than 50% chance of success. [52]

One study conducted on 20 patients with either scoliosis, kyphosis, or kyphoscoliosis found that the most improvement occurred within the first 3 weeks of treatment. According to this study, the spinal curve had improved by 63.7% during the first two weeks, which decreased to 24.3% at 3 weeks, and to 15.9% at 4 weeks. [38] Other studies have found similar results. One study conducted on 21 patients found that 45% of improvement occurred within the first 3 weeks. [53] Another study on 24 patients found that a mean improvement of 82% occurred during the first three weeks. [54]

Much of the research utilized as evidence of the efficacy of HGT has been criticized for a lack of a control group and a small sample size. [55] Some research has suggested that HGT leads to statistically insignificant improvement. [56] Paul Sponseller, an Orthopedic surgeon at Johns Hopkins University, claims in his study "The use of traction in the treatment of severe spinal deformity" that his research found "no statistically significant difference in main coronal curve correction (62% vs. 59%), operative time, blood loss, and total complication rate (27% vs. 52%)." However, his data did showcase that people who had not undergone HGT required surgical resection 30% more often. [55] In a study on 25 patients with severe spinal deformities who had been treated with spinal surgery, a mean correction of 44 degrees was found in patients who had not undergone HGT prior to the operation, and a mean correction of 52 was found in patients who had been treated with HGT. The researchers concluded that this difference was not statistically significant, and therefore HGT should not be used as the general treatment for these issues, and should be reserved for specific cases. [57]

Some research suggests that HGT may be less effective than other forms of traction, such as Halo-femoral traction or Halo-pelvic traction. [58] [59] HGT also has been found to require lengthy hospital stays, which many patients dislike about the treatment. [60] In the study by Paul Sponsellor, he found that patients who had undergone HGT spent almost twice the amount of time hospitalized as those who had not received the treatment. [55] HGT is significantly safer than other forms of traction. It is less likely to produce significant complications such as blood loss, [59] [61] neurological side effects, and spine stiffness or degeneration. [62] HGT also allows patients to remain social and active, whilst other forms of traction severely restrict movement. [63] These reasons have led to HGT becoming the standard preoperative treatment for patients with severe spinal deformities. [64]

Related Research Articles

<span class="mw-page-title-main">Scoliosis</span> Medical condition of the spine

Scoliosis is a condition in which a person's spine has an irregular curve. The curve is usually S- or C-shaped over three dimensions. In some, the degree of curve is stable, while in others, it increases over time. Mild scoliosis does not typically cause problems, but more severe cases can affect breathing and movement. Pain is usually present in adults, and can worsen with age. As the condition progresses, it may alter a person's life, and hence can also be considered a disability.

<span class="mw-page-title-main">Kyphosis</span> Medical condition

Kyphosis is an abnormally excessive convex curvature of the spine as it occurs in the thoracic and sacral regions. Abnormal inward concave lordotic curving of the cervical and lumbar regions of the spine is called lordosis. It can result from degenerative disc disease; developmental abnormalities, most commonly Scheuermann's disease; Copenhagen disease, osteoporosis with compression fractures of the vertebra; multiple myeloma; or trauma. A normal thoracic spine extends from the 1st thoracic to the 12th thoracic vertebra and should have a slight kyphotic angle, ranging from 20° to 45°. When the "roundness" of the upper spine increases past 45° it is called kyphosis or "hyperkyphosis". Scheuermann's kyphosis is the most classic form of hyperkyphosis and is the result of wedged vertebrae that develop during adolescence. The cause is not currently known and the condition appears to be multifactorial and is seen more frequently in males than females.

<span class="mw-page-title-main">Laminectomy</span> Surgical removal of a lamina

A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending on the problem, more conservative treatments may be viable.

<span class="mw-page-title-main">Pectus excavatum</span> Congenital deformity of the chest

Pectus excavatum is a structural deformity of the anterior thoracic wall in which the sternum and rib cage are shaped abnormally. This produces a caved-in or sunken appearance of the chest. It can either be present at birth or develop after puberty.

