Beyond the Cobb angle: the radiographic measurement differences from halo gravity traction in patients with severe spine deformities before scoliosis surgical correction. Cross-sectional study

Beyond the Cobb angle: the radiographic measurement differences from halo gravity traction in patients with severe spine deformities before scoliosis surgical correction. 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Cross-sectional study Alderico Girão Campos de Barros, Giancarlo Jorio Almeida, Gabriel Farias Alves, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6588244/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Sep, 2025 Read the published version in European Spine Journal → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Preoperative halo gravity traction (HGT) is widely used in the management of severe spinal deformities to improve surgical outcomes and reduce risks associated with definitive correction. However, its effects on radiographic parameters beyond the Cobb angle improvement remain underexplored. This study evaluated whether HGT provides additional radiographic benefits beyond the Cobb angle correction, particularly in the shoulder, trunk, pelvis, and lower limb alignment. Methods We conducted a retrospective analysis of patients with severe spinal deformities who underwent HGT from 2017 to 2023 in a public quaternary orthopaedic institution. Radiographic measurements taken before and after traction were compared, assessing coronal and sagittal alignment, pelvic obliquity, shoulder alignment, and spinopelvic parameters. Statistical significance was determined using paired tests (p ≤ 0.05). Results Among the 15 patients (mean age: 16.9 years) included, HGT led to significant reductions in coronal Cobb (22.2%) and sagittal Cobb (21.3%). Shoulder balance improved, as indicated by decreased clavicular angle and T1 tilt. Trunk misalignment was reduced, with improvements in apical vertebra translation, coronal balance, and thoracic trunk shift. Pelvic obliquity corrections were statistically significant. Spinopelvic parameters showed minimal and non-significant changes. No major complications were reported. Conclusion HGT benefits extend beyond Cobb angle reduction, significantly improving overall spinal alignment. These findings suggest that HGT may contribute to a more balanced and harmonious correction while remaining a safe treatment. MeSH: Traction; Scoliosis; Spinal curvatures; Radiography Figures Figure 1 Figure 2 Figure 3 Introduction In developing countries, the waiting time for severe scoliosis surgery (exceeding 90–100 degrees of the Cobb angle) is well above the ideal.[ 1 , 2 ] Numerous factors affect the time until treatment, such as location, magnitude and stiffness of the curve, sagittal and coronal balances, the patient’s clinical condition and its capacity to tolerate extensive procedures, the surgical team’s expertise, and the available resources.[ 3 – 5 ] The management of these patients requires the use of diverse strategies: halo gravity traction (HGT), internal temporary distraction, anterior and posterior column releases, osteotomies, and correction manoeuvres. Most of the time, these tools are used in combination.[ 3 , 6 – 8 ] The cranial halo was introduced during the 1960s by Perry and Nickel to treat patients with scoliosis secondary to poliomyelitis.[9] Since then, several means of traction have been developed, such as halo-femoral, halo-pelvic and halo-tibial, presenting satisfactory outcomes.[ 4 ] Due to its lower complication rate and greater patient tolerance, HGT is the most widely used.[ 5 , 10 ] and has become fundamental in managing complex spine deformities in the last decades. Beyond the clinical symptoms benefits, this tool can modify the final surgical strategy, sparing the patient of bigger osteotomies.[ 11 ] However, most studies on the benefits of preoperative HGT in treating complex spinal deformities focus on the improvement of the angular value of the curve.[ 4 , 5 , 10 , 12 ] This study aimed to evaluate whether these benefits go beyond the magnitude of the curve measured by the Cobb angle. We hypothesized that there may also be an improvement in other radiographic parameters related to the balance of shoulders, trunk, pelvis and lower limbs. Methods To verify the hypothesis that HGT could bring benefits beyond the Cobb angle correction, we designed this observational, retrospective study carried out by reviewing medical records and radiographic images of patients with severe spinal deformities treated with preoperative HGT in a referral centre. We compared the imaging measurements registered before and after traction as routinely performed in a quaternary orthopaedic health institute that is part of a public health system. The study protocol was approved by the local ethics committee, and the patients or their guardians consented to their images and photographs to be shown in anonymized case descriptions like the ones reported here. This article is reported following the STROBE guideline.[ 13 ] All consecutive cases of patients with scoliosis, with all curve etiologies, were included in this study if they had been submitted to HGT from 2017 to 2023 in the same institution. Patients with deformities of less than 100 degrees of Cobb were excluded. We also excluded cases where halo traction was used only during surgery or between surgical stages and patients undergoing less than two weeks of traction. According to the service routine, the halo had been applied with patients under sedation, with 4 to 6 traction pins each, following the principles of cranial halo application, and tensioned to 6 to 8 in-lb, considering a normal cranial density. Traction was started approximately 12 hours after the procedure, with an initial weight of 5 kg. The traction weight was increased every 24 hours by approximately 1 kg, according to the patient’s tolerance. Each patient was encouraged to use and alternate between traction in bed, in a traction chair and with an orthostasis traction device. All patients underwent physiotherapy and nutritional reinforcement during hospitalization to improve their nutritional status and lung capacity for subsequent definitive surgery. After reaching maximum tolerance weight in traction or 50% of body weight, patients continued in HGT traction until there was no further improvement in the deformity according to Cobb angle measurements. For this study, we collected, from the medical records, only the results of the initial radiographs and the final preoperative HGT radiographs without any evaluation of the surgical results. Coronal and sagittal trunk balance parameters, shoulder balance, pelvic obliquity and spinopelvic parameters were analysed based on the Scoliosis Research Society’s Spinal Deformity Study Group Radiographic Measurement Manual.[ 14 ] The evaluated parameters were: curve angle using the Cobb method for the proximal thoracic, main thoracic and thoracolumbar or lumbar curves; the T1 tilt angle; the clavicular angle; the radiographic shoulder height (RSH); the Risser scale of skeletal maturity; the apical vertebra translation; the coronal balance; the thoracic trunk shift; the leg length discrepancy; the sacral obliquity; the pelvic obliquity through Maloney and Osebold methods; the thoracic sagittal alignment; the sagittal vertebral alignment (SVA); the sagittal Cobb; and the spinopelvic parameters.[ 15 – 17 ] Improvement was assessed through weekly radiography scans under traction and subsequent comparison of these with previous radiographs. Once a plateau of deformity improvement was reached, the surgery was scheduled. One author (GJA) collected data from medical records and anonymised and registered them in a Microsoft Excel spreadsheet. All parameters were measured with the Surgimap software, version 2.3.2.1, validated for spine surgery planning[ 18 , 19 ]. The parameters were initially measured by GJA (spine surgery fellow), with posterior revision by two senior surgeons (AGCB and LECTS). Statistical analysis was performed using the GraphPad Prism 8 software (GraphPad Software). The data were assessed for normality using the Kolmogorov-Smirnoff test. The results of the numerical variables were presented as means and standard deviations. For categorical variables, frequencies and percentages were calculated. Paired T or Wilcoxon tests were used to compare pre and post-HGT values. A p-value of 0.05 or lower was considered significant. Results From 2017 to 2023, 15 patients underwent preoperative HGT and were found eligible to be included in this study; none were excluded. Eight (53.3%) were female. The patients’ ages ranged from 9 to 32 years, with an average of 16.9 years. Their skeletal maturity from Risser 0 to 5 [2 Risser 0 patients (13.3%); 1 Risser 2 (6.6%); 2 Risser 3 (13,3%); 1 Risser 4 (6,6%); and 9 Risser 5 (60%)]. Table 1 describes the demographic and radiographic characteristics of all patients