| Objective: To design and improve a "new Halo-Gravity traction device"(HGT),observe and evaluate the clinical effect and security of one-staged HGT or HPT(Halo-Pelvic traction)combined with two-stage posterior column osteotomy orthopedic surgery for severe rigid spinal deformity.Method: Based on the traditional Halo-gravity traction device,we adopt a modular and combined design concept to develop a new HGT device suitable for patients with severe rigid spinal deformity.The main structure of the new HGT device consists of a skull fixation sleeve module,an adjustable wheelchair,and a connection adjustment rod,each component can be detached,the size of the skull fixation sleeve component and the position of the connection rod can be freely adjusted to adapt to different sizes of the skull and different height.Severe rigid spinal deformity was retrospectively analyzed from February 2015 to October 2019.Patients who underwent staged orthopedic strategies(Stage one: underwent HPT or HPT,Stage two: combined with simple posterior column osteotomy and pedicle screw internal fixation).Severe rigid spine deformity was defined as: the coronal Cobb angle of the main curve in full length X-ray > 90 °(or the sagittal Cobb angle of thoracic kyphosis > 80 °)and Bending image flexibility is less than 25%.All patients' gender,age,height,weight,etiology,and types of spinal deformity were recorded.Which underwent one-stage HPT or HPT continuous traction,two-stage simple posterior column osteotomy and pedicle screw internal fixation,and some patients with severe razor deformity underwent thoracotomy at the same time.X-ray examinations of the full length of the spine were performed pre-traction,post-traction,immediately after the surgery,6 months after the operation,and at the last follow-up.the coronal Cobb angle,thoracic kyphosis,Apical Vertebral Translation(AVT),distance from C7 Plumb Line to Center Sacral Vertical Line(C7PL-CSVL),horizontal distance from C7 Plumb Line to posterior superior angle of Sacrum 1(SVA)and other radiographic parameters were measured and compared before and after treatment.Observe and record the occurrence and outcome of perioperative complications.SPSS20.0 statistical software was used for analysis.The comparison of height and weight between the two groups before and after traction was performed by T test.The comparison of main curve Cobb angle,thoracic kyphosis Cobb angle,AVT,C7PL-CSVL,and SVA was based on One-way analysis of variance,if the data does not meet the normal distribution or the variance is uneven,the rank sum test is needed,the difference was considered statistically significant when P<0.05.Result:Clinical data: According to the exclusion criteria,a total of 30 patients with severe rigid spinal deformity were included in this study,8 males and 22 females,of which 26 cases in the HPT group and 4 in the HGT group.The average age of patients in the HPT group was 18.6 ± 9.2 years(11 to 48 years);the average traction time was 8.9 ± 3.8 weeks(5 to 15 weeks);the average follow-up time was 14.4 ± 10.5 months(7 to 36 months);all patients underwent Simple posterior column osteotomy and pedicle screw internal fixation surgery,including 7 cases with thoracotomy and 5 cases with satellite rod technology;the average operation time was 275.5 ± 41.2min(241?370min);the average bleeding was 509.6 ± 155.6ml(300-800ml);average fusion segment was 13.8 ± 2.3(7-17).The average age of patients in the Halo-gravity traction group was 9.7 ± 2.0 years(8-12 years),and the mean follow-up time was 12.0 ± 3.4 months(9-15 months).The average traction time was 12.3 ± 1.7 weeks(10-14 weeks).All patients underwent a simple posterior spinal osteotomy and pedicle screw internal fixation in two stage.Two of them underwent growth rod technique.The average operation time was 183.3 ± 25.1min(160?210min),and the average surgical bleeding volume was 286.7 ± 141.5ml(200?450ml).Compared between the two groups,the HGT group was younger(p = 0.000),had shorter operation time(p = 0.000),and had less bleeding(p = 0.001),but the traction time was longer than the HPT group(p = 0.011).The role of traction in correcting spinal deformities:In the HPT group,the Cobb angle of the main curve before traction was 123.7 ± 14.9 °(91-147.8 °),and its flexibility in the Bending position was 11.6%(3.6-22.8%).The pre-traction thoracic kyphotic Cobb angle was 87.3 ± 24.2 °(57.1 ? 