<span class="mw-page-title-main">Klippel–Feil syndrome</span> Congenital condition characterised by fusion of two or more vertebrae in the neck

Klippel–Feil syndrome (KFS), also known as cervical vertebral fusion syndrome, is a rare congenital condition characterized by the abnormal fusion of any two of the seven bones in the neck. It can result in a limited ability to move the neck and shortness of the neck, resulting in the appearance of a low hairline. Most people only have one or two of those symptoms so it may not be noticeable without medical imaging.

<span class="mw-page-title-main">Back brace</span> Corrective medical device worn around a patients back

A back brace is a device designed to limit the motion of the spine in cases of bone fracture or in post-operative spinal fusiona, as well as a preventative measure against some progressive conditions or to correct patient posture.

<span class="mw-page-title-main">Traction (orthopedics)</span> Process for straightening broken bones

Traction is a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system. There are two types of traction: skin traction and skeletal traction. They are used in orthopedic medicine.

<span class="mw-page-title-main">Spinal fusion</span> Immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies

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<span class="mw-page-title-main">Kyphoscoliosis</span> Medical condition

Kyphoscoliosis describes an abnormal curvature of the spine in both the coronal and sagittal planes. It is a combination of kyphosis and scoliosis. This musculoskeletal disorder often leads to other issues in patients, such as under-ventilation of lungs, pulmonary hypertension, difficulty in performing day-to-day activities, psychological issues emanating from anxiety about acceptance among peers, especially in young patients. It can also be seen in syringomyelia, Friedreich's ataxia, spina bifida, kyphoscoliotic Ehlers–Danlos syndrome (kEDS), and Duchenne muscular dystrophy due to asymmetric weakening of the paraspinal muscles.

<span class="mw-page-title-main">Scheuermann's disease</span> Medical condition

Scheuermann's disease is a self-limiting skeletal disorder of childhood. Scheuermann's disease describes a condition where the vertebrae grow unevenly with respect to the sagittal plane; that is, the posterior angle is often greater than the anterior. This uneven growth results in the signature "wedging" shape of the vertebrae, causing kyphosis. It is named after Danish surgeon Holger Scheuermann.

Tethered cord syndrome (TCS) refers to a group of neurological disorders that relate to malformations of the spinal cord. Various forms include tight filum terminale, lipomeningomyelocele, split cord malformations (diastematomyelia), occult, dermal sinus tracts, and dermoids. All forms involve the pulling of the spinal cord at the base of the spinal canal, literally a tethered cord. The spinal cord normally hangs loose in the canal, free to move up and down with growth, and with bending and stretching. A tethered cord, however, is held taut at the end or at some point in the spinal canal. In children, a tethered cord can force the spinal cord to stretch as they grow. In adults the spinal cord stretches in the course of normal activity, usually leading to progressive spinal cord damage if untreated. TCS is often associated with the closure of a spina bifida. It can be congenital, such as in tight filum terminale, or the result of injury later in life.

Richard Michael Hodes is an American physician specializing in cancer, heart disease, and spinal conditions. Since the 1980s he has worked in Ethiopia and has adopted a number of children from the country. He is medical director of the American Jewish Joint Distribution Committee. He is the consultant at a Catholic mission working with sick destitutes suffering from heart disease, spine disease, and cancer. He has worked with refugees in Rwanda, Zaire, Tanzania, Somalia, and Albania and was previously responsible for the health of Ethiiopians immigrating to Israel.

Oheneba Boachie-Adjei is a Ghanaian orthopaedic surgeon. He specializes in spinal reconstruction and the treatment of kyphosis and scoliosis. He is professor of orthopaedic surgery at Weill Cornell Medical College in New York City, in the United States, and is an attending orthopaedic surgeon at Hospital for Special Surgery, at New York-Presbyterian Hospital and at Memorial Sloan-Kettering Cancer Center, all in New York City. From 1972 to 1976 he studied at Brooklyn College, Brooklyn, New York, in the United States, where he completed a BS degree summa cum laude. He then studied medicine at the Columbia University College of Physicians and Surgeons.

The management of scoliosis is complex and is determined primarily by the type of scoliosis encountered: syndromic, congenital, neuromuscular, or idiopathic. Treatment options for idiopathic scoliosis are determined in part by the severity of the curvature and skeletal maturity, which together help predict the likelihood of progression. Non-surgical treatment should be pro-active with intervention performed early as "Best results were obtained in 10-25 degrees scoliosis which is a good indication to start therapy before more structural changes within the spine establish." Treatment options have historically been categorized under the following types:

  1. Observation
  2. Bracing
  3. Specialized physical therapy
  4. Surgery

Max Aebi is a Swiss-Canadian spine surgeon.

