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STUDY DESIGN Retrospective review. OBJECTIVE To evaluate the effect of pre-operative Halo-gravity traction (HGT) in the treatment of severe focal kyphosis in the upper thoracic spine (UTS), and to propose the indications that HGT could serve as an alternative for three-column osteotomy (3CO) among these patients. SUMMARY OF BACKGROUND DATA The HGT has been proven to be effective for severe kyphoscoliosis secondary to multiple etiologies. However, the safety and efficacy of HGT in severe focal kyphosis in UTS was still unclear. METHODS Patients with focal kyphosis in UTS undergoing HGT and without 3CO operation were reviewed. The sagittal focal kyphosis was measured at pre-, post-traction and post-operation. The neurologic function at pre-traction, post-traction and post-operation were assessed according to the ASIA grading. The complications during HGT, operation and follow-up were recorded. The comparison between pre-traction and post-traction was performed using paired samples t test. RESULTS A total of 19 patients were included in this study, with a mean age of 13.2 ± 5.8 years. The average duration of HGT was 62.6 ± 8.4 days, during which the average kyphosis decreased from 95.3 ± 16.4° to 64.1 ± 19.2° (P < 0.001). After HGT, the ASIA grade improved from C to D in 3 patients and from C to E in 3 patients, from D to E in 7 patients, from B to D in 1patient. No deterioration in neurologic function was observed during HGT. The neurological status in one patient improved from ASIA C at pre-traction to ASIA E at post-operation, but deteriorated to C at 4 years follow-up. CONCLUSIONS Preoperative HGT could help to correct deformity and improve neurological deficit. 3CO procedure might be unnecessary in patients with severe focal kyphosis in UTS with the utilization of HGT. LEVEL OF EVIDENCE 4.