European Spine Journal

https://doi.org/10.1007/s00586-023-07525-7

REVIEW ARTICLE

Halo‑pelvic traction in the treatment of severe scoliosis:

a meta‑analysis
Yan Sun1 · Yong Zhang1 · Haoning Ma2 · Mingsheng Tan2 · Zhihai Zhang1

Received: 7 November 2022 / Revised: 7 November 2022 / Accepted: 2 January 2023

© The Author(s) 2023

Abstract
Purpose To provide better evidence of the efficacy and safety of preoperative halo-pelvic traction on the improvements of
deformity and pulmonary functions in patients with severe scoliosis.
Methods Electronic database searches were conducted including the Cochrane Library, PubMed, Web of Science and
Embase. All studies of halo-pelvic traction for the management of severe spinal deformity were included. We referred to a
list of four criteria developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the quality of included
studies. The meta-analysis was performed using RevMan 5.4 software.
Results Based on the study selection criteria, a total of eight articles consisting of a total of 210 patients were included.
Statistically significant differences were found in coronal Cobb angle (P < 0.001), sagittal Cobb angle (P < 0.001) and height
(P < 0.001) between pre- and post-traction. Sensitivity analysis was conducted, and there were substantial changes in het-
erogeneity with preoperative thoracoplasty subgroup in coronal Cobb angle (P < 0.001). Three trials including 74 subjects
reported FVC and FEV1 predicted value between pre- and post-traction. There were statistically significant differences in
FVC, FVC%, FEV1 and FEV1% (P < 0.001). The complication rate was 6.6–26.7%, and symptoms disappeared after reason-
able traction strategy and intensive care.
Conclusions Preoperative halo-pelvic traction achieved significant improvements in spinal deformity and pulmonary func-
tions, with minor and curable complications. Thus, it is an effective and safe solution before surgery and may be the optimal
choice for severe scoliosis. In light of the heterogeneity and limitations, future researches are needed to better determine the
long-term efficacy on comprehensive assessment and to explore the appropriate traction system.

Keywords Halo-pelvic traction · Severe scoliosis · Radiographic outcome · Pulmonary function · Meta-analysis

Background stage. There is a lack of unified diagnostic criteria for severe

Severe scoliosis is a complex three-dimensional spinal
deformity, usually accompanied by severe cardiopulmonary
function impairment, and a significant increase in mortal-
ity due to the aggravation of the natural course in the late
* Mingsheng Tan
zrtanms@163.com
* Zhihai Zhang
gamzzh@163.com
1
Department of Orthopaedics, Guang’an Men Hospital,
China Academy of Chinese Medical Sciences, No.5
Beixiange St, Xicheng District, Beijing 100053,
People’s Republic of China
2
Department of Orthopaedics, China-Japan Friendship
Hospital, Beijing 100029, People’s Republic of China
spinal deformity, and it is usually diagnosed when scoliosis
or kyphosis Cobb angle is greater than 90° [1]. The need for
safe treatment of rigid severe spinal deformity is especially
urgent in China, where the major curves of an extensive
number of patients can be more than 120° [2]. However,
the optimal treatment for patients with a large major curve
remains to be determined due to the critical condition, higher
incidence of postoperative pulmonary complications, high
correction rate expectation and technical difficulty. Spinal
deformity surgery was the preferred treatment option, but
direct one-stage orthopedic surgery had been recognized as
wildly risky and high demanding, which required complex
osteotomies and prolonged high-intensity or even multiple
surgeries, resulting in serious complications such as pul-
monary complications, massive blood loss and irrevers-
ible damage to the spinal cord [3]. Therefore, preoperative