Anterior vertebral body tethering (AVBT) is a relatively new surgery for the treatment of scoliosis in pediatric patients. Left untreated, severe scoliosis can worsen and eventually affect a person's lungs and heart.

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<span class="mw-page-title-main">David S. Feldman</span> Orthopedic Surgeon

David S. Feldman is an American orthopedic surgeon, author, contributor to NIH, and Associate Director of the Paley Orthopedic and Spine Institute. His work involves spinal deformities and complex conditions such as Arthrogryposis, skeletal dysplasia|, scoliosis, multiple hereditary exostoses, congenital pseudarthrosis of the tibia, hip dysplasia, and Legg–Calvé–Perthes disease as well as lower limb deformities and limb length discrepancies. He was previously Professor of Orthopedic Surgery and Pediatrics at NYU Langone Medical Center.

Pierre Stagnara was a French spinal surgeon. He has been described as a "pioneer" in the study of spinal deformities, "one of the greatest figures of French spinal surgery." Stagnara was born in January 16, 1917 in Loriol-sur-Drôme, France. He studied medicine in the city of Lyon. During World War II he was drafted into the French army. After the war, he worked in a variety of hospitals throughout Lyon. In 1959 he became the Chief of the Centre des Massues and served in this position until his retirement in 1982. Whilst working at the institution he pioneered many orthopedic techniques. Including the non-surgical management of scoliosis.

