Utilization patterns in preoperative halo gravity traction for pediatric spine patients: are we stretching the indications?

Abstract

To describe registry-observed trends in preoperative halo gravity traction (HGT) utilization across a multicenter pediatric spine database. This retrospective study used the Pediatric Spine Study Group (PSSG) registry to identify patients treated with preoperative HGT between 2009 and 2024. Patients with cervical pathology or intraoperative-only traction were excluded. Variables included demographics, diagnosis, age at HGT initiation, pre-halo coronal curvature, and sagittal kyphosis. Utilization trends were assessed using binomial logistic regression; coronal curve severity trends were evaluated using linear regression; and etiologic composition was assessed using one-vs-rest binomial logistic regression. The cohort had a mean age of 7.5 ± 3.6 years at HGT initiation, with 56.1% female. Age at index surgery increased modestly over the study period (β = 0.18 years/year), driven primarily by growth-friendly procedures. Baseline coronal curve severity increased modestly (+ 0.85°/year; p = 0.003). Mean pre-halo sagittal kyphosis was 80.0 ± 29.5° and remained stable. HGT was increasingly represented among growth-friendly procedures (OR 1.08/year; p < 0.001), while its use preceding definitive fusion remained stable. Etiologic distribution did not change across the study period. Within this large multicenter registry, HGT use increasingly preceded growth-friendly procedures over time, while its application before definitive fusion remained stable. Pre-traction coronal curve severity and age at HGT initiation increased gradually, potentially reflecting a growing willingness to defer surgery in anticipation of HGT's ability to temporize larger curves.