Traction for Idiopathic Scoliosis Before Surgery No Better Than No Traction
Idiopathic scoliosis, side-to-side curving of the spine for no known reason, can be quite severe in some teens. The curve, which is measured by degrees, not only affects the shape of the back, but it can affect breathing and the heart because of the limited space in the chest. As a result, treatment for the more severe curves is important, but there is debate as to which treatment is the best.
Although any surgery has risks, spinal surgery has the additional risk of damaging the nerves and causing neurological complications. Other complications include problems with the hardware (rods, screws, plates) that are used to straighten the back and hold the new shape in place. As a result, many doctors prefer to try traction first, using tension and force, to change the curve of the spine, before attempting surgery. If the curve can be lessened, with traction, this makes it easier to work correct the spine surgically.
To do traction, patients are put in a halo, which is a device where pins are placed in the patient's skull and attached to a metal ring around the forehead and the back of the head, usually about the level just above the ear. While the patient is in bed, the halo is then attached to a series of weights that will gently pull on the spine to straighten it slowly. The traction must be in place at all times and is attached to a bed but can also be attached to a wheelchair or a specially designed walker. Unfortunately, there are no reliable studies to determine if the traction is a better option than surgery. The authors of this study looked back at previous research to compare the correction of scoliosis in both traction and surgical treatments.
Researchers found 53 patients who had undergone spine-straightening surgery. Thirty patients had been treated with traction before surgery. These patients had curves in their spine of more than 90 degrees or they were inflexible, being unable to bend more than 25 degrees. The control group included 23 patients who had scoliosis with curves of more than 100 degrees or kyphosis (hunchback) of more than 120 degrees, . These patients did not have traction before surgery. All the patients were under 18 years old and were followed for two years.
The halo traction was applied while the patients were under general anesthetic, according to each child's size and weight. The traction was started immediately after surgery, starting with light weights and gradually increasing until the weight was, at most, between 33 percent and 50 percent of the patient's body weight. The patients were allowed out of bed to use specially equipped wheelchairs or walkers that accommodated the traction apparatus. The length of treatment varied between two and 12 weeks, depending on the severity of the curve, the surgeon's choice, and the patient's overall health, such as any problems with breathing because of the curvature of the spine.
Two years following treatment, the researchers the angle that the spines had been corrected in all 53 children. In the halo group, the mean correction was 62 percent and in the surgery without traction group, it was 59 percent. The second, compensating curve, was 55 percent in the halo group and 51 percent in the without traction group. Among the children with kyphosis, this curve decreased on an average of 10 percent in the halo group and 21 percent in the non-traction group.
The researchers also looked at the rate of surgical complications. There was one patient in each group who experienced breathing and nerve complications during surgery, but they were fine afterwards. The non-traction group had problems with the hardware during surgery in two patients, while only one in the traction group had similar complications. The article lists the non-traction group as having three "other" complications and the traction group having two "other" complications.
Finally, patients with kyphosis who didn't have traction had a few more complications than those with scoliosis. The kyphosis group had five patients who had problems with either back and chest pain, difficulty fitting braces, or eating. In the kyphosis group who did have traction, only one complication- further curving of the spine- was reported. When the researchers looked at the 23 patients who had acute idiopathic scoliosis, of whom 15 had halo traction and eight didn't, they found that the patients who had traction stayed in the hospital almost twice as long as those who did not have traction. After two years, the patients were assessed again. The patients who had had halo traction had a 33 percent rate of complications compared with 25 percent in the non-traction group.
The authors wrote that traction is safe and effective in correcting spinal deformities, with the traction allowing a slow and gradual partial straightening of the spinal curve. This makes it easier for the surgeon when the spinal surgery is performed. In one study done by Mehlman and colleagues, 24 patients had the halo traction before surgery and only one had neurological complications after surgery. Another research team, Qian and colleagues did find that some patients who have halo traction have a complication called temporary brachial plexus palsy, which is a weakening of the nerves and muscles around the arm and shoulder.
In conclusion, the authors wrote that there was no difference between the curve correction, spine length, operating time or complications between the halo traction group and the control group, although there was a significant difference in the length of stay in the hospital. Therefore, when deciding whether to use the halo traction, surgeons must take into account the impact of the treatment. More and more, halo traction isn't needed because of advanced surgical techniques. However, as the surgeries become more demanding, surgeons need be sure about assessing the patient's baseline condition (condition as is, before surgery) and being aware of the need of quality monitoring of the patient's neurological status during the surgery.
Paul D. Sponseller, MD, et al. The Use of Traction in the Treatment of Severe Spinal Deformity. In Spine. October 2008. Vol. 33. No. 21. Pp. 2305-2309.