individually. Table 1 Baseline demographic and radiographic characteristics of patients with severe spinal deformities undergoing halo gravity traction (HGT) before scoliosis surgical correction. Measurements of Cobb angles in radiographs taken at admission and post HGT traction. Patient Scoliosis diagnosis Sex Age (years) Risser Time under HGT (days) Initial Cobb Post-HGT Cobb Reduction Initial sagittal Cobb Post-HGT sagittal Cobb Reduction 1 Adolescent idiopathic M 32 5 30 165.7 89.6 46% 148.4 126.3 15% 2 Congenital M 11 0 54 17 12.7 25% 115.2 89 23% 3 Adolescent idiopathic F 18 5 54 127.7 108.9 15% 99.2 92.8 6% 4 Adolescent idiopathic F 13 4 42 143.3 130.6 9% 73.6 53.2 28% 5 Adolescent idiopathic F 17 5 95 148.3 70.9 52% 101.2 92.3 9% 6 Neuromuscular M 9 0 27 106.5 94.9 11% 80.6 53 34% 7 Adolescent idiopathic M 11 2 30 127.5 99.2 22% 119.4 86.3 28% 8 Adolescent idiopathic M 20 5 28 129.2 104.4 19% 92.8 104.7 -13% 9 Congenital F 29 5 23 132.7 131.1 1% 125.8 120.4 4% 10 Adolescent idiopathic M 19 5 14 148.6 127.6 14% 123.7 103.1 17% 11 Syndromic M 11 3 30 132.2 111.1 16% 84.3 30.5 64% 12 Adolescent idiopathic F 20 5 55 131.5 88.5 33% 55.9 39.3 30% 13 Adolescent idiopathic F 15 5 30 125.5 105.7 16% 70.3 54.9 22% 14 Adolescent idiopathic F 18 5 36 117.9 86.5 27% 70.3 61.4 13% 15 Congenital F 10 3 38 120.9 88.1 27% 79.1 46.7 41% Average : 16.9 39.1 125.0 96.7 22.2% 96.0 76.9 21.3% According to the protocol, all participants received HGT preoperative treatment until there was no further improvement in the deformity. There were no major complications or intolerance requiring HGT interruption. The traction time ranged from 14 to 55 days, averaging 39.1 days. Coronal Cobb reduced on average 22.2%, and the sagittal Cobb reduced 21.3% (Table 1 ). A statistically significant reduction in Cobb angles was found between the pre- and post-traction for the proximal thoracic (of 7.7 degrees), main thoracic (31.2), and thoracolumbar or lumbar curves (15.1) (Table 2 ). Table 2 Radiographic measurements in patients with severe spinal deformities pre and post halo gravity tension (HGT) treatment Variables Pre-HGT Post-HGT P-value Proximal thoracic Cobb (degrees) 59.0 ± 20.2 51.3 ± 21.5 0.02 a Main thoracic Cobb (degrees) 124.6 ± 34.4 93.4 ± 33.5 < 0.0001 b Thoracolumbar lumbar Cobb (degrees) 53.0 ± 36.6 37.9 ± 24.4 0.0064 a T1 tilt angle (degrees) 23.6 ± 27.7 18.8 ± 18.0 0.15 a Clavicular angle (degrees) 7.3 ± 5.5 4.0 ± 3.6 0.015 a Apical vertebra translation (mm) 85.4 ± 27.8 68.5 ± 31.4 0.01 a Coronal balance (mm) 23.8 ± 19.4 14.3 ± 14.5 0.03 a Thoracic trunk shift (mm) 33.7 ± 22.2 18.1 ± 15.7 0.003 b Leg length discrepancy (mm) 14.4 ± 13.3 7.1 ± 6.0 0.007 b Sacral obliquity (degrees) 8.5 ± 6.8 5.7 ± 5.5 0.005 a Osebold (degrees) 7.9 ± 8.6 4.2 ± 4.0 0.009 b Maloney (degrees) 10.9 ± 9.1 5.8 ± 8.0 0.0004 b Sagittal vertebral alignment 32.5 ± 66.6 36.4 ± 55.0 0.45 b T2T12 96.1 ± 33.9 74.2 ± 17.5 0.06 a T2T5 12.5 ± 28.0 12.5 24.8 > 0.999 a T5T12 95.4 ± 24.5 79.8 ± 21.6 0.01 a Sagittal Cobb (degrees) 95.9 ± 26 76 ± 30.3 0.0003 a Pelvic tilt (degrees) 10.6 ± 10.5 7.5 ± 8.8 0.42 b Pelvic incidence (degrees) 47.2 ± 27.0 47.7 ± 30.9 0.32 b Sacral slope (degrees) 34.0 ± 6.5 34.9 ± 7.2 0.72 a Lumbar lordosis (degrees) 77.1 ± 19.5 70.6 ± 18.5 0.20 b T: number of the thoracic vertebra. a Paired T test; b Wilcoxon test. Table 2 shows variables related to shoulder alignment. There was a statistically significant decrease in clavicular angle (of 3.3 degrees). A T1 tilt angle decrease occurred (of 4.8 degrees), albeit not statistically significant. The planned radiographic shoulder height (RSH) evaluation could not be performed in this study due to limitations in the images available, as the acromioclavicular joint appeared clearly in only a few cases. The trunk misalignment also decreased, as shown by the change in the apical vertebra translation (difference of 16.9 mm), the coronal balance (reducing 9.5 mm), and the thoracic trunk shift (15.6 mm less post-traction). All changes in trunk misalignment were statistically significant. Pelvic obliquity also improved (Table 2 ). Leg length discrepancy (7.3 mm less) significantly decreased, as did sacral obliquity (2.8 degrees less) and in the Maloney (5.1) and the Osebold methods (3.7). In the sagittal plane, we observed an improvement in the sagittal Cobb deformity (19.9 degrees of difference). However, there were no appreciable changes in the spinopelvic parameters after traction, described by pelvic tilt (3.1 degrees), pelvic incidence (only 0.5), sacral slope (0.9) and lumbar lordosis (6.5). The sagittal vertebral alignment also had a non-statistically significant increase of 3.9 millimetres. Figures 1 , 2 and 3 describe cases where improvements were clinically visible (through photographs) and, sometimes, statistically significant (by imaging measurements) before and after HGT. Discussion The vast majority of studies [ 5 , 6 , 11 , 12 ] involving preoperative HGT and patients with spinal deformity are restricted to the radiographic evaluation of the degree of improvement in the angular value of the curve using the Cobb method. This finding was confirmed in our results: indeed, the Cobb angle improved in all patients. However, we investigated other radiological parameters to estimate the three-dimensional improvement of the deformity, such as the balance of the shoulders, trunk and pelvis, which could also have benefited from traction. These are often the changes that draw the most attention during the clinical examination, and their correction brings a more harmonious result and greater patient satisfaction.[ 20 – 22 ] Even when such a significant improvement in angular value is not obtained with the use of HGT, such as in cases with complex congenital defects, or when the clinical condition does not allow a major osteotomy, the improvement of secondary structured curves that are made flexible through prolonged traction can be clinically significant. These were confirmed in this study, where all shoulder alignment and all pelvic obliquity evaluations had statistically significant differences, which were clinically significant in photographs and imaging analyses (examples shown in the Figures). These are flagrant benefits from HGT only that need to be confirmed in randomised clinical trials where ethically appropriate. The surgical management of patients with severe and rigid spinal deformities is quite challenging, both from an orthopaedic and clinical point of view. Often, these patients cannot receive adequate surgical treatment or are neglected. The decision to operate them is difficult and must be shared with other specialists, the patient and family members, clarifying the complexity, time and risks. In these cases, HGT could be fundamental in improving the deformity in just a few weeks, allowing the patient to undergo less aggressive spinal surgery. The indication for HGT follows a combination of criteria: extension and rigidity of the deformity, the degree of pulmonary involvement, the presence of neurological deficit in a severe decompensated curve and preoperative adaptation of the spinal cord to the stress of surgical correction.[ 4 ] There is already considerable evidence for the preoperative HGT advantages, such as a reduced need for three-column osteotomy, lower neurological risk, time for preoperative nutritional support, reduced stress on implants, improvement of respiratory function and strengthening of the doctor-patient relationship.[ 4 , 6 , 11 , 12 , 23 ] In our study, we also systematically measured radiographical improvements. Using HGT in a walker/chair potentially allows greater patient acceptance when compared to other methods of halo cranial traction due to the relative freedom for locomotion, social interaction and exercise, associated with preservation of bone quality, improvement of muscle mass and cardiorespiratory condition[ 24 – 29 ]. However, we did not have access to patients’ acceptance from the medical records. Acceptance or tolerance for traction time should be an important patient-measured outcome (PMO) to consider in future prospective studies. In our clinical experience, the understanding and involvement of the entire multidisciplinary team in the treatment is fundamental. As shown in our results, most patients tolerate the prolonged use of HGT well (in no case reported here HGT had to be interrupted), but this adherence must always be encouraged with emphatic clarifications about the role that the method plays in both reducing risks, complications and obtaining better results. The team in our hospital checks the tolerance daily and we usually see that the first few days are more demanding, with complaints of mild to moderate headache and irritability, especially in young children. After this initial phase, the adaptation is satisfactory. Throughout the traction period, it is important to carry out daily neurological medical evaluations and provide guidance to the patient and their relatives regarding possible complications that may arise, which are generally not serious.