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halo-traction was recommended to increase the safety and
correction rate of second-stage surgery [4, 5].
In 1959, halo-pelvic traction was first reported by Perry
and Nickel to immobilize unstable cervical segments [6].
In 1971, O'Brien et al. [7] reported 118 cases of scoliosis
treated with halo-pelvic traction. Since then, the technique
was recognized by spinal surgeons in a real sense. First-
stage halo-pelvic traction may improve patients’ cardiopul-
monary and digestive function, reduce the risks of second-
stage osteotomy, and increase correction rate [8, 9]. As such,
earlier postoperative rehabilitation is permitted. Compared
to widely used halo-gravity traction, halo-pelvic traction
may be more applicable for severe rigid spinal deformity.
Indeed, halo-pelvic traction provides effective, continuous,
controllable corrective strength for patients with severe spi-
nal deformities. Also, it is reliable and has fewer complica-
tions which can be significantly relieved by considerate care,
reasonable traction strength and duration. Patients treated
with halo-pelvic traction avert long-term bed rests; therefore,
the incidence of bed-related complications is significantly
reduced, such as bed sores and respiratory infections [2, 10].
There were currently clinical studies with modified halo-
pelvic traction devices. However, definite conclusions of
halo-pelvic traction on severe scoliosis were still lacking.
Thus, we conducted this study to provide better evidence of
the efficacy and safety of preoperative halo-pelvic traction
on the improvements of deformity and pulmonary functions
in patients with severe scoliosis.
Methods
Search strategy
Electronic database searches were conducted including the
Cochrane Library, PubMed, Web of Science and Embase.
Our search strategies were the combinations of “Scoliosis”
(MeSH Terms) and the relevant keyword “Halo-pelvic trac-
tion.” The language was restricted to English or Chinese,
with no limitation on subheadings.
Study selection
All studies of halo-pelvic traction for the management of
severe spinal deformity were included in the present study.
Non-clinical studies, full-text article could not be obtained,
and cross-sectional studies, case reports, comments and
reviews were excluded.
Data extraction
The data processing was managed by two authors with End-
note X8 software independently, and disagreements were
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European Spine Journal
resolved by the third author. Information for each eligible
study included ① descriptive statistics such as author infor-
mation, publication year, study design, country, data sources
and sample sizes; ② intervention characteristics such as
detailed halo-pelvic traction strategy; and ③ the outcome of
interest: coronal Cobb angle, sagittal Cobb angle, SVA, FVC
predicted value, FEV1 predicted value, height and adverse
events.
Quality assessment and risk of bias
We referred to a list of four criteria developed by the Agency
for Healthcare Research and Quality (AHRQ) to assess the
quality of included studies [11, 12]. The four criteria were:
① defining the source of information; ② listing inclusion
and exclusion criteria; ③ indicating the time period used for
identifying patients; and ④ explaining any patient exclusions
from the analysis. Each criterion was described as “Yes” or
“No” or “Unknown” according to each study.
Statistical analysis
The meta-analysis was performed using RevMan 5.4 soft-
ware. The mean difference (MD) of 95% CIs was used
regarding continuous outcomes of halo-pelvic traction. Sta-
tistical heterogeneity was evaluated utilizing the I2 test. I2
value of less than 25% indicated low heterogeneity and less
than 50% indicated moderate heterogeneity. Then, a fixed
effects model was adopted. Otherwise, an I2 value greater
than 50% was regarded as significant heterogeneity, and
a random effects model was adopted. If there was signifi-
cant heterogeneity, a subgroup analysis was performed by
sequentially removing included study. P < 0.05 were consid-
ered statistically significant.
Results
Study characteristics
Based on the study selection criteria, a total of eight arti-
cles consisting of a total of 210 patients were included [2,
10, 13–18]. The study selection process is shown in Fig. 1.
Three included studies had a controlled group, while the
other did not. The traction strategy was different regarding
elongation rate and traction period. Treatment strategies
also varied including traction-fusion and traction-surgical
release-fusion. The characteristics of the included trials are
summarized in Table 1.
European Spine Journal
Fig. 1  Flow diagram of the
study selection process
Quality assessment
As shown in Table 2, all the studies defined the source of
information and indicated time period used for identify-
ing patients; all but two studies did not list clear inclusion
and exclusion criteria of patients; only one study explained
patient exclusions from analysis.
Radiographic measurement
Eight trials including 210 subjects reported coronal Cobb
angle between pre- and post-traction. As shown in Fig. 2,
statistically significant difference was found [MD = 57.39
(95%CI 45.57 – 69.20), P < 0.001, I2 = 98%], and a random
effects model was utilized due to severe heterogeneity. A
sensitivity analysis was conducted to evaluate the effect of
studies on the overall outcome by sequentially removing
studies. Of note, there was substantial change in heteroge-
neity when reducing to a subgroup of two studies with pre-
operative thoracoplasty [MD = 68.47 (95%CI 65.47–71.48),
P < 0.001, I2 = 0%].
Eight trials including 210 subjects reported sagittal Cobb
angle between pre- and post-traction. As shown in Fig. 3, a
statistically significant difference was found [MD = 44.75
(95%CI 35.26–54.23), P < 0.001, I2 = 97%], and a random
effects model was utilized due to severe heterogeneity. Simi-
larly, a sensitivity analysis was conducted, and no substantial
change was shown in heterogeneity.
Six trials including 146 subjects reported height between
pre- and post-traction. As shown in Fig. 4, statistically sig-
nificant differences were found in height [MD = − 12.65
(95%CI − 14.32 to − 10.98), P < 0.001, I2 = 49%]. A fixed
effects model was utilized due to moderate heterogeneity.
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 European Spine Journal

