Multistage correction of severe kyphoscoliosis and pulmonary compromise in adults through combined halo-pelvic traction and posterior spinal techniques

Abstract

Patients with kyphoscoliosis can present with a variety of chief complaints, including axial back pain, concerns about cosmesis, progressively worsening respiratory function, and even neurological deficits. Correction of severe adult kyphoscoliosis remains challenging due to the severity of the deformity and poor cardiopulmonary function. Direct one-stage corrective surgery can lead to enormous complications and unsatisfactory outcomes when dealing with patients with severe kyphoscoliosis. Preoperative halo-pelvic traction (HPT) has become popular in the management of severe scoliosis. The present study aimed to summarize the efficacy and safety of the staged strategy. Patients with severe kyphoscoliosis complicated by severe pulmonary impairment who underwent staged treatment and met the inclusion and exclusion criteria from Jan 2019 to Jan 2020 were retrospectively reviewed. Data including patient demographics, major coronal curve and kyphosis, pulmonary function test results, distraction time, and complications at different stages of treatment were recorded. Twenty-three patients (16 male and 7 female) with severe kyphoscoliosis and severe pulmonary impairment were included in the study. The mean age of these patients was 26.2 ± 5.7 years. The mean duration of traction before posterior release surgery was 4.0 ± 1.0 months and 4.4 ± 1.0 months after posterior release surgery. Mean follow-up was 40.4 ± 3.9 months. The main curve and kyphosis at admission were 145 ± 11.8° and 149 ± 21.7°, respectively. After HPT, the main curve and kyphosis decreased to 114 ± 12.3° and 124 ± 22.9°, respectively. The FVC and FVC% at admission were 1.44 ± 0.63 L and 39.0 ± 16.19%, respectively. The FVC and FVC% improved significantly after HPT. According to the Nash-Moe classification, the rotation of the apical vertebrae was grade IV in all patients, and the rotation did not improve during the traction. The operative time for posterior release was 266 ± 49 min. The average bleeding of posterior release was 600 ± 242 ml. HPT was maintained after the posterior release surgery. The mean operating time of the posterior correction surgery was 588 ± 53 min, and the mean bleeding was 1605 ± 313 ml. Correction rates were 56.6% and 68.5% in the coronal and sagittal planes, respectively. Staged treatment is an effective and safe strategy to correct severe kyphoscoliosis complicated by severe pulmonary impairment. Preoperative HPT combined with posterior release surgery can significantly reduce spinal deformity and improve pulmonary function. Posterior vertebra column resection (PVCR) is an effective technique for correcting kyphoscoliosis, but it is a technically demanding procedure.

Keywords: Halo-pelvic traction; Posterior release surgery; Posterior vertebra column resection; Severe kyphoscoliosis; Staged treatment.

Fig. 1

The process of staged strategy of treatment for severe kyphoscoliosis and severe pulmonary impairment.

Fig. 2

CT images of the pelvic and pins of patient with HPT.

Fig. 3

widening of atlantoaxialgap and atlantooccipital gap during the traction.

Fig. 4

A 23-year-old male patient with severe kyphoscoliosis and severe pulmonary impairment underwent staged treatment. On admission, the humpback deformity was obvious (a,b), the Cobb angle of main curve was 143° (c), and the angle of kyphosis was 150° (d); after 4 months of HPT, the humpback deformity has been improved (e,f), and the main curve reduced to 102° (g), the kyphosis reduced to 130° (h); another 5 months of HPT after posterior release surgery, the humpback deformity was still obvious (i,j), and the main curve reduced to 62° (g), the kyphosis reduced to 92° (h); after final surgical correction including PVCR and instrument fusion, the humpback deformity has been improved significantly (m,n), and the main curve reduced to 53° (o), the kyphosis reduced to 41° (p).

Fig. 4

A 23-year-old male patient with severe kyphoscoliosis and severe pulmonary impairment underwent staged treatment. On admission, the humpback deformity was obvious (a,b), the Cobb angle of main curve was 143° (c), and the angle of kyphosis was 150° (d); after 4 months of HPT, the humpback deformity has been improved (e,f), and the main curve reduced to 102° (g), the kyphosis reduced to 130° (h); another 5 months of HPT after posterior release surgery, the humpback deformity was still obvious (i,j), and the main curve reduced to 62° (g), the kyphosis reduced to 92° (h); after final surgical correction including PVCR and instrument fusion, the humpback deformity has been improved significantly (m,n), and the main curve reduced to 53° (o), the kyphosis reduced to 41° (p).