[ 5 , 10 ] No major complications were noted in the medical records in the cohort reported here. The reduction observed in clavicle angle in this study is a clear benefit from HGT. Beyond the Cobb reduction, the literature shows an important relationship between shoulder alignment and satisfaction with the surgery. The clavicle angle is one of the most reliable methods to evaluate shoulder height in the context of complex spinal deformities. It is also closely related to patient satisfaction after surgery.[ 16 , 30 ] While we could not evaluate the RSH, the literature directly correlates it to clavicle angle.[ 17 ] T1 tilt did not show a statistically significant reduction after HGT in our study; however, T1 tilt is only mildly related to shoulder balance.[ 31 ] In a study that evaluated mainly teenage girls after surgical correction of scoliosis, shoulder imbalance of 2 centimetres or more was associated with “resentment and grievances”.[ 20 ] The female teenager in Fig. 2 had shoulder alignment improvements visible even in simple photographs. Both the coronal alignment and thoracic trunk shift (TTS) were significantly reduced with HGT. In another study of patients with adolescent idiopathic scoliosis,[ 32 ] the post-surgical satisfaction score in the Scoliosis Research Society-30 questionnaire positively correlated with coronal alignment correction and curve correction rates. The literature also shows an association between TTS and pelvic obliquity (PO), as well as TTS and back pain.[ 33 ] The clinical trunk deformity directly influences the perception of function and self-image in patients with spinal deformities.[ 34 ] In our study, we chose the Osebold and the Maloney methods for calculating PO due to their greater correlation between examiners and preference for most spinal surgeons.[ 15 ] On both methods, there was a statistically significant decrease in PO. Its correction is essential for improving sitting balance and walking in all patients with neuromuscular scoliosis.[ 15 ] An uncorrected PO is also associated with worse health-related quality of life in children and their caregivers at the end of surgical treatment for early-onset scoliosis.[ 35 ] While not addressed directly in our study, improving global spinal alignment has been shown to diminish pain from friction of the ilium and the lower ribs. [ 36 ] Fig. 3 shows a case where this friction was clearly reduced. The length of stay on HGT is multifactorial and the decision must be individualized. In most cases in the literature, and as per routine in our service, after a few weeks, a plateau of improvement is reached, and surgery is scheduled. In the literature, the time of traction varies from 2 to 12 weeks in preoperative HGT, achieving a response of 24.1% reduction in the Cobb angle.[ 30 ] In our study, patients underwent HGT from 2 to 13 weeks, showing an average improvement in the cobb of 22.2%, at which point the surgical procedure was scheduled. In most cases, even in the most severe and rigid curves, the response to traction is satisfactory for both patients and clinicians. The response may be so good in certain situations that the initial surgical plan is altered.[ 11 ] The clinical and radiographic improvement obtained in the alignment of the trunk, shoulders and pelvis, with or without improvement in the angular value, may influence the surgical technique chosen. Surgeons can then avoid major vertebral osteotomies and their inherent complications.[ 10 ] In our cohort, in some cases, a less aggressive surgical technique could be chosen after the radiographical changes seen with traction (although this was not a variable in this study). All previously discussed aspects must be considered when making decisions regarding the best course of action, as well as the patient's profile, the training of the surgical team and the availability of resources.[ 6 , 8 , 37 ] Conclusion The benefits of preoperative halo gravity traction in patients with severe spinal deformities go beyond reducing the curve’s angular value (Cobb angle) and include improving radiographic parameters related to the balance of the shoulders, trunk, pelvis and lower limbs. Declarations Author Contribution AGCB: Study conception, data collection and analysis (imaging review), manuscript writing, final approvalGJA: Data collection and analysis (imaging and patient charts review), manuscript writing, final approvalGFA: Data collection and analysis (patient charts review), manuscript writing, final approvalACL: Data analysis (statistics), manuscript critical review, final approvalLECTS: Data collection and analysis (imaging review), manuscript critical review, final approval Acknowledgement The authors thank Patricia Logullo, PhD, CMPP (Palavra Impressa), for manuscript editing services. References Guiroy A, Carazzo C, Camino-Willhuber G et al (2023) Time to surgery for adolescent idiopathic scoliosis: How long does it take? A multicenter study. World Neurosurg X 19:100187. https://doi.org/10.1016/j.wnsx.2023.100187 Ahn H, Kreder H, Mahomed N et al (2011) Empirically derived maximal acceptable wait time for surgery to treat adolescent idiopathic scoliosis. 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Spine 30:1682–1687. https://doi.org/10.1097/01.brs.0000170590.21071.c1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Sep, 2025 Read the published version in European Spine Journal → Version 1 posted Editorial decision: Revision requested 08 Jul, 2025 Reviews received at journal 15 Jun, 2025 Reviews received at journal 09 Jun, 2025 Reviewers agreed at journal 06 Jun, 2025 Reviewers agreed at journal 03 Jun, 2025 Reviewers invited by journal 13 May, 2025 Editor assigned by journal 10 May, 2025 Submission checks completed at journal 10 May, 2025 First submitted to journal 04 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6588244","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456764430,"identity":"50151707-8e47-4ad8-a29f-8f09b42280e2","order_by":0,"name":"Alderico Girão Campos de Barros","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYDACdgYDBhBiYAbxKg6ABQ88wKeFGUXLmQMMPCAtCQS1wABjG0QLAz4t/M3MGx9XFNjJybvzPvzwcd4dOXuxww+BttjJ6TZg1yJxmK3Y8IxBsrHhYXZjyZnbnhnzSKcZALUkG5sdwGHNYR4zyQaDA4kbm9kYpHm3HU7skU4AaTmQuA2HFvnDPOY/oVqYf/POAWlJ/4BXiwHQFkaQlvnMbGzSvA0gLTn4bTEE+gXosGRjA6AWyxnHDhvz3M4pOJBggNsvcsebN35s+AMMsf5jzDc+1ByWY5+dvvnDhwo7OZzeh7sQVYEBdlUoQL6BCEWjYBSMglEwMgEAa7tc6QAuBPIAAAAASUVORK5CYII=","orcid":"","institution":"(INTO) National Institute of Orthopedics and Traumatology","correspondingAuthor":true,"prefix":"","firstName":"Alderico","middleName":"Girão Campos","lastName":"de Barros","suffix":""},{"id":456764431,"identity":"571df0d7-718e-445a-9c35-b9d885af651c","order_by":1,"name":"Giancarlo Jorio Almeida","email":"","orcid":"","institution":"(INTO) National Institute of Orthopedics and Traumatology","correspondingAuthor":false,"prefix":"","firstName":"Giancarlo","middleName":"Jorio","lastName":"Almeida","suffix":""},{"id":456764432,"identity":"73ab0161-e630-4207-99a6-2b41f9781a7d","order_by":2,"name":"Gabriel Farias Alves","email":"","orcid":"","institution":"(INTO) National Institute of Orthopedics and Traumatology","correspondingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"Farias","lastName":"Alves","suffix":""},{"id":456764433,"identity":"f4105c90-8592-4fb9-8586-fdbcd4674b9e","order_by":3,"name":"Ana Carolina Leal","email":"","orcid":"","institution":"(INTO) National Institute of Orthopedics and Traumatology","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Carolina","lastName":"Leal","suffix":""},{"id":456764434,"identity":"76facf4e-43ac-4aea-9bf2-3f1d8fcb6709","order_by":4,"name":"Luis Eduardo Carelli Teixeira da Silva","email":"","orcid":"","institution":"(INTO) National Institute of Orthopedics and Traumatology","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Eduardo Carelli Teixeira da","lastName":"Silva","suffix":""}],"badges":[],"createdAt":"2025-05-04 11:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6588244/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6588244/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00586-025-09270-5","type":"published","date":"2025-09-12T15:57:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82891363,"identity":"37142c7f-d309-4b84-af18-1036379d4eb4","added_by":"auto","created_at":"2025-05-16 12:12:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107550,"visible":true,"origin":"","legend":"\u003cp\u003eAspect of a 20-year-old male patient (patient #8) presenting a neglected severe scoliosis due to multiple congenital malformations, with important trunk shift and a severe restrictive lung disease. Due to his clinical conditions, no major osteotomies were performed. Nevertheless, a satisfactory outcome was accomplished with halo gravity traction (HGT). (a) and (b) preoperative photographs, right lateral view and anterior view; (c) and (d) preoperative radiographs, anterior-posterior (AP) and lateral; (e) and (f) last radiograph with HGT, AP and lateral; (g) and (h) postoperative radiographs, AP and lateral; (i) and (j) postoperative photographs, lateral and anterior views.