References

  1. ↑ Teixeira da Silva, Luis Eduardo Carelli; de Barros, Alderico Girão Campos; de Azevedo, Gustavo Borges Laurindo (2015-07-01). "Management of severe and rigid idiopathic scoliosis". European Journal of Orthopaedic Surgery & Traumatology. 25 (1): 7–12. doi:10.1007/s00590-015-1650-1. ISSN   1432-1068. PMC   4488473 . PMID   26033753.
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  4. ↑ LaValva, Scott M.; Pahys, Joshua M.; Garg, Sumeet; Bumpass, David B.; Sucato, Daniel J.; Kelly, Michael P.; Lenke, Lawrence G.; Gupta, Munish C.; Sponseller, Paul D.; Boachie-Adjei, Oheneba; Shah, Suken A.; Yaszay, Burt; Psds, the Fox; Cahill, Patrick J. (2023-02-01). "Preoperative Halo-Gravity Traction for Severe Pediatric Spinal Deformity: Can It Replace a Vertebral Column Resection? Original Research". Journal of the Pediatric Orthopaedic Society of North America. 5 (1). doi: 10.55275/JPOSNA-2023-496 . ISSN   2768-2765. S2CID   256540483.
  5. ↑ Sacramento-Domínguez, Cristina; Cynthia, Nguyen; Yankey, Kwadwo Poku; Tutu, Henry Osei; Wulff, Irene; Akoto, Harry; Boachie-Adjei, Oheneba; FOCOS SPINE RESEARCH GROUP (2021-07-01). "One-stage multiple posterior column osteotomies and fusion and pre-op halo-gravity traction may result in a comparative and safer correction of complex spine deformity than vertebral column resection". Spine Deformity. 9 (4): 977–985. doi:10.1007/s43390-021-00289-4. ISSN   2212-1358. PMID   33604824. S2CID   231961692.
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  29. 1 2 3 4 5 6 Akbarnia, Behrooz A.; Yazici, Muharrem; Thompson, George H. (2010-12-31). The Growing Spine: Management of Spinal Disorders in Young Children. Springer Science & Business Media. pp. 384–389. ISBN   978-3-540-85207-0.
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  32. ↑ Wang, Jianqiang; Han, Bo; Hai, Yong; Su, Qingjun; Chen, Yuxiang (2021-11-01). "How helpful is the halo-gravity traction in severe spinal deformity patients?: A systematic review and meta-analysis". European Spine Journal. 30 (11): 3162–3171. doi:10.1007/s00586-021-06902-4. ISSN   1432-0932. PMID   34185131. S2CID   235664288.
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  37. 1 2 Reed, Logan A.; Mihas, Alexander; Butler, Reed; Pratheep, Guna; Manoharan, Sakthivel Rajaram; Theiss, Steven; Viswanathan, Vibhu Krishnan (2022-08-01). "Halo Gravity Traction for the Correction of Spinal Deformities in the Pediatric Population: A Systematic Review and Meta-Analysis". World Neurosurgery. 164: e636–e648. doi:10.1016/j.wneu.2022.05.026. ISSN   1878-8750. PMID   35577210. S2CID   248794517.
  38. 1 2 Park, Daniel K.; Braaksma, Brian; Hammerberg, Kim W.; Sturm, Peter (2013). "The Efficacy of Preoperative Halo-Gravity Traction in Pediatric Spinal Deformity: The Effect of Traction Duration". Clinical Spine Surgery. 26 (3): 146–154. doi:10.1097/BSD.0b013e318237828c. ISSN   2380-0186. PMID   23750343. S2CID   9013634.
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  40. 1 2 Braun, Sebastian; Brenneis, Marco; Schönnagel, Lukas; Caffard, Thomas; Diaremes, Panagiotis (2023). "Surgical Treatment of Spinal Deformities in Pediatric Orthopedic Patients". Life. 13 (6): 1341. Bibcode:2023Life...13.1341B. doi: 10.3390/life13061341 . ISSN   2075-1729. PMC   10302009 . PMID   37374124.
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  42. ↑ Pourtaheri, Sina; Shah, Suken A.; Ditro, Colleen P.; Holmes, Laurens; MacKenzie, William G. (2016). "Preoperative halo-gravity traction with and without thoracoscopic anterior release for skeletal dysplasia patients with severe kyphoscoliosis". Journal of Children's Orthopaedics. 10 (2): 135–142. doi:10.1007/s11832-016-0721-0. PMC   4837168 . PMID   27016925.
  43. ↑ El-Shaker, Mohammed; Watts, Hugh G. (1991). "Acute Brachial Plexus Neuropathy Secondary to Halo-Gravity Traction in a Patient with Ehlers-Danlos Syndrome". Spine. 16 (3): 385–386. doi:10.1097/00007632-199103000-00029. ISSN   0362-2436. PMID   1851333.
  44. ↑ Qian, Bang-Ping; Qiu, Yong; Wang, Bin (2006), "Brachial Plexus Palsy Associated with Halo Traction before Posterior Correction in Severe Scoliosis", Research into Spinal Deformities 5, IOS Press, pp. 538–542, retrieved 2023-11-03
  45. ↑ Caubet, Jean-François; Emans, John B. (2011). "Halo-Gravity Traction Versus Surgical Release Before Implantation of Expandable Spinal Devices: A Comparison of Results and Complications in Early-Onset Spinal Deformity". Clinical Spine Surgery. 24 (2): 99–104. doi:10.1097/BSD.0b013e3181d96e7d. ISSN   2380-0186. PMID   21445022. S2CID   22466948.
