11 Application of Closed Spinal Traction



10.1055/b-0035-121757

11 Application of Closed Spinal Traction

Nirit Weiss

Introduction


Emergency closed spinal traction may be performed for patients who present with cervical spinal misalignment and/or instability secondary to trauma. Use of lighter weight (5–10 lb) can maintain alignment and immobilize an unstable spine, if closed traction reduction is not deemed appropriate at the time. Reduction of fracture dislocation and realignment with increased weight (10–80 lb) can decompress the spinal cord and nerve roots. After successful application of traction, bracing or surgery may be deemed appropriate. If traction is unsuccessful, surgery likely follows. Manipulation under anesthesia (MUA) may be helpful in patients who fail awake inline traction reduction. 1 Weighted inline halo ring traction can be converted to long-term halo-vest immobilization if needed. Most commonly used traction options are Gardner-Wells (G-W) tongs and Halo rings.



Indications




  • Cervical spinal misalignment due to traumatic fracture/dislocation



  • Spinal cord/nerve root compression due to misalignment



  • Cervical spinal instability due to traumatic fracture or ligamentous instability requiring immobilization that cannot be adequately achieved with external orthoses alone



  • Awake, cooperative patient



  • Availability of radiographic/clinical monitoring during reduction



  • Absence of skull fracture or prior bur hole at proposed pin sites



  • Absence of occipitoatlantal or atlantoaxial dissociation or complete ligamentous injury at any level



  • Absence of fracture/instability at level rostral to intended level of treatment



  • Absence of known significant associate traumatic cervical disk herniation, which can worsen neurologic deficit under traction



Preprocedure Considerations



Radiographic Imaging




  • X-ray and/or computed tomography (CT) evidence of fracture, subluxation, misalignment, instability ( Fig. 11.1 ).



  • Role of pretraction magnetic resonance imaging (MRI) remains controversial 2 : One-third to one-half of patients with facet subluxation have evidence of disk herniation or disruption on MRI. Inline traction in the presence of ventral cord compression may lead to neurologic injury. However, less than 1% of patients have been found in studies to have permanent neurologic deterioration resulting from application of cervical traction—despite the presence of herniated ventral disks. Depending on the time needed to obtain the MRI, the benefits of early reduction should be weighed against the risk of reduction in the face of potential unidentified ventral compression from disk herniation. In awake, cooperative patients, physical exam can be monitored while increasing traction weight, and pretraction MRI may have lower utility. In unconscious patients, significant efforts to obtain pretraction MRI should be made. Patients with incomplete injuries have greatest risk of neurologic deterioration.



Medication




  • Systemic: Nonsedating pain medication (morphine, fentanyl) and muscle relaxant (diazepam) intravenously (IV) as needed to allow for patient cooperation and successful reduction.



  • Local: 1% lidocaine or 1% lidocaine/0.5% bupivacaine (1:1 mixture) applied to scalp and pericranium of planned pin site locations.



Operative Field Preparation




  • Alcohol prep followed by povidone/iodine to planned pin sites.



  • Antibacterial (bacitracin) ointment to pins prior to placement.

Fig. 11.1 Lateral radiograph in patient with high-grade spondylolithesis at C4-5 due to bilateral facet dislocation after traction tongs placement and prior to weight application.


Operative Procedure



Positioning (Fig. 11.2)

Figure Fig. 11.2 Procedural Steps Patient is positioned for application of traction, typically supine, head in neutral position. Pearls • It is easier to place an “open” halo ring than a closed ring while supine. Check lateral X-ray in position prior to proceeding. If one needs to reduce kyphosis, a shoulder roll can be placed. If the plan is to eventually place in halo vest, one can “preplace” the back of the halo vest for the patient to lie on. 3


Selection of Pin Sites (Fig. 11.3a, b)

Figure Fig. 11.3 Procedural Steps (a) Gardner-Wells tongs. Two pin sites are required. (A, green) The ideal pin site placement is along the superior temporal line, above the temporalis muscle belly (mark as transparency below skin), approximately 3 to 4 cm above pinna. For neutral traction, pin directly in line above external auditory meatus (EAM). To induce a flexion correction (e.g., of jumped facets), (B, red) place 3 cm posterior to EAM; to induce an extension (e.g., for subluxation), (C, blue) place 3 cm anterior to EAM, along the superior temporal line. After preparation with alcohol and povidone iodine, local anesthetic is injected. (b) Halo ring. Select four pin sites, each marked with a pen: two anterior, two posterior. The two anterior sites should be 1 cm above orbital rim, above lateral half of the orbit (to avoid the supraorbital and supratrochlear nerves and the frontal sinus). Posterior pins should be in region of mastoid. After preparation with alcohol and povidone iodine, local anesthetic is injected. Pearls • Halo rings are available in MRI compatible models which can facilitate later imaging. Weights are typically not MRI-compatible and must be removed for MRI imaging. • Ensure there are no skull fractures or bur holes in region of proposed pin sites. Do not place pins into thin squamous temporal bone. • Select pin sites while assistant holds the halo ring in place, or use “suction cup” stabilizing posts to hold ring while selecting appropriate sites. Pin sites should be selected to allow for the ring to sit symmetrically around the head. • Pin sites should be selected to allow for a 1- to 2-cm space circumferentially between the scalp and the halo ring. Pins should be placed in holes that allow for most perpendicular entry into skull. 4 • Prep with alcohol followed by povidone iodine. Inject lidocaine or lidocaine/bupivacaine mixture as above into proposed pin sites, into scalp and pericranium. May incise scalp prior to pinning to avoid contamination with skin flora.

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17 Spinal Epidural Compression 12 Emergency Management of Odontoid Fractures 16 Thoracolumbar Fractures 14 Cervical Facet Dislocation 15 Classification and Treatment of Thoracic Fractures 13 Cervical Burst Fractures

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Jun 13, 2020 | Posted by in NEUROSURGERY | Comments Off on 11 Application of Closed Spinal Traction

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