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6588244/v1/b5a5bcde37124e03b250a195.jpg"},{"id":82892752,"identity":"76de5a18-2f85-4972-9deb-0432233f76ef","added_by":"auto","created_at":"2025-05-16 12:20:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92408,"visible":true,"origin":"","legend":"\u003cp\u003eAspect of a 10-year-old girl (patient #15) with a rapidly progressive severe scoliosis due to multiple congenital malformations. Halo gravity traction(HGT) followed by closing wedge osteotomy were performed. Note how much HGT improved the apparent limb discrepancy, the shoulder and pelvic alignment (red arrows), before the surgery. (a) Computed tomography (CT) scan (not used in measurements for this study), coronal view, showing multiple bone fusions; (b) preoperative clinical photograph; (c) preoperative anterior-posterior (AP) radiograph; (d) post-HGT clinical photograph; (e) final AP radiograph with HGT; (f) post-operative clinical photograph; (g) post-operative AP radiograph.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6588244/v1/1fd0d56b2fa9d893d4670dcf.jpg"},{"id":82891364,"identity":"ad5a447e-e2fb-4ff2-9299-b6b0dbe92034","added_by":"auto","created_at":"2025-05-16 12:12:47","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":81931,"visible":true,"origin":"","legend":"\u003cp\u003eShoulder and pelvic parameters improvement after halo gravity traction(HGT). (a) Pre-HGT anterior-posterior (AP) radiograph of the spine with an important rigid pelvic obliquity (patient #7) (b) Post-HGT AP radiograph showing the improvement of the pelvic obliquity (patient #7). (c) Pre-HGT AP radiographic view with significant shoulder malalignment (patient #4). (d) Correction of shoulder alignment post-HGT (patient #4).\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6588244/v1/c60ab74346eac6d3bfb4c19b.jpg"},{"id":91818343,"identity":"f2206049-24eb-4249-b780-778f42bc2b8e","added_by":"auto","created_at":"2025-09-22 07:03:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1024624,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6588244/v1/5094c87d-5c2d-4839-af8d-78bc4f6a7f10.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond the Cobb angle: the radiographic measurement differences from halo gravity traction in patients with severe spine deformities before scoliosis surgical correction. Cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn developing countries, the waiting time for severe scoliosis surgery (exceeding 90\u0026ndash;100 degrees of the Cobb angle) is well above the ideal.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Numerous factors affect the time until treatment, such as location, magnitude and stiffness of the curve, sagittal and coronal balances, the patient\u0026rsquo;s clinical condition and its capacity to tolerate extensive procedures, the surgical team\u0026rsquo;s expertise, and the available resources.[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The management of these patients requires the use of diverse strategies: halo gravity traction (HGT), internal temporary distraction, anterior and posterior column releases, osteotomies, and correction manoeuvres. Most of the time, these tools are used in combination.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe cranial halo was introduced during the 1960s by Perry and Nickel to treat patients with scoliosis secondary to poliomyelitis.[9] Since then, several means of traction have been developed, such as halo-femoral, halo-pelvic and halo-tibial, presenting satisfactory outcomes.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Due to its lower complication rate and greater patient tolerance, HGT is the most widely used.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and has become fundamental in managing complex spine deformities in the last decades. Beyond the clinical symptoms benefits, this tool can modify the final surgical strategy, sparing the patient of bigger osteotomies.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, most studies on the benefits of preoperative HGT in treating complex spinal deformities focus on the improvement of the angular value of the curve.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] This study aimed to evaluate whether these benefits go beyond the magnitude of the curve measured by the Cobb angle. We hypothesized that there may also be an improvement in other radiographic parameters related to the balance of shoulders, trunk, pelvis and lower limbs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e To verify the hypothesis that HGT could bring benefits beyond the Cobb angle correction, we designed this observational, retrospective study carried out by reviewing medical records and radiographic images of patients with severe spinal deformities treated with preoperative HGT in a referral centre. We compared the imaging measurements registered before and after traction as routinely performed in a quaternary orthopaedic health institute that is part of a public health system.\u003c/p\u003e \u003cp\u003eThe study protocol was approved by the local ethics committee, and the patients or their guardians consented to their images and photographs to be shown in anonymized case descriptions like the ones reported here. This article is reported following the STROBE guideline.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAll consecutive cases of patients with scoliosis, with all curve etiologies, were included in this study if they had been submitted to HGT from 2017 to 2023 in the same institution. Patients with deformities of less than 100 degrees of Cobb were excluded. We also excluded cases where halo traction was used only during surgery or between surgical stages and patients undergoing less than two weeks of traction.\u003c/p\u003e \u003cp\u003eAccording to the service routine, the halo had been applied with patients under sedation, with 4 to 6 traction pins each, following the principles of cranial halo application, and tensioned to 6 to 8 in-lb, considering a normal cranial density. Traction was started approximately 12 hours after the procedure, with an initial weight of 5 kg. The traction weight was increased every 24 hours by approximately 1 kg, according to the patient\u0026rsquo;s tolerance. Each patient was encouraged to use and alternate between traction in bed, in a traction chair and with an orthostasis traction device. All patients underwent physiotherapy and nutritional reinforcement during hospitalization to improve their nutritional status and lung capacity for subsequent definitive surgery. After reaching maximum tolerance weight in traction or 50% of body weight, patients continued in HGT traction until there was no further improvement in the deformity according to Cobb angle measurements.\u003c/p\u003e \u003cp\u003eFor this study, we collected, from the medical records, only the results of the initial radiographs and the final preoperative HGT radiographs without any evaluation of the surgical results. Coronal and sagittal trunk balance parameters, shoulder balance, pelvic obliquity and spinopelvic parameters were analysed based on the Scoliosis Research Society\u0026rsquo;s Spinal Deformity Study Group Radiographic Measurement Manual.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The evaluated parameters were: curve angle using the Cobb method for the proximal thoracic, main thoracic and thoracolumbar or lumbar curves; the T1 tilt angle; the clavicular angle; the radiographic shoulder height (RSH); the Risser scale of skeletal maturity; the apical vertebra translation; the coronal balance; the thoracic trunk shift; the leg length discrepancy; the sacral obliquity; the pelvic obliquity through Maloney and Osebold methods; the thoracic sagittal alignment; the sagittal vertebral alignment (SVA); the sagittal Cobb; and the spinopelvic parameters.[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eImprovement was assessed through weekly radiography scans under traction and subsequent comparison of these with previous radiographs. Once a plateau of deformity improvement was reached, the surgery was scheduled. One author (GJA) collected data from medical records and anonymised and registered them in a Microsoft Excel spreadsheet. All parameters were measured with the Surgimap software, version 2.3.2.1, validated for spine surgery planning[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The parameters were initially measured by GJA (spine surgery fellow), with posterior revision by two senior surgeons (AGCB and LECTS).