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Concepts in Cervical Traction

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 VOL VIII No 3 : July-September 2006 161

TRACTION TECHNIQUES
Concepts in Cervical Traction

AMIT AGRAWAL
Assistant Professor
Deptt. of Neurosurgery
GK SINGH
Professor
Deptt. of Orthopaedics
PANKAJ KUMAR
Assistant Professor
Deptt. of Orthopaedics
BP Koirala Institute of
Health Sciences, Dharan,
Nepal
ABSTRACT
Skeletal traction is one of the most ancient (as well as one of the most modern) medical
treatments known. It is a technique in which a longitudinal force to the axis of the spinal
column is applied to stretch soft tissues, to separate joint surfaces or bony structures
and it has been applied widely for pain relief of neck muscle spasm or nerve root
compression. The effects of skull traction on the cervical spine are unpredictable,
since the degree of soft-tissue damage associated with bony injury varies and
therefore cannot be accurately assessed. Traction, particularly if it is prolonged,
excessive or applied in the wrong direction, may cause damage by stretching the
cord. Cervical traction is a widely used procedure for many cervical pathological
conditions, however, if not applied properly, it can lead to irreversible neurological
deficits and sometimes can be associated with fatal outcome.

INTRODUCTION THE HISTORY OF SPINAL TRACTION

For decades, cervical traction has been applied
widely for relief of pain of due to neck muscle
spasm or nerve root compression.1 It is a tech-
“Cervical traction is a
nique in which a longitudinal force to the axis of the
technique in which a spinal column is applied to stretch soft tissues, to
longitudinal force to separate joint surfaces or bony structures. Trac-
the axis of the spinal tion separates the vertebral motor units, anteflexes
column is applied to the segmental alignment of vertebral segments,
stretch soft tissues, and decreases the physiological lordotic curva-
to separate joint ture. Cervical traction must be constant so that the
surfaces or bony muscles may tire and the strain falls on the joints.1
structures” The force is usually applied to the skull through a
series of weights or a fixation device and requires
that the patient is either kept in bed or placed in a
halo vest.
Table 1: Indications