Table 1  Summary of the included studies

References Year Study design n Male Female Age (Years) Treatment Elongation rate Traction period

Qi et al. [13] 2020 Cohort 30 8 22 30.00 ± 9.33 TF First week: 0.5 cm/day 5.37 ± 0.93 weeks
Second week: 0.3–
0.5 cm/2-3 days
Wang et al. [16] 2021 Cohort 14 6 8 19.8 ± 5.0 TRF First week: 0.5–0.7 cm/day 35.2 ± 8.3 days
Second week: 0.2–0.5 cm/day
3rd week: 0.1–0.2 cm/day
Xu et al. [17] 2020 Cohort 24 9 15 28.8 ± 10.0 TRF First week: 1 cm/day 2.5 ± 1.1 weeks
Second week: 0.3–0.5 cm/days
Wang et al. [2] 2020 Cohort 32a 8 24 20.8 ± 3.5 TF First week: 1 cm/day 35.3 ± 5.9 days
Second week: 0.5 cm/day 3rd
week: 0.3–0.5 cm/2-3 days
Cohort 30b 10 20 29.9 ± 5.8 TRF First week: 1 cm/day 41.4 ± 6.5 days
Second week: 0.5 cm/day 3rd
week: 0.3–0.5 cm/2-3 days
Yu et al. [14] 2020 Cohort 18 5 13 25.3 ± 3.6 TRF NR NR
Ouyang et al. [18] 2020 Cohort 16 7 9 16.3 (14–22) TRF First week: 0.15–0.5 cm/day 2–4 weeks
Wang ZP et al. [15] 2020 Cohort 16 7 9 17.6 (14–28) TF 0.1–0.3 cm/day 3.4 (1–1.4) months
Chen et al. [10] 2021 Cohort 30 10 20 20.0 ± 1.05 TRF 0.3–0.5 cm/day 138.3 ± 28.83 days
a,b
Patients were analyzed separately based on whether vertebral column resection was performed
TF traction-fusion, TRF traction-surgical release-fusion, NR not reported

Table 2  Quality assessment of Reference Quality assessment

the included studies
Defining the Listing inclusion Indicating time period Explaining any patient
source of infor- and exclusion used for identifying exclusions from
mation criteria patients analysis

Qi Yes Yes Yes No

Wang (2020) Yes No Yes Yes
Yu Yes Yes Yes No
Wang (2021) Yes Yes Yes No
Xu Yes Yes Yes No
Ouyang Yes No Yes No
Wang ZP Yes Yes Yes No
Chen Yes Yes Yes No

Pulmonary Function
Three trials including 74 subjects reported FVC or FVC%
between pre- and post-traction. As shown in Fig. 5, sta-
tistically significant differences were found in FVC
[MD = − 0.33 (95%CI − 0.48 to − 0.18), P < 0.001,
I 2 = 0%] and FVC% [MD = − 15.06 (95%CI − 18.26 to
− 11.86), P < 0.001, I 2 = 50%], respectively. A fixed
effects model was utilized due to moderate heterogeneity.
Three trials including 74 subjects reported FEV1 or
FEV1% between pre- and post-traction. As shown in
Fig. 6, statistically significant differences were found in
FEV1 [MD = − 0.21 (95%CI − 0.35 to − 0.07), P < 0.001,
I2 = 0%] and FEV1% [MD = − 10.60 (95%CI − 13.18 to
− 8.02), P < 0.001, I2 = 0%], respectively. A fixed effects
model was utilized.
Publication bias
Sagittal Cobb angle was the primary outcome of included tri-
als. Therefore, the outcome index was used to make a fun-
nel plot to detect publication bias, as shown in Fig. 7. Visual
inspection of the funnel plots showed symmetry, suggesting
that there was no publication bias.