\u003c/p\u003e \u003cp\u003eStatistical analysis was performed using the GraphPad Prism 8 software (GraphPad Software). The data were assessed for normality using the Kolmogorov-Smirnoff test. The results of the numerical variables were presented as means and standard deviations. For categorical variables, frequencies and percentages were calculated. Paired T or Wilcoxon tests were used to compare pre and post-HGT values. A p-value of 0.05 or lower was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2017 to 2023, 15 patients underwent preoperative HGT and were found eligible to be included in this study; none were excluded. Eight (53.3%) were female. The patients\u0026rsquo; ages ranged from 9 to 32 years, with an average of 16.9 years. Their skeletal maturity from Risser 0 to 5 [2 Risser 0 patients (13.3%); 1 Risser 2 (6.6%); 2 Risser 3 (13,3%); 1 Risser 4 (6,6%); and 9 Risser 5 (60%)]. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the demographic and radiographic characteristics of all patients individually.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographic and radiographic characteristics of patients with severe spinal deformities undergoing halo gravity traction (HGT) before scoliosis surgical correction. Measurements of Cobb angles in radiographs taken at admission and post HGT traction.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScoliosis diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRisser\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTime under HGT (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInitial Cobb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePost-HGT Cobb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eReduction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eInitial sagittal Cobb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePost-HGT sagittal Cobb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eReduction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e165.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e89.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e148.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e126.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e115.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e127.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e108.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e99.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e92.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e143.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e130.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e73.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e53.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e148.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e70.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e52%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e101.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e92.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeuromuscular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e106.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e94.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e80.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e34%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e127.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e99.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e119.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e86.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e129.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e104.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e92.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e104.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e132.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e131.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e125.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e120.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e148.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e127.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e123.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e103.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSyndromic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e132.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e111.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e84.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e64%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e131.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e55.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e30%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e125.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e105.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e70.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdolescent idiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e117.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e86.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e70.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e61.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e120.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e79.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e41%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAverage\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e125.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e96.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e22.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e96.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e76.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e21.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the protocol, all participants received HGT preoperative treatment until there was no further improvement in the deformity. There were no major complications or intolerance requiring HGT interruption. The traction time ranged from 14 to 55 days, averaging 39.1 days. Coronal Cobb reduced on average 22.2%, and the sagittal Cobb reduced 21.3% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A statistically significant reduction in Cobb angles was found between the pre- and post-traction for the proximal thoracic (of 7.7 degrees), main thoracic (31.2), and thoracolumbar or lumbar curves (15.1) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiographic measurements in patients with severe spinal deformities pre and post halo gravity tension (HGT) treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-HGT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-HGT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal thoracic Cobb (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e59.0\u0026thinsp;\u0026plusmn;\u0026thinsp;20.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.3\u0026thinsp;\u0026plusmn;\u0026thinsp;21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain thoracic Cobb (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e124.6\u0026thinsp;\u0026plusmn;\u0026thinsp;34.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.4\u0026thinsp;\u0026plusmn;\u0026thinsp;33.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e \u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracolumbar lumbar Cobb (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e53.0\u0026thinsp;\u0026plusmn;\u0026thinsp;36.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.9\u0026thinsp;\u0026plusmn;\u0026thinsp;24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0064\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1 tilt angle (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;27.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavicular angle (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApical vertebra translation (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e85.4\u0026thinsp;\u0026plusmn;\u0026thinsp;27.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;31.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronal balance (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic trunk shift (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e33.7\u0026thinsp;\u0026plusmn;\u0026thinsp;22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.1\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e \u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg length discrepancy (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.4\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e \u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral obliquity (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsebold (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e \u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaloney (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0004\u003c/b\u003e \u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSagittal vertebral alignment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e32.5\u0026thinsp;\u0026plusmn;\u0026thinsp;66.