Muscle spasm

Degenerative disc diseases

Herniated/protruding intervertebral discs

Nerve root compression

Osteoarthritis

Capsulitis of the vertebral joints

Pathology of the anterior or posterior longitudinal ligaments

Management of facet joint impingement or pain

Joint hypomobility
Skeletal traction (also referred to as distraction),
is one of the most ancient (as well as one of the
most modern) medical treatments known. The
Egyptian papyri (circa 3,000 BC), uncovered by
Edwin Smith in 1862 identify the use of axial
traction for the purpose of reducing spinal fracture
dislocations as well as the treatment of many other
less serious conditions. The modern era of science
related clinical care in regard to externally applied
spinal traction began in 1933 when W. Gayle
Crutchfield (1900-1972) first introduced his cranial
tongs for the purpose of cervical spine traction in
order to restore normal vertebral alignment. 2 Halo
traction was introduced in 1960 as another method
of immobilising the cervical spine; both methods
involve inserting metal pins into the cranial vault.3
USES OF SPINAL TRACTION (TABLE 1)
There are a number of medically accepted uses for
spinal traction, which include the mobilisation of
soft tissues or joints, decompression of pinched
nerve roots, and reduction of herniated interver-
tebral discs. Low weight cervical spinal traction
may be beneficial in the early treatment of cervical
radiculopathy caused by a disc herniation. Cur-
rently, the most important use of traction is for the
162 VOL VIII No 3 : July-September 2006
management of cervical spine instability.4,5 The
usual management is by early reduction of the
dislocation to relieve spinal cord compression,
“Currently, the most with stabilization to protect the cord from further
important use of injury. In lower cervical spine dislocations, and in
fracture dislocations with facet fractures, the pos-
traction is for the
terior elements are ruptured. The supraspinous
management of and interspinous ligaments, the ligamentum
cervical spine flavum, and the facet joint capsule may be rup-
instability. The usual tured or there may be a fracture through the neural
management is by arch. When intervertebral subluxation has oc-
early reduction of the curred there must also be disruption of the disc.4,5
dislocation to relieve Extension traction has been advocated for use in
spinal cord functional restoration of cervical lordosis in pa-
compression, with tients who have had a loss of their normal cervical
stabilization to protect curve. This procedure involves the sustained use
of traction, with the cervical spine in an extended
the cord from further
posture.
injury”
MECHANISM OF ACTION
Some authors believe that traction, especially with
a slight degree of neck flexion, could open the
posterior articulations, widen the intervertebral
foramen, disengage the facet surface, and elon-
gate the posterior muscular tissues and ligaments.1
Traction also elongates intervertebral disc spaces
and reduces protruded (herniated) discs, result-
ing in the decompression (release) of the irritated
nerve roots resulting in reducing discomfort and
symptom relief. There are two mechanisms that
“Traction elongates may help reduce protrusion discs:
intervertebral disc
Negative pressure of the disc spaces that is
spaces and reduces created during traction, which sucks the pro-
protruded (herniated) truded disc back inside.
discs, resulting in the
Pushing effect of the posterior longitudinal
decompression ligament that exists on the back of the verte-
(release) of the bral body and disc, which is straightened
irritated nerve roots during traction.6
resulting in reducing
METHODS OF APPLICATION
discomfort and Spinal traction relies on the application of a dis-
symptom relief” tractive (“upward”) force being applied to the
skull while the rest of the body is held in place. The
use of a device that is firmly attached to the skull
is required for the successful application of this
force. In the early days of spinal traction, combi-
nations of straps and harnesses were used that
Table 2: Physiological effects

Decrease in cervical neuromuscular activity

Decrease in muscle spasm

Decrease in pain

Improved blood flow

Reduction of disc lesion or myofacial adhesions
were wrapped around the head and connected to
the mechanism responsible for applying the force
(Glisson Sling Halter Traction). The drawbacks of
this type of system are that long-term use of the
straps, particularly with heavy weights, damages
the underlying skin of the chin and neck leading
to pressure sores. Throughout the middle of the
20th century, advances were made which utilised
hooks or tongs that were firmly attached to the
skull. The main complication from the use of skull
tongs was a possibility for penetration of the skull
by the pins used to attach the tongs to the head.
A solution to this problem appeared in the early
1980s through an advance known as the
Gardner-Wells tongs. This U-shaped device was
specifically shaped to control pressure at the sites
of pin attachment to the head, thereby signifi-
cantly decreasing the risk of damage to the skull.
Another device that is acceptable for the applica-
tion of spinal traction is the halo, which is basically
a ring that is attached to the head through a series
of four pins. The traction force is initially applied
through both of these devices by fixing the
patient’s torso in bed while a series of weights are
gradually added to the tongs or halo. For patients
requiring long-term treatment, the halo vest is
preferentially used over the Gardner-Wells tongs
and bed-based traction. Harnesses or slings are
still used for the treatment of disc herniations as
mentioned earlier. In these cases the amount of
weight used is low and the time spent in traction
is intermittent.6
TECHNIQUE OF PIN TRACTION
The skull tong pins are applied through small
incisions over the parietal eminences in line with
the mastoid processes. A weight of 10 lbs is
attached to this over a pulley and neck is kept in
neutral position. The head end of the frame is
raised to produce countertraction by the body
weight. Lateral view radiographs of the cervical
spines are taken to check for reduction of the
dislocation. If dislocation persists, weight is in-
creased and radiographs repeated. When the dis-
location is found reduced in the radiograph, neck
is slowly extended over a pad support and the
weight reduced to a minimum to maintain the
reduction.
CERVICAL TRACTION AND WEIGHT
There is no evidence that mid and lower cervical
spine separation occurs at forces less than 20 lbs.
It has been found that 25-40 lbs of force for the mid
and lower cervical spine is often clinically effec-