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European Spine Journal

Fig. 2  A forest plot depicting the changes in coronal Cobb angle of scoliosis patients between pre- and post-traction measurements

Fig. 3  A forest plot depicting the changes in sagittal Cobb angle of scoliosis patients between pre- and post-traction measurements

Fig. 4  A forest plot depicting the changes in height of scoliosis patients between pre- and post-traction measurements

13

Fig. 5  A forest plot depicting the changes in FVC predicted value of scoliosis patients between pre- and post-traction measurements
Fig. 6  A forest plot depicting the changes in FEV1 predicted value of scoliosis patients between pre- and post-traction measurements
Discussion
Since halo-pelvic traction was applied for spinal deformi-
ties in 1971, it became the optimal treatment due to
desired correction rate [7, 19]. However, the utilization of
halo-pelvic traction has gradually declined with the rise
of internal fixation. Clinically, the long period of wear for
7.5 months leads to intense discomfort and various com-
plications in most patients [20]. Generally, internal fixa-
tion or osteotomy is feasible for most spinal deformities.
Nevertheless, patients with rigid severe spinal deformity
suffer from combination of cardiopulmonary and diges-
tive dysfunction [21, 22], the relative poor nutritional sta-
tus [23]. One-stage orthopedics surgical operation may
encounter complex or infeasible osteotomy, long opera-
tion time, massive intraoperative and postoperative blood
loss [24], and even irreversible spinal cord injury [25].
As such, the incidence of various complications in the
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perioperative period is significantly increased [26]. Indeed,
it is difficult to achieve a satisfactory curative effect after
one-stage orthopedic surgery, especially when the Cobb
angle exceeds 120º [2]. Preoperative reduction in Cobb
angles, improvement of pulmonary function, cardiac func-
tion and basic nutritional status significantly reduced the
risk of surgery [27]. Thus, preoperative halo-traction was
recommended to increase the correction rate and safety of
second-stage surgery.
In the present study, halo-pelvic traction achieved signifi-
cant improvements in preoperative correction. The results
showed that the pooled mean change of coronal and sagittal
Cobb angle was 63.36º and 49.66º, respectively. In addition,
there showed an increase in height with the pooled mean
change of 13.92 cm. According to spinal biomechanics, the
constant longitudinal force induced persistent fatigue of
muscles, slight displacement and rupture of tendons, liga-
ments, blood vessels and spinal cord cells. As such, tissue
cells spontaneously repaired to adapt to new structural
European Spine Journal
Fig. 7  Funnel plot to detect
publication bias for the studies
states, and the correction was achieved. Clinically, it had
substantial advantages by sharing the orthopedic pressure
during surgery, simplifying the procedure and reducing
the risk of nerve damage. Moreover, the extension of spine
length may significantly increase the volume of the thoracic
and abdominal cavity which effectively improves the pul-
monary and digestive function, nutritional status and better
tolerance for aggressive surgery [28]. In addition, it may
also provide a basis for surgical efficacy and prognosis. The
principle was that the spinal flexibility can be evaluated by
slow and continuous traction, so as to predict the correction
degree of scoliosis, which played a crucial role in the pre-
vention of spinal cord and nerve injury caused by excessive
correction. Then, we performed sensitivity analyses due to
severe heterogeneity. A combination of halo-pelvic traction
and thoracoplasty before osteotomy showed better results
regarding the coronal Cobb angle with the pooled mean
change of 68.47º. However, the difference was not signifi-
cant in outcomes with or without thoracoplasty. According
to the report [2], the average 2-year correction rate was 65%
and 64% respectively. Of note, Koller et al. [29] indicated
that the change was more observable in flexible curves.
We speculated that differences in spine flexibility may be a
major reason for severe heterogeneity.
In general, creating a better chest wall or chest volume was
a commonly used way to improve lung function in patients
with severe spinal deformities [30]. Halo-pelvic traction
improved the pulmonary functions regarding FVC and FEV1
in the present study, mainly as it successfully corrected the
curvature, stretched the spine, improved the volume of the
thoracic cavity and function of the diaphragm [31]. LaMont
et al. [32] demonstrated the correlation between pulmonary
function tests and thoracic height after halo-gravity traction.
Huh et al. [33] reported that the Cobb angle was negatively
correlated with FVC. However, one meta-analysis showed
that the Cobb angle improved more significantly than lung
function in patients, which may be due to the inherent defect
of noncontinuous traction by halo-gravity traction [12].
Patients with severe scoliosis often encounter malnutrition
due to physical inactivity and metabolic disorders [4]. The
nutritional status was not reported in the current study. How-
ever, it was noted that growing rod constructs was beneficial
to improvement in percentage weight gain, especially for idi-
opathic and congenital scoliosis [34]. There may be several
reasons. One mechanism may be reduced energy expenditure
through improved respiratory function [35], in addition to the
intensive intervention of the clinical dietitian during hospi-
talization [32]. Besides, it may also correlate to the correction
of gastrointestinal malalignment [36]. Overall, future studies
are warranted to fully confirm these conclusions.
Compared to widely used halo-gravity traction, halo-pel-
vic traction may be more applicable for severe rigid spinal
deformity. Theoretically, halo-pelvic traction provides fur-
ther effective, continuous, controllable corrective strength. It
was proved to be an ideal treatment for tuberculous kyphosis
represented by rigid severe spinal deformities [22]. On the
contrary, the strength of halo-gravity traction may reach a
plateau within 2 weeks and subject to small traction weight of
up to one-half body weight. In a comparative study, patients
treated with halo-pelvic traction exhibited a better correction
13

