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

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