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.4\u0026thinsp;\u0026plusmn;\u0026thinsp;55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2T12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e96.1\u0026thinsp;\u0026plusmn;\u0026thinsp;33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.2\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2T5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;28.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5 24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT5T12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e95.4\u0026thinsp;\u0026plusmn;\u0026thinsp;24.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.8\u0026thinsp;\u0026plusmn;\u0026thinsp;21.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSagittal Cobb (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e95.9\u0026thinsp;\u0026plusmn;\u0026thinsp;26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u0026thinsp;\u0026plusmn;\u0026thinsp;30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0003\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic tilt (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.42 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic incidence (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.2\u0026thinsp;\u0026plusmn;\u0026thinsp;27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.7\u0026thinsp;\u0026plusmn;\u0026thinsp;30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral slope (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.72 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar lordosis (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e77.1\u0026thinsp;\u0026plusmn;\u0026thinsp;19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eT: number of the thoracic vertebra. \u003csup\u003ea\u003c/sup\u003e Paired T test; \u003csup\u003eb\u003c/sup\u003e Wilcoxon test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows variables related to shoulder alignment. There was a statistically significant decrease in clavicular angle (of 3.3 degrees). A T1 tilt angle decrease occurred (of 4.8 degrees), albeit not statistically significant. The planned radiographic shoulder height (RSH) evaluation could not be performed in this study due to limitations in the images available, as the acromioclavicular joint appeared clearly in only a few cases.\u003c/p\u003e \u003cp\u003eThe trunk misalignment also decreased, as shown by the change in the apical vertebra translation (difference of 16.9 mm), the coronal balance (reducing 9.5 mm), and the thoracic trunk shift (15.6 mm less post-traction). All changes in trunk misalignment were statistically significant.\u003c/p\u003e \u003cp\u003ePelvic obliquity also improved (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Leg length discrepancy (7.3 mm less) significantly decreased, as did sacral obliquity (2.8 degrees less) and in the Maloney (5.1) and the Osebold methods (3.7).\u003c/p\u003e \u003cp\u003eIn the sagittal plane, we observed an improvement in the sagittal Cobb deformity (19.9 degrees of difference). However, there were no appreciable changes in the spinopelvic parameters after traction, described by pelvic tilt (3.1 degrees), pelvic incidence (only 0.5), sacral slope (0.9) and lumbar lordosis (6.5). The sagittal vertebral alignment also had a non-statistically significant increase of 3.9 millimetres.\u003c/p\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e describe cases where improvements were clinically visible (through photographs) and, sometimes, statistically significant (by imaging measurements) before and after HGT.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe vast majority of studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] involving preoperative HGT and patients with spinal deformity are restricted to the radiographic evaluation of the degree of improvement in the angular value of the curve using the Cobb method. This finding was confirmed in our results: indeed, the Cobb angle improved in all patients. However, we investigated other radiological parameters to estimate the three-dimensional improvement of the deformity, such as the balance of the shoulders, trunk and pelvis, which could also have benefited from traction. These are often the changes that draw the most attention during the clinical examination, and their correction brings a more harmonious result and greater patient satisfaction.[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Even when such a significant improvement in angular value is not obtained with the use of HGT, such as in cases with complex congenital defects, or when the clinical condition does not allow a major osteotomy, the improvement of secondary structured curves that are made flexible through prolonged traction can be clinically significant. These were confirmed in this study, where all shoulder alignment and all pelvic obliquity evaluations had statistically significant differences, which were clinically significant in photographs and imaging analyses (examples shown in the Figures). These are flagrant benefits from HGT only that need to be confirmed in randomised clinical trials where ethically appropriate.\u003c/p\u003e \u003cp\u003eThe surgical management of patients with severe and rigid spinal deformities is quite challenging, both from an orthopaedic and clinical point of view. Often, these patients cannot receive adequate surgical treatment or are neglected. The decision to operate them is difficult and must be shared with other specialists, the patient and family members, clarifying the complexity, time and risks. In these cases, HGT could be fundamental in improving the deformity in just a few weeks, allowing the patient to undergo less aggressive spinal surgery.\u003c/p\u003e \u003cp\u003eThe indication for HGT follows a combination of criteria: extension and rigidity of the deformity, the degree of pulmonary involvement, the presence of neurological deficit in a severe decompensated curve and preoperative adaptation of the spinal cord to the stress of surgical correction.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] There is already considerable evidence for the preoperative HGT advantages, such as a reduced need for three-column osteotomy, lower neurological risk, time for preoperative nutritional support, reduced stress on implants, improvement of respiratory function and strengthening of the doctor-patient relationship.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] In our study, we also systematically measured radiographical improvements.\u003c/p\u003e \u003cp\u003eUsing HGT in a walker/chair potentially allows greater patient acceptance when compared to other methods of halo cranial traction due to the relative freedom for locomotion, social interaction and exercise, associated with preservation of bone quality, improvement of muscle mass and cardiorespiratory condition[\u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, we did not have access to patients\u0026rsquo; acceptance from the medical records. Acceptance or tolerance for traction time should be an important patient-measured outcome (PMO) to consider in future prospective studies. In our clinical experience, the understanding and involvement of the entire multidisciplinary team in the treatment is fundamental. As shown in our results, most patients tolerate the prolonged use of HGT well (in no case reported here HGT had to be interrupted), but this adherence must always be encouraged with emphatic clarifications about the role that the method plays in both reducing risks, complications and obtaining better results.\u003c/p\u003e \u003cp\u003eThe team in our hospital checks the tolerance daily and we usually see that the first few days are more demanding, with complaints of mild to moderate headache and irritability, especially in young children. After this initial phase, the adaptation is satisfactory. Throughout the traction period, it is important to carry out daily neurological medical evaluations and provide guidance to the patient and their relatives regarding possible complications that may arise, which are generally not serious.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] No major complications were noted in the medical records in the cohort reported here.\u003c/p\u003e \u003cp\u003eThe reduction observed in clavicle angle in this study is a clear benefit from HGT. Beyond the Cobb reduction, the literature shows an important relationship between shoulder alignment and satisfaction with the surgery. The clavicle angle is one of the most reliable methods to evaluate shoulder height in the context of complex spinal deformities. It is also closely related to patient satisfaction after surgery.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] While we could not evaluate the RSH, the literature directly correlates it to clavicle angle.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] T1 tilt did not show a statistically significant reduction after HGT in our study; however, T1 tilt is only mildly related to shoulder balance.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] In a study that evaluated mainly teenage girls after surgical correction of scoliosis, shoulder imbalance of 2 centimetres or more was associated with \u0026ldquo;resentment and grievances\u0026rdquo;.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] The female teenager in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e had shoulder alignment improvements visible even in simple photographs.\u003c/p\u003e \u003cp\u003eBoth the coronal alignment and thoracic trunk shift (TTS) were significantly reduced with HGT. In another study of patients with adolescent idiopathic scoliosis,[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] the post-surgical satisfaction score in the Scoliosis Research Society-30 questionnaire positively correlated with coronal alignment correction and curve correction rates. The literature also shows an association between TTS and pelvic obliquity (PO), as well as TTS and back pain.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] The clinical trunk deformity directly influences the perception of function and self-image in patients with spinal deformities.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] In our study, we chose the Osebold and the Maloney methods for calculating PO due to their greater correlation between examiners and preference for most spinal surgeons.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] On both methods, there was a statistically significant decrease in PO. Its correction is essential for improving sitting balance and walking in all patients with neuromuscular scoliosis.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] An uncorrected PO is also associated with worse health-related quality of life in children and their caregivers at the end of surgical treatment for early-onset scoliosis.[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] While not addressed directly in our study, improving global spinal alignment has been shown to diminish pain from friction of the ilium and the lower ribs. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows a case where this friction was clearly reduced.\u003c/p\u003e \u003cp\u003eThe length of stay on HGT is multifactorial and the decision must be individualized. In most cases in the literature, and as per routine in our service, after a few weeks, a plateau of improvement is reached, and surgery is scheduled. In the literature, the time of traction varies from 2 to 12 weeks in preoperative HGT, achieving a response of 24.1% reduction in the Cobb angle.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] In our study, patients underwent HGT from 2 to 13 weeks, showing an average improvement in the cobb of 22.2%, at which point the surgical procedure was scheduled.\u003c/p\u003e \u003cp\u003eIn most cases, even in the most severe and rigid curves, the response to traction is satisfactory for both patients and clinicians. The response may be so good in certain situations that the initial surgical plan is altered.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The clinical and radiographic improvement obtained in the alignment of the trunk, shoulders and pelvis, with or without improvement in the angular value, may influence the surgical technique chosen. Surgeons can then avoid major vertebral osteotomies and their inherent complications.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In our cohort, in some cases, a less aggressive surgical technique could be chosen after the radiographical changes seen with traction (although this was not a variable in this study). All previously discussed aspects must be considered when making decisions regarding the best course of action, as well as the patient's profile, the training of the surgical team and the availability of resources.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe benefits of preoperative halo gravity traction in patients with severe spinal deformities go beyond reducing the curve\u0026rsquo;s angular value (Cobb angle) and include improving radiographic parameters related to the balance of the shoulders, trunk, pelvis and lower limbs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAGCB: Study conception, data collection and analysis (imaging review), manuscript writing, final approvalGJA: Data collection and analysis (imaging and patient charts review), manuscript writing, final approvalGFA: Data collection and analysis (patient charts review), manuscript writing, final approvalACL: Data analysis (statistics), manuscript critical review, final approvalLECTS: Data collection and analysis (imaging review), manuscript critical review, final approval\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank Patricia Logullo, PhD, CMPP (Palavra Impressa), for manuscript editing services.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGuiroy A, Carazzo C, Camino-Willhuber G et al (2023) Time to surgery for adolescent idiopathic scoliosis: How long does it take? A multicenter study. World Neurosurg X 19:100187. https://doi.org/10.1016/j.wnsx.2023.100187\u003c/li\u003e\n \u003cli\u003eAhn H, Kreder H, Mahomed N et al (2011) Empirically derived maximal acceptable wait time for surgery to treat adolescent idiopathic scoliosis. Can Med Assoc J 183:E565\u0026ndash;E570. https://doi.org/10.1503/cmaj.101511\u003c/li\u003e\n \u003cli\u003eSucato DJ (2010) Management of Severe Spinal Deformity: Scoliosis and Kyphosis. Spine 35:2186\u0026ndash;2192. https://doi.org/10.1097/BRS.0b013e3181feab19\u003c/li\u003e\n \u003cli\u003eMcIntosh AL, Ramo BS, Johnston CE (2019) Halo Gravity Traction for Severe Pediatric Spinal Deformity: A Clinical Concepts Review. Spine Deform 7:395\u0026ndash;403. https://doi.org/10.1016/j.jspd.2018.09.068\u003c/li\u003e\n \u003cli\u003eRinella A, Lenke L, Whitaker C et al (2005) Perioperative Halo-Gravity Traction in the Treatment of Severe Scoliosis and Kyphosis. Spine 30:475\u0026ndash;482. https://doi.org/10.1097/01.brs.0000153707.80497.a2\u003c/li\u003e\n \u003cli\u003eTeixeira Da Silva LEC, De Barros AGC, De Azevedo GBL (2015) Management of severe and rigid idiopathic scoliosis. Eur J Orthop Surg Traumatol 25:7\u0026ndash;12. https://doi.org/10.1007/s00590-015-1650-1\u003c/li\u003e\n \u003cli\u003eBuchowski JM, Skaggs DL, Sponseller PD (2007) Temporary Internal Distraction as an Aid to Correction of Severe Scoliosis: Surgical Technique. J Bone Jt Surg 89:297\u0026ndash;309. https://doi.org/10.2106/JBJS.G.00163\u003c/li\u003e\n \u003cli\u003eNaves CD, Silva LECTD, Barros AGCD et al (2017) Correction of severe stiff scoliosis through extrapleural interbody release and osteotomy (LIEPO). Coluna/Columna 16:296\u0026ndash;301. https://doi.org/10.1590/s1808-185120171604179165\u003c/li\u003e\n \u003cli\u003eNickel VL, Perry J, Garrett A, Heppenstall M (1989) The halo. A spinal skeletal traction fixation device. By Vernon L. Nickel, Jacquelin Perry, Alice Garrett, and Malcolm Heppenstall, 1968. Clin Orthop Relat Res. ;(239):4\u0026ndash;11. PMID: 2912634.\u003c/li\u003e\n \u003cli\u003eCechin IE, Alves GF, Barros AGCD, Silva LECTD (2023) Complications of prolonged halo-gravitational tractional in spinal deformity surgeries. Coluna/Columna 22(1):e265394. https://doi.org/doi:10.1590/S1808-185120222201265394\u003c/li\u003e\n \u003cli\u003eSponseller PD, Takenaga RK, Newton P et al (2008) The Use of Traction in the Treatment of Severe Spinal Deformity. Spine 33:2305\u0026ndash;2309. https://doi.org/10.1097/BRS.0b013e318184ef79\u003c/li\u003e\n \u003cli\u003eKoller H, Zenner J, Gajic V et al (2012) The impact of halo-gravity traction on curve rigidity and pulmonary function in the treatment of severe and rigid scoliosis and kyphoscoliosis: a clinical study and narrative review of the literature. Eur Spine J 21:514\u0026ndash;529. https://doi.org/10.1007/s00586-011-2046-5\u003c/li\u003e\n \u003cli\u003evon Elm E, Altman DG, Egger M et al (2007) Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 335:806\u0026ndash;808. https://doi.org/10.1136/bmj.39335.541782.AD\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Brien MF, Kuklo TR, Blanke KM, Lenke LG (2008) Spinal Deformity Study Group Radiographic Measurement Manual. Medtronic\u003c/li\u003e\n \u003cli\u003eKarkenny AJ, Magee LC, Landrum MR et al (2021) The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis. https://doi.org/10.2106/JBJS.OA.20.00143. JBJS Open Access 6:\u003c/li\u003e\n \u003cli\u003eMenezes CM, Lima RS, Falcon RS, Souza Junior RED (2019) The importance of clavicle angle and height of the coracoid process in idiopathic scoliosis. Coluna/Columna 18:196\u0026ndash;199. https://doi.org/10.1590/s1808-185120191803196866\u003c/li\u003e\n \u003cli\u003eGajaseni P, Labianca L, Kalakoti P, Weinstein S (2022) Achieving Shoulder Balance Using Medial and Lateral Radiological Measures in Adolescent Idiopathic Scoliosis. Iowa Orthop J 42(1):47\u0026ndash;51\u003c/li\u003e\n \u003cli\u003eDiebo BG, Ferrero E, Lafage R et al (2015) Recruitment of Compensatory Mechanisms in Sagittal Spinal Malalignment Is Age and Regional Deformity Dependent: A Full-Standing Axis Analysis of Key Radiographical Parameters. Spine 40:642\u0026ndash;649. https://doi.org/10.1097/BRS.0000000000000844\u003c/li\u003e\n \u003cli\u003eAkbar M, Terran J, Ames CP et al (2013) Use of Surgimap Spine in Sagittal Plane Analysis, Osteotomy Planning, and Correction Calculation. Neurosurg Clin N Am 24:163\u0026ndash;172. https://doi.org/10.1016/j.nec.2012.12.007\u003c/li\u003e\n \u003cli\u003eSmyrnis PN, Sekouris N, Papadopoulos G (2009) Surgical assessment of the proximal thoracic curve in adolescent idiopathic scoliosis. Eur Spine J 18:522\u0026ndash;530. https://doi.org/10.1007/s00586-009-0902-3\u003c/li\u003e\n \u003cli\u003eRaso VJ, Lou E, Hill DL et al (1998) Trunk distortion in adolescent idiopathic scoliosis. J Pediatr Orthop 18:222\u0026ndash;226\u003c/li\u003e\n \u003cli\u003eTheologis TN, Jefferson RJ, Simpson AH et al (1993) Quantifying the cosmetic defect of adolescent idiopathic scoliosis. Spine 18:909\u0026ndash;912. https://doi.org/10.1097/00007632-199306000-00016\u003c/li\u003e\n \u003cli\u003eWatanabe K, Lenke LG, Bridwell KH et al (2010) Efficacy of perioperative halo-gravity traction for treatment of severe scoliosis (\u0026ge;\u0026thinsp;100\u0026deg;). J Orthop Sci 15:720\u0026ndash;730. https://doi.org/10.1007/s00776-010-1523-8\u003c/li\u003e\n \u003cli\u003eBogunovic L, Lenke LG, Bridwell KH, Luhmann SJ (2013) Preoperative Halo-Gravity Traction for Severe Pediatric Spinal Deformity: Complications, Radiographic Correction and Changes in Pulmonary Function. Spine Deform 1:33\u0026ndash;39. https://doi.org/10.1016/j.jspd.2012.09.003\u003c/li\u003e\n \u003cli\u003eIyer S, Boachie-Adjei O, Duah HO et al (2019) Halo Gravity Traction Can Mitigate Preoperative Risk Factors and Early Surgical Complications in Complex Spine Deformity. Spine 44:629\u0026ndash;636. https://doi.org/10.1097/BRS.0000000000002906\u003c/li\u003e\n \u003cli\u003eMehlman CT, Al-Sayyad MJ, Crawford AH (2004) Effectiveness of Spinal Release and Halo-Femoral Traction in the Management of Severe Spinal Deformity. J Pediatr Orthop 24\u003c/li\u003e\n \u003cli\u003eKoptan W, ElMiligui Y (2012) Three-staged correction of severe rigid idiopathic scoliosis using limited halo-gravity traction. Eur Spine J 21:1091\u0026ndash;1098. https://doi.org/10.1007/s00586-011-2111-0\u003c/li\u003e\n \u003cli\u003eThorsness RJ, Faust JR, Behrend CJ, Sanders JO (2015) Nonsurgical Management of Early-onset Scoliosis. J Am Acad Orthop Surg 23:519\u0026ndash;528. https://doi.org/10.5435/JAAOS-D-14-00019\u003c/li\u003e\n \u003cli\u003eHan X, Sun W, Qiu Y et al (2016) Halo Gravity Traction Is Associated with Reduced Bone Mineral Density of Patients with Severe Kyphoscoliosis. BioMed Res Int 2016:8056273. https://doi.org/10.1155/2016/8056273\u003c/li\u003e\n \u003cli\u003eYang C, Wang H, Zheng Z et al (2017) Halo-gravity traction in the treatment of severe spinal deformity: a systematic review and meta-analysis. Eur Spine J 26:1810\u0026ndash;1816. https://doi.org/10.1007/s00586-016-4848-y\u003c/li\u003e\n \u003cli\u003eAkel I, Pekmezci M, Hayran M et al (2008) Evaluation of shoulder balance in the normal adolescent population and its correlation with radiological parameters. Eur Spine J 17:348\u0026ndash;354. https://doi.org/10.1007/s00586-007-0546-0\u003c/li\u003e\n \u003cli\u003eGhandehari H, Mahabadi MA, Mahdavi SM et al (2015) Evaluation of Patient Outcome and Satisfaction after Surgical Treatment of Adolescent Idiopathic Scoliosis Using Scoliosis Research Society-30. Arch Bone Jt Surg 3(2):109\u0026ndash;113\u003c/li\u003e\n \u003cli\u003eTrobisch PD, Samdani AF, Pahys JM, Cahill PJ (2011) Postoperative trunk shift in Lenke 1 and 2 curves: how common is it? and analysis of risk factors. Eur Spine J 20:1137\u0026ndash;1140. https://doi.org/10.1007/s00586-011-1820-8\u003c/li\u003e\n \u003cli\u003eAsher M, Lai SM, Burton D, Manna B (2004) The Influence of Spine and Trunk Deformity on Preoperative Idiopathic Scoliosis Patients\u0026rsquo;. Health-related Qual Life Questionnaire Responses: Spine 29:861\u0026ndash;868. https://doi.org/10.1097/00007632-200404150-00008\u003c/li\u003e\n \u003cli\u003eMatsumoto H, Fano AN, Ball J et al (2022) Uncorrected Pelvic Obliquity Is Associated With Worse Health-related Quality of Life (HRQoL) in Children and Their Caregivers at the End of Surgical Treatment for Early Onset Scoliosis (EOS). J Pediatr Orthop 42(4):e390\u0026ndash;e396. 10.1097/BPO.0000000000002096\u003c/li\u003e\n \u003cli\u003eBrubaker ML, Sinaki M (2016) Successful management of iliocostal impingement syndrome: A case series. Prosthet Orthot Int 40(3):384\u0026ndash;387. https://doi.org/10.1177/0309364615605394\u003c/li\u003e\n \u003cli\u003eSuk S-I, Chung E-R, Kim J-H et al (2005) Posterior Vertebral Column Resection for Severe Rigid Scoliosis. Spine 30:1682\u0026ndash;1687. https://doi.org/10.1097/01.brs.0000170590.21071.c1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6588244/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6588244/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003ePreoperative halo gravity traction (HGT) is widely used in the management of severe spinal deformities to improve surgical outcomes and reduce risks associated with definitive correction. However, its effects on radiographic parameters beyond the Cobb angle improvement remain underexplored. This study evaluated whether HGT provides additional radiographic benefits beyond the Cobb angle correction, particularly in the shoulder, trunk, pelvis, and lower limb alignment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective analysis of patients with severe spinal deformities who underwent HGT from 2017 to 2023 in a public quaternary orthopaedic institution. Radiographic measurements taken before and after traction were compared, assessing coronal and sagittal alignment, pelvic obliquity, shoulder alignment, and spinopelvic parameters. Statistical significance was determined using paired tests (p\u0026thinsp;\u0026le;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 15 patients (mean age: 16.9 years) included, HGT led to significant reductions in coronal Cobb (22.2%) and sagittal Cobb (21.3%). Shoulder balance improved, as indicated by decreased clavicular angle and T1 tilt. Trunk misalignment was reduced, with improvements in apical vertebra translation, coronal balance, and thoracic trunk shift. Pelvic obliquity corrections were statistically significant. Spinopelvic parameters showed minimal and non-significant changes. No major complications were reported.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHGT benefits extend beyond Cobb angle reduction, significantly improving overall spinal alignment. These findings suggest that HGT may contribute to a more balanced and harmonious correction while remaining a safe treatment.\u003c/p\u003e\u003ch2\u003eMeSH:\u003c/h2\u003e \u003cp\u003eTraction; Scoliosis; Spinal curvatures; Radiography\u003c/p\u003e","manuscriptTitle":"Beyond the Cobb angle: the radiographic measurement differences from halo gravity traction in patients with severe spine deformities before scoliosis surgical correction. Cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 12:12:42","doi":"10.21203/rs.3.rs-6588244/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-08T16:15:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-15T19:43:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T12:01:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103962590427129734447372804559209586258","date":"2025-06-06T09:29:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54267676532714561802738609856013135903","date":"2025-06-03T09:12:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-13T23:59:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-10T07:36:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-10T07:35:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-05-04T11:45:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"92cf1faa-288e-48aa-b091-df88fa850e94","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T06:59:38+00:00","versionOfRecord":{"articleIdentity":"rs-6588244","link":"https://doi.org/10.1007/s00586-025-09270-5","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2025-09-12 15:57:18","publishedOnDateReadable":"September 12th, 2025"},"versionCreatedAt":"2025-05-16 12:12:42","video":"","vorDoi":"10.1007/s00586-025-09270-5","vorDoiUrl":"https://doi.org/10.1007/s00586-025-09270-5","workflowStages":[]},"version":"v1","identity":"rs-6588244","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6588244","identity":"rs-6588244","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}