131.2 °),the Cobb angle of the main curve and the thoracic kyphosis were corrected to 74.1 ± 22.1 °(40.1%)and 53.9 ± 23.5 °(38.3%)after traction;Cobb angle of main curve and thoracic kyphosis after secondary orthopedic surgery were 58.9 ± 22.9 °(compared with pre-traction,the rate of deformity correction was 52.4%),50.2 ± 18.3 °(42.5%),traction And the surgical correction rate was satisfactory.At the last follow-up,the main curve of the scoliosis and thoracic kyphosis were 61.0 ± 22.6 ° and 50.0 ± 18.3 °,respectively.The orthopedic loss was slightly,and there was no statistical significance.In the HGT group,the Cobb angle of the main curve was 95.0 ± 4.9 °(90-101 °),the flexibility of the Bending position was 21.5%(17-25%),and the Cobb angle of the main curve was corrected to 70.3 ± 1.7 ° at the end of traction.Compared with before traction,the deformity correction rate was 27.0%;after the second-stage orthopedic correction,the Cobb angle of the main curve was further corrected to 40.3 ± 9.5 °,and the correction rate was 57% compared with that before traction.At the last follow-up,the Cobb angle of the main curve was 41.3 ± 6.0,and no significant loss of orthopedics was seen.The correction rate of coronary scoliosis in the HPT group was better than that in the HGT group(p = 0.022).There was no statistical difference between the two groups after fusion(p = 0.467).Effect of traction on restoring spinal balance:In the HPT group,pre-traction and post-traction,the C7PL-CSVL were 32.4 ± 12.7mm and 13.7 ± 6.1mm,respectively.Coronal balance at the end of traction improved by 57.7%(p <0.05),and postoperative which turned into 12.4 ± 6.8mm(61.7%,compared with pre-traction,p <0.05);SVA were 37.4 ± 22.5mm and 15.5±7.4mm at pre-traction and post-traction,the improvement was 59%(p <0.05),and which was 16.6 ± 8.9mm(56%,compared with before traction,p <0.05)after operative.In terms of shoulder balance recovery,the T1 inclination angles before and after traction were 19.7 ± 17.9 ° and 7.6 ± 9.6 °,respectively,and the rate of improvement from traction was 61.4%(p <0.05)and 8.9 ± 10.3 ° from operation(54%)(P <0.05);the shoulder height of radiography before and after traction were 27.6 ± 16.1mm and 10.8 ± 8.0mm,respectively,and 9.3 ± 5.0mm after operation.At the end of traction and postoperative,the rate of improvement was 60.9% and 66%,respectively(p <0.05).The C7PL-CSVL before and after traction in the HGT group were 18.8 ± 1.5mm and 8.0 ± 1.2mm(57%),and 6.4 ± 1.1mm(66%,compared to before traction);SVA before and after traction were 51.5 ± 15.4mm and 25.5 ± 1.3mm(50%),and turned into 21.5 ± 1.5mm(58%,compared to before traction)after fusion.Coronal and sagittal plane balances were significantly improved after traction,and further improved after surgery(p < 0.05).Both HPT and HGT can effectively improve the overall spine balance,and there is no statistical difference between the two groups(p = 0.359).Complications:A total of 14 complications occurred during the perioperative period,and all appeared in the HPT group,of which 9 were traction-related complications,3 patients had transient cranial nerve palsy during traction,and improved after adjusting the traction stretch height;6 patients had needle way or nail canal related complications during traction,of which 5 patients had skin cuts with infections in the needle canal,and healed well after timely dressing change and anti-infection,another patient had loose pelvic needles during traction,which continue to complete the traction after replacing the pelvic needle.There were 5 cases of surgery-related complications,4 cases had pleural injury during operation,and pleural effusion appeared after operation,the pleural drainage tube was placed under CT guidance,and all of them improved within 1 week;1 patient had brachial plexus palsy after operation,she improved after physical therapy and oral nutritional neurotherapy.Conclusion:1.Both HGT and HPT can effectively correct spinal deformities and effectively restore the overall balance of the spine.Compared with the three-column osteotomy technique represented by PVCR,the spinal traction method combined with the two-staged post-column osteotomy technique can significantly reduce surgical trauma,shorten the operation time,more important is to reduce serious perioperative complications such as nerve injury.So it is a safe and effective technical strategy for the treatment of severe rigid spinal deformity.2.The correction effect and efficiency of HPT for coronal deformity are stronger than HGT,but the patient's comfort is poor,and the rate of traction-related complications is higher than the latter.Therefore,the clinical application scope of them is different: HPT is more suitable for older Patients with severe rigid and mature bone development;HGT is more suitable for younger patients with immature bone development,less rigid,and poor tolerance. |
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