The principle of spring-loaded points for cervical traction

Technical note

W. JAMES GARDNER, M.D.

Neurological Surgery, 822 Keith Building, Cleveland, Ohio

The author describes a skull traction tong devised for bedside application. The instrument eliminates the need for shaving, incising, or drilling. KEY WORDS cervical traction spring loading skull tongs

HIS paper describes a new type of instrument for cervica! traction, the "skull traction tong.' * The tong consists of a rigid member that follows the coronal contour of the calvarium. At each end there is a threaded hole which accommodates a screw for advancement of the cone-shaped points through the scalp to the outer table. These points are tilted in the direction of pull, so that with traction they tend to press in rather than pull out (Fig. 1 ). One of the points is rendered retractable by an enclosed spring calibrated to indicate when a squeezing pressure of 30 lbs is attained. This figure was arrived at as a result of experience with the Gardner skull clamp. Here adequate fixation is accomplished at 40 lbs, which when distributed on each of the two points of the opposing rocker arm is 20 lbs.

T e c h n i q u e of Application The entire assembly may be autoclaved, but this is not necessary, since the instrument is designed for emergency bedside application under antiseptic rather than aseptic conditions. The recommended procedure is as follows: the needle-sharp points are removed and placed in a cup of antiseptic solution. The scalp is sterilized by an aerosol spray that coats and penetrates the hair through to the skin. The antiseptic is then rubbed in, a local anesthetic is injected, and time is allowed for it to take effect. After respraying the scalp, the instrument is reassembled and applied so that the instructions face upward. As the tapered points are advanced, the skin is stretched increasingly snugly about them. This effectively seals the point of entry and prevents bleeding. On encountering bone, the stiff spring yields until the outer end of the springloaded point barely protrudes beyond the
543

*The skull tong is available from Trent Wells, Inc., South Gate, California 90280.
1. Neurosurg. / Volume 39 / October, 1973

W. James Gardner

FI6. 2. When the outer end (arrow) of the spring-loaded point barely protrudes beyond the flat surface, the spring is fully compressed. advancement is rarely indicated, since pressure atrophy allows additional bone penetration without retightening. The depth of penetration is self-limited by a gradual lessening of spring tension accompanied by an exponential increase in the surface area of contact between the tapered points and the bone. The pressure on each point is exactly the same regardless of whether one has been advanced farther than the other. The curve of the instrument allows the traction loop to seek its proper position. With the patient supine, rotation of the head may be prevented by placing a sandbag under each projecting knurled end. This is particularly important in fractures of the odontoid. In the absence of paralysis or pulmonary problems, an alternating pressure pad will eliminate the need for turning. Discussion The tong, applied as recommended, has been left in place for periods of more than 8 weeks with no evidence of infection. It has been used to apply traction in cervical spondylosis, and also to widen the interspace for insertion of the bone plug in anterior interbody fusion. It has been used in one patient with an associated depressed fracture at the vertex. In a mentally disturbed patient, precautions may be necessary to prevent unscrewing of the points.
Address reprint requests to: W. James Gardner, M.D., Neurological Surgery, 822 Keith Building, Cleveland, Ohio 44115.

Fro. 1. The points are applied above the ears and below the "equator." Flexion or extension of the head is determined by height of the pulley. flat surface of the knurled end (Fig. 2). This indicates that the spring is fully compressed and is exerting 30 lbs of "squeeze" between the points. The tong is tilted back and forth to insure proper seating, and then retightened if the indicator has recessed. Only in rare instances need the point be advanced after 24 hours. Since the total excursion of the spring is 5 mm, neither point may penetrate too far because of pressure atrophy. When the patient is turned on his side for back care, the added weight on one point constitutes no problem. However, it is suggested that this added weight be placed on the point that is not spring-loaded. The points of the tong rarely pull out when properly applied just below the temporal ridges (Fig. 1 ), and will readily tolerate 65 lbs of traction. A metal plate containing instructions is fastened to the assembly, so as to be always available. Because of continuous pressure exerted by the spring on a very small cross-sectional area, the points tend to penetrate the outer table at an initially high rate. After 24 hours they will have penetrated about 1 mm and will require retightening of the screw to bring the indicator flush with the outer flat surface of the screw assembly. Thereafter,

544

J. Neurosurg. / Volume 39 / October, 1973