Intraoperative Use of Rib-to-Pelvis Traction to Correct Pelvic Obliquity in the Neuromuscular Spine

Introduction The goal of posterior spinal fusion in neuromuscular scoliosis is to obtain a balanced trunk as well as accommodative, pressurefree seating on a level pelvis. Development of pelvic obliquity or involvement of the pelvis in the scoliotic curve can cause difficulties with seating, costopelvic impingement, and worsening pulmonary function, ultimately leading to difficulty with caregiving, decubitus ulcers, or other comorbidities. Over time, flexible deformities become more rigid, making correction of the pelvic obliquity more difficult. Correcting pelvic obliquity can be challenging in this patient population due to poor bone quality. Unit rod instrumentation has traditionally controlled pelvic obliquity well. While thirdgeneration instrumentation is technically difficult with extension to the pelvis, previous results were less than encouraging. More recently, use of third-generation instrumentation has shown improved results. Anteroposterior surgery has recently fallen out of favor due to patient comorbidities and comparable success and decreased complications of posterior surgery. Ideally, indirect correction performed before instrumentation can decrease risk of failure at either the bone-implant interface or failure of the implant itself. Many types of traction techniques have previously been implemented in order to achieve this correction prior to instrumentation. Methods have included preoperative halo-gravity traction, intraoperative halo-femoral traction, halopelvic traction, and temporary rods from vertebral body to vertebral body.