Pulling toward safety: a systematic review of preoperative halo-gravity and halo-femoral related complications in spinal deformity.

PURPOSE: Halo traction is frequently initiated in severe scoliosis or kyphosis prior to fusion surgery to achieve partial correction, improve surgical tolerance, and reduce neurologic risk from excessive intraoperative correction. Halo-gravity and halo-femoral traction are the most common modalities. Despite efficacy, traction carries risks, such as pin-site infection, skin breakdown, and neurologic complications. This systematic review aimed to categorize, quantify, and analyze complications of preoperative halo traction in pediatric patients across all spinal deformity etiologies, while identifying demographic and clinical trends.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, 28 publications were included. Two reviewers independently extracted demographic, clinical, and complication data. Complication burden was summarized as incidence rates (events per patient-day) and pooled with random effects meta-analysis (REML estimator, inverse-variance weighting). Pooled estimates were back-transformed to events per 100 patient-days with Knapp-Hartung confidence intervals.

RESULTS

Across 777 patients (mean age 15.4 years, mean traction duration 62 days), the overall complication rate was 0.39 per 100 patient-days (≈1 per 256 patient-days). Implant-related complications, particularly pin-site infections, were most common (0.29 per 100 patient-days), whereas neurologic and systemic events were rare. Longer traction duration was associated with reduced incidence of complications per patient-day in traction (IRR, 0.98 per additional day; p = 0.0096), while no associations were identified with sex, age, or initial Cobb angle.

CONCLUSION

Halo traction is relatively safe, but associated with frequent implant-related morbidity across ages and deformity types. Vigilance and standardized protocols, particularly during the early phase of treatment, remain critical to minimizing risk.