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  47. 1 2 Garabekyan, Tigran; Hosseinzadeh, Pooya; Iwinski, Henry J.; Muchow, Ryan D.; Talwalkar, Vishwas R.; Walker, Janet; Milbrandt, Todd A. (2014). "The results of preoperative halo-gravity traction in children with severe spinal deformity". Journal of Pediatric Orthopaedics B. 23 (1): 1–5. doi:10.1097/BPB.0b013e32836486b6. ISSN   1060-152X. PMID   23942045. S2CID   30015658.
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  53. ↑ Tokunaga, Makoto; Minami, Shohei; Kitahara, Hiroshi; Isobe, Keijiro; Nakata, Yoshinori; Moriya, Hideshige (2000-02-15). "Vertebral Decancellation for Severe Scoliosis". Spine. 25 (4): 469–474. doi:10.1097/00007632-200002150-00013. ISSN   0362-2436. PMID   10707393.
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  55. 1 2 3 Sponseller, Paul D.; Takenaga, Ryan K.; Newton, Peter; Boachie, Oheneba; Flynn, Jack; Letko, Lynn; Betz, Randal; Bridwell, Keith; Gupta, Munish; Marks, Michelle; Bastrom, Tracey (2008-10-01). "The Use of Traction in the Treatment of Severe Spinal Deformity". Spine. 33 (21): 2305–2309. doi: 10.1097/BRS.0b013e318184ef79 . ISSN   0362-2436. PMID   18827696. S2CID   205510406.
  56. ↑ Flierl, S.; Carstens, C. (1997). "Der Effekt der Halo-Schwerkraft-Traktion bei der präoperativen Behandlung der neuromuskulären Skoliose". Zeitschrift für Orthopädie und ihre Grenzgebiete (in German). 135 (2): 162–170. doi:10.1055/s-2008-1039574. ISSN   0044-3220. PMID   9214176. S2CID   260354631.
  57. ↑ Seller, K.; Haas, S.; Raab, P.; Krauspe, R.; Wild, A. (2005). "Die präoperative Halo-Extension bei hochgradiger Lähmungsskoliose". Zeitschrift für Orthopädie und ihre Grenzgebiete (in German). 143 (5): 539–543. doi:10.1055/s-2005-836750. ISSN   0044-3220. PMID   16224673. S2CID   260354087.
  58. ↑ Sun, Yan; Zhang, Yong; Ma, Haoning; Tan, Mingsheng; Zhang, Zhihai (2023-03-01). "Halo-pelvic traction in the treatment of severe scoliosis: a meta-analysis". European Spine Journal. 32 (3): 874–882. doi: 10.1007/s00586-023-07525-7 . ISSN   1432-0932. PMID   36622456. S2CID   255545260.
  59. 1 2 Shi B, Liu D, Shi B, Li Y, Xia S, Jiang E, Qiu Y, Zhu Z. A Retrospective Study to Compare the Efficacy of Preoperative Halo-Gravity Traction and Postoperative Halo-Femoral Traction After Posterior Spinal Release in Corrective Surgery for Severe Kyphoscoliosis. Med Sci Monit. 2020 Feb 4;26:e919281. doi: 10.12659/MSM.919281. PMID 32015301; PMCID: PMC7020739.
  60. ↑ Buchowski, Jacob M.; Skaggs, David L.; Sponseller, Paul D. (2007). "Temporary Internal Distraction as an Aid to Correction of Severe Scoliosis: Surgical Technique". JBJS. 89 (2): 297–309. doi:10.2106/JBJS.G.00163. ISSN   0021-9355. PMID   17768223.
  61. ↑ Rohozynskyi, Valentyn & Levytskyi, Anatolii & Dolianytskyi, Mykola & Benzar, Irina. (2020). Valentyn A. Rohozynskyi, Anatolii F. Levytskyi, Mykola M. Dolianytskyi, Irina M. Benzar. TREATMENT OF SEVERE SPINAL DEFORMATIONS IN CHILDREN WITH IDIOPATHIC SCOLIOSIS USING HALO-GRAVITY TRACTION. Wiadomosci lekarskie (Warsaw, Poland : 1960). 73. 2144-2149. 10.36740/WLek202010107.
  62. ↑ Chen, Jian; Sui, Wen-yuan; Yang, Jing-fan; Deng, Yao-long; Xu, Jing; Huang, Zi-fang; Yang, Jun-lin (2021-01-23). "The radiographic, pulmonary, and clinical outcomes of patients with severe rigid spinal deformities treated via halo-pelvic traction". BMC Musculoskeletal Disorders. 22 (1): 106. doi: 10.1186/s12891-021-03953-y . ISSN   1471-2474. PMC   7825157 . PMID   33485304.
  63. ↑ Koptan, Wael; ElMiligui, Yasser (2012-06-01). "Three-staged correction of severe rigid idiopathic scoliosis using limited halo-gravity traction". European Spine Journal. 21 (6): 1091–1098. doi:10.1007/s00586-011-2111-0. ISSN   1432-0932. PMC   3366138 . PMID   22160155.
  64. ↑ Yang, Zhao; Liu, Yang; Qi, Longtao; Wu, Shanshan; Li, Jingwen; Wang, Yu; Jiang, Bin (2021). "Does Preoperative Halo-Gravity Traction Reduce the Degree of Deformity and Improve Pulmonary Function in Severe Scoliosis Patients With Pulmonary Insufficiency? A Systematic Review and Meta-Analysis". Frontiers in Medicine. 8. doi: 10.3389/fmed.2021.767238 . ISSN   2296-858X. PMC   8655856 . PMID   34901083.
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