rate and pulmonary function, with less high-grade osteoto-
mies [10]. Halo-gravity traction was widely used in clinical
practice largely due to its convenience and the lower inci-
dence of traction-related complications [28]. However, halo-
pelvic traction was reliable with relatively minor complica-
tions which can be significantly relieved by considerate care,
reasonable traction strength and duration. In this study, the
complication rate was 6.6%—26.7% including pin infections,
cervical stiffness and neurological symptoms. More impor-
tantly, no permanent neurological deficits or death occurred
and symptoms disappeared after prompt traction adjustment
and intensive care. In recent years, clinical studies showed
the testing and improvement of various details of the traction
frame in halo-pelvic traction devices [2, 13, 17, 37]. Indeed,
the effect of traction was better when the resultant force line is
located on the concave side of the spinal deformity. Therefore,
the modified halo-pelvic traction with the rod located ante-
rolateral to the patient is more suitable for severe kyphosis.
Nevertheless, three-dimensional printing techniques and bio-
mechanical measurement were necessary to verify the stabil-
ity and rationality of the innovative design, and to promote the
standardized design which would greatly improve the curative
effect and popularize halo-pelvic traction treatment.
Limitation
To the best of our knowledge, this was the first meta-anal-
ysis to evaluate the effectiveness and safety of halo-pelvic
traction on severe scoliosis. However, the study had some
limitations. First, the number of studies included was lim-
ited, which may influence the overall research conclusions.
Second, different treatments, elongation rates and duration
of traction may increase heterogeneity. Also, the included
studies lacked control groups to draw sufficient conclusions.
Third, the present study only analyzed pre- and post-traction
data. The long-term correction efficacy, respiratory system
function, quality of life, nutritional status and complications
remain to be observed. Based on the above, more RCTs are
needed in the future to better determine efficacy and facili-
tate standardized treatment regimens.
Conclusion
In conclusion, preoperative halo-pelvic traction achieved
significant improvements in spinal deformity and pulmonary
functions, with minor and curable complications. Our sys-
tematic review and meta-analysis provided moderate-quality
evidence that halo-pelvic traction was an effective and safe
solution before surgery, and it may be the optimal choice for
severe scoliosis. Future researches are needed to determine
the long-term efficacy on comprehensive assessment and
explore the appropriate traction strategy.
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European Spine Journal
Acknowledgements The authors acknowledge the staff in this study
for their collaboration involved in this work.
Funding None.
Data availability The datasets analyzed during the current study are
available from the corresponding author on reasonable request.
Declarations
Conflict of interest The authors declare that they have no conflict of
interest.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
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