“In the case of a
patient with sagittal
canal compromise, due
to congenital
stenosis or acquired
central canal stenosis,
the extension traction
procedure may be
neurologically
detrimental to the
patient, as this
position may produce
spinal cord
compression”
Table 3: Contraindications

Unstable spine

Vertebral fractures

Extruded disc fragmentation or rupture

Spinal cord compression

Acute strains or sprains

Joint hypermobility

Pregnancy

Conditions in which vertebral flexion is contraindicated

Conditions which worsen following traction treatments

Osteoporosis
VOL VIII No 3 : July-September 2006
tive in conditions where a separation of the inter-
vertebral space is desirable (e.g. herniated cervical
disc, interforaminal nerve root encroachment,
degenerative disc or joint disease and facet joint
impingement). In other conditions where the
muscles are primarily affected, less force may be
effective. Examples include suboccipital or upper
trapezius muscle tension or shortening. As little as
10 lbs force may be necessary when treatment is
directed to the upper cervical area. While applying
weight, patient comfort and clinical response
should be the guide.7-10
CONTRAINDICATIONS (TABLE 3)
The average sagittal canal diameter in the lower
cervical region is 17 millimeters. Extension causes
the sagittal diameter to decrease in the lower
cervical region, while simultaneously causing the
spinal cord to widen in its anterior to posterior
dimension. In the normal cervical spine, with a
normal sagittal canal diameter, the sustained ex-
tension position should not be hazardous to the
patient. However, in the case of a patient with
sagittal canal compromise, due to congenital steno-
sis or acquired central canal stenosis, the exten-
sion traction procedure may be neurologically
detrimental to the patient, as this position may
produce spinal cord compression.11,12 When the
cervical spine is dislocated below the C2 level, any
injury to the spinal cord occurs by sagittal defor-
mation, and the severity of the damage is probably
proportional to the severity of compression at the
time of injury. Such compression is aggravated by
the presence of a narrow spinal canal.13
COMPLICATIONS
The primary aim of treatment in traumatic instabil-
ity of the cervical spine is to achieve reduction and
stability while preserving neurological function,
using slowly increasing skull traction, closed ma-
nipulation or open reduction with surgical fu-
sion.14 Neurological deterioration has been re-
ported to occur after skull traction,15,16 during
163
operative reduction17 and after disc prolapse.18,19
Deterioration of neurological function after the
initial cord injury occurs, may result from anatomi-
cal, chemical, and vascular changes within the
cord which are probably secondary to ischaemia
and hypoxia.20 An ascending cord lesion may be
produced by vascular disruption.21
DISC DISRUPTION AND PROLAPSE
The sagittal diameter of the spinal canal is an
important determinant of the severity of cord
damage in cervical spine injury.13 Rupture of the
posterior longitudinal ligament and the posterior
annulus may then allow extrusion of the disc
which may cause spinal cord compression follow-
ing reduction. The recognition of such an ex-
truded disc is now possible by improved soft-
tissue imaging, particularly the use of magnetic
resonance imaging (MRI).14,18,19,22-24 If disc extru-
sion is demonstrated, then decompression through
an anterior approach should be carried out before
reduction and stabilisation.5,18,19
INJURY TO THE VERTEBRAL ARTERIES
During reduction, injury to the vertebral arteries
resulting in ischaemic damage to the brain is
possible. This is extremely rare, since the vertebral
arteries pass through the transverse processes
and must be compromised by a bilateral facet
dislocation.25,26
PROLONGED TRACTION
Traction, particularly if it is prolonged, excessive,
or applied in the wrong direction, may cause
damage by stretching the cord.14
CANAL STENOSIS AND DETERIORATION
The commonly used method of closed reduction
which involves flexion before lifting the facets
clear will initially reduce the diameter of the spinal
canal, potentially increasing cord compression.27
CORD OEDEMA
Swelling of the cord may result from the initial
accident or from the process of reduction. Experi-
mental work in animals shows that cord oedema
starts after a few minutes to four hours, and can
last for two weeks after the injury.28,29 Any direct
trauma to the cord at operation, or indirect trauma
by traction, may aggravate the oedema, and the
swollen cord may then be compressed within a
reduced bony canal, by fragments of vertebra,
disc protrusion or damage to the ligamentum
flavum, leading to a progression to paralysis.14
164 VOL VIII No 3 : July-September 2006
TEETH AND THE TEMPOROMANDIBULAR JOINTS
Conventional cervical traction methods use head
halters that fit under the chin. During a cervical
traction treatment that uses one of these head
halters, force is transmitted through the chin strap
to the teeth and the temporomandibular joints
become weight-bearing structures. It has been
“Cervical traction may
shown that some patients experience consider-
be dangerous when an
able discomfort in the temporomandibular joints
unstable lesion is with traditional cervical traction. This is particu-
accidentally larly true if an abnormal dental occlusion exists
overdistracted” such as the absence of posterior teeth.30 Cervical
traction involving force on the jaw should be
carried out with caution. Particularly in the elderly
patients, excessive pressure on the jaw can lead to
intracapsular bleeding and haematoma in the tem-
poromandibular joint.31
OVERDISTRACTION
Cervical traction may be dangerous when an un-
stable lesion is accidentally overdistracted. A few
cases have been reported in the literature, some
with neurological complications.32 Occipitocervical
dislocations, fractures of the odontoid process,
Hangman’s fractures, hyperextension/distraction
injuries and bilateral dislocations or fracture dis-
“Occipitocervical
locations may cause disruption of both the ante-
dislocations, fractures rior and posterior elements and are specially vul-
of the odontoid nerable to overdistraction when skull traction is
process, Hangman’s used. To prevent accidental overdistraction dur-
fractures, ing skull traction, the use of less weight than is
hyperextension/ generally proposed in the literature is recom-
distraction injuries and mended.32
bilateral dislocations
or fracture SOFT TISSUE INJURY AND TRACTION
dislocations may The effects of skull traction on the cervical spine
are unpredictable, since the degree of soft-tissue
cause disruption of
damage associated with bony injury varies and
both the anterior and therefore cannot be accurately assessed. Traction
posterior elements and is potentially harmful to the injured spinal cord.33,34
are specially
vulnerable to
FUSION AND STIFFNESS OF LIGAMENTS
overdistraction when The precise cause of the fusion is not known but
skull traction is used” it has been shown from studies of the visco-elastic
behaviour of the spine that the posterior ligaments
stiffen abruptly when subjected to more than 60
per cent of their breaking strain. Distraction force
can result in disturbance of the bony attachments
of the cervical ligaments causing local haemorrhage
and later bone formation.35
SKULL CALIPER DISENGAGEMENT
Accidental disengagement of skull caliper disen-
gaged rarely can cause further damage to the cord.
MRI, CT, myelography and CT-myelography are
currently available to show cord compression.36
INFECTION
Skull traction carries a risk of infection of not only
the subcutaneous tissue but also the bone, the
extradural and subdural spaces, and the brain
itself.37 Although in the majority of cases it is
relatively trivial, involving merely a local cellulitis,
it can lead to more serious complications such as
local osteomyelitis and extradural abscesses.38,39
To minimise the frequency of infection when using
skull traction it is essential that the surgeon should
be aware of the potential risks and pathogenesis
of intracranial infection so that adequate preven-
tative measures can be taken; a sufficient area of
the scalp should be shaved and the calipers must
be fitted in a scrupulously sterile fashion, taking
care that the metal pins do not penetrate the inner
table of the skull. The wound surrounding the pins
should be treated with great care throughout the
period of skull traction.37
CONCLUSIONS
Cervical traction is a widely used procedure for
many cervical pathological conditions. If not ap-
plied properly it can lead to irreversible neurologi-
cal deficits and sometimes may